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Gift  Of 

Dr.  MA.  StARR 


"It  may  be  said,  without  reserve,  that  this  work  is  the  most  clear,  concise, 
and  complete  text-book  upon  diseases  of  the  nervous  system  in  any  language. 
And  when  the  large  number  of  such  works  which  have  appeared  in  Germany, 
France,  and  England  within  the  past  ten  years  is  considered  this  implies  high 
praise." — Tlie  American  Journal  of  the  Medical  Sciences. 


VOLUME  I 

DISEASES  OP  THE  SPINAL  CORD  AND  NERVES 

Illustrated.     Cloth,  S3. 50 


A  MANUAL 


Diseases  of  the  Nervous  System 


BY 

W.  R.  GOWERS,  M.D.,  F.R.C.P.,  F.R.S. 

CONSULTING   PHYSICIAN   TO  UNIVERSITY   COLLEGE   HOSPITAL;    PHYSICIAN   TO   THE  NATIONAL 
HOSPITAL  FOR  THE  PARALYZED  AND   EPILEPTIC 


SECOND    EDITION 

REVISED    AND    ENLARGED 


VOLUME  II 

DISEASES  OF  THE  BRAIN  AND  CRANIAL  NERVES 
GENERAL  AND   FUNCTIONAL  DISEASES    OF  THE   NERVOUS 

SYSTEM 


WITH  ONE  HUNDRED   AND   EIGHTY-TWO   ILLUSTRATIONS 
INCLUDING  A  LARGE  NUMBER  OF  FIGURES 


PHILADELPHIA 

P.    BLAKISTOX,    SON    &    CO. 

1012    WALNUT    STREET 
1893 


11 
;H3 


v, 


2. 


«T 


Xote. — Tfte  illustrations  of  ichich  the  source  is  not  stated  are  original,  and 
part  of  the  copyright  of  the  book. 


Press  of  Wm.  F.  Fell  &  Co., 

1220-24  SANSOM  ST., 

PHILADELPHIA- 


PREFACE   TO   VOL.   II. 


The  delay  in  the  appearance  of  the  second  edition  of  this 
volume  has  been  due  to  the  time  needed  for  its  thorough  revision, 
and  the  incorporation  of  the  chief  results  of  the  investigations 
of  the  last  five  years.  Numerous  additions  have  been  made, 
and  many  sections  have  been  re-written,  in  the  endeavour  to 
present,  as  far  as  possible,  the  current  knowledge  of  the  sub- 
jects considered.  In  spite  of  some  condensation  these  additions 
involve  an  increase  of  about  a  hundred  pages. 

I  am  much  indebted  to  M.  Richer  for  permitting  me  to  repro- 
duce some  of  his  very  effective  illustrations  of  the  phenomena  of 
the  attacks  of  "  Hysteria  major/5  and  trust  that  the  figures  will 
serve  to  make  his  work,  clinical  and  artistic,  more  widely  known 
in  this  country. 

For  the  index,  and  also  for  most  useful  help  in  the  process  of 
revision  and  in  the  correction  of  the  proofs,  I  have  to  thank  my 
friend  and  colleague,  Dr.  James  Taylor. 

W.  R.  GO  WEES. 


Queen  Anne  Street,  London  ; 
July,  1893. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/manualofdisease02gowe 


CONTENTS. 


PART  IV.— DISEASES  OF  THE  BRAIN: 

INTRODUCTION:    THE    STRUCTURE    AND    FUNCTIONS 
OF  THE  BRAIN 

The  Cebebbal  Coetex 

Relation    to   the    Skull,   6 ;     Structure,   10 ;    Functional 
Regions,  12 

Connecting  Tbacts,  Centeal  Ganglia,  &o. 

Obigin  of  the  Cbanial  Nebves 

'Hypoglossal  Nerve,  44 ;  Accessory,  Vagus,  Glosso-pharyn 
geal   Nerves,    45 ;    Auditory    Nerve,   47 ;  Sixth   Nerve 


PAGE 

1 
2 


Fourth  Nerve,  52 
Olfactory  Nerve,  56 


itation,   96 ;   Head 


Facial  Nerve,  49  ;  Fifth  Nerve,  50 
Third  Nerve,  53  ;  Optic  Nerve,  54 ; 

Cebebelltth  . 

Blood-vessels  of  the  Bbaln 

Secondaet  Degeneeations 

Symptoms  of  Bbain  Disease 
Motor  Symptoms  . 

Hemiplegia,  74  ;  Convulsions,  90 
Sensory  Symptoms 

Loss  of  Sensation,  94 ;  Sensory   Ir 
ache,  96  ;  Vertigo,  97 
Mental  Symptoms. 

Loss  of  Consciousness,  99 ;    Apoplexy,    100 ;    Delirium 
104 ;  Mental  Failure,  107 
Affections  of  Speech 

Defects  of  Articulation,  110  ;  Cerebral  Defects  110 
General  Symptoms 

Temperature,  Pulse,  &c,  126 
Ophthalmoscopic  Symptoms  .  « 

DISEASES  OF  THE  CRANIAL  NERVES,  &c. 

Olfactoby  Nebve  :  Affections  of  Smell 


25 
43 


56 

60 

67 

72 
74 

94 

98 

109 

125 

131 

138 
138 


Vlll  CONTENTS. 

PAGE 

Optic  Nerve  :   Affections  of  Sight       .  .  .     142 

Etiology,  143  ;  Investigation  of  the  Functions  of  the  Optic 
Nerve,  145  ;  Symptoms,  147  ;  Diagnosis,  162  ;  Prognosis, 
163 ;  Treatment,  163 ;  Functional  Amblyopia  and 
Amaurosis,  163  ;  Irritation-symptoms,  166 

Motor  Nerves  of  the  Eyeball  .  .  .     168 

Paralysis  of  Ocular  Muscles  .  .  .     168 

General  Symptoms  of  Paralysis,  170  ;  Paralysis  of  Indi- 
vidual Muscles,  176  ;  Affections  of  Special  Nerves,  180 ; 
Internal  Ocular  Palsy,  182  ;  Compound  Ocular  Palsies, 

185  ;  Causes  and  Causal  Varieties,  189 
Nuclear  Ocular  Palsy       ....     194 
Other  Forms  of  Ptosis,  200 ;  Treatment,  201 
Spasm  of  Ocular  Muscles     ....     204 
Nystagmus,  207 ;    Spasm  of  Levator,  211 ;    Treatment, 
213 

Fifth  Nerve  .....     213 

Paralysis,  214 ;  Causes,  214 ;  Symptoms,  215  ;  Diagnosis, 

218  ;    Treatment,  220 
Spasm,  221 ;  Diagnosis,  223  ;  Treatment,  224 
Affections  of  Taste  ....     224 

Facial  Nerve  .  .  .  .     229 

Paralysis,  230  ;  Causes,  230 ;  Symptoms,  235  ;  Pathology, 
243;  Diagnosis,  244;  Prognosis,  245  ;  Treatment,  246  ; 
Spasm,    248 ;    Symptoms,     252  ;    Pathology,     256 ;    Dia- 
gnosis, 256  ;  Prognosis,  257  ;  Treatment,  257 ;  Blepharo- 
spasm, 259 

Auditory  Nerve  :   Disturbance  of  Hearing        .  .     260 

Deafness,  261 ;  Hyperacusis,  267 ;  Irritation,  Tinnitus 
Aurium,  268 

Glosso-Pharyngeal  Nerve       ....    276 

Pneumogasteic  and  Accessory  Nerves  .  .  .    278 

Pneumogastric  and  Internal  Accessory  .  .     279 

Pharyngeal  Branches,  281 ;  Laryngeal  Branches,   282  ; 

Pulmonary    Branches,    294 ;    Cardiac    Branches,    295 ; 

Gastric  Branches,  296  ;  Treatment,  297 
External  Accessory  ....     299 

Hypoglossal  Nerve   .....     302 
Paralysis  of  Tongue,  302 ;  Spasm  of  Tongue,  304 
Paralysis  of  the  Palate         ....     306 

LOCALISATION  OF  CEREBRAL  DISEASE  .  .     308 

Cortex,  308  ;  Centrum  Ovale,  313  ;  Corpus  Callosum,  314 ; 
Central  Ganglai,  Internal  Capsule,  314 ;  Corpora  Quadri- 
gemina,  Cms  Cerebri,  317  ;  Pons,  318  ;  Medulla,  319 ; 
Bilateral  Lesions,  Cerebellum,  320 


CONTENTS.  IX 

PAGE 

DISEASES  OF  THE  MEMBRANES  OP  THE  BRAIN  .    323 

Congestion   ......     323 

iNFLAMMiSION  .....      323 

Dura  Mater :  Pachymeningitis  .  .  .     323 

Hsematoma,  325 
Pia  Mater  :  "  Meningitis,"  Simple  and  Tubercular  .     328 

Causes,  328 ;   Anatomical  Characters,   331 ;    Symptoms, 

336  ;  Pathology,  347  ;  Diagnosis,  348  ;  Treatment,  356 

Epidemic  Cerebrospinal  Meningitis   . 


ORGANIC  DISEASES  OP  THE  BRAIN 
Anemia  . 

Hyperemia  .  . 

hemorrhage 


358 

368 

368 
373 

384 


Etiology,  384 ;  Pathological  Anatomy,  391 ;  Symptoms, 
396;  Pathology,  405;  Diagnosis,  406;  Prognosis,  410 ; 
Treatment,  411 
Infantile  Meningeal  Hemorrhage  (Cerebral  Birth  Pcdsy)     413 

Softening  of  the  Brain  ....    421 

From  Arterial  Occlusion,  Embolism,  Thrombosis,  &c.       .     422 

General    Etiology    and    Pathology,    422 ;    Pathological 

Anatomy,    427  ;     Symptoms,    431  ;     Obstruction     of 

Particular  Arteries,  436  ;  Diagnosis,  441  ;  Treatment, 

445 

Thrombosis  in  the  Cerebral  Veins  and  Sinuses       .  .     450 

Infantile  Hemiplegia  (Acute  Cerebral  Palsy  of  Childhood)     456 

Inflammation  of  the  Brain    ....     463 
Acute  Inflammation,  463  ;  Chronic  Inflammation,  468 

Abscess  of  the  Brain  ....     470 

General  Etiology,  470 ;  Special  Etiology  and  Pathology, 
474  ;  Symptoms,  478 ;  Diagnosis,  483  ;  Prognosis,  485  ; 
Treatment,  486 

InTK A- CRANIAL    TUMOURS  .  .  .  .      488 

Etiology,  488;  Pathology,  490;  Symptoms,  504;  Dia- 
gnosis, 519  ;  Prognosis,  Treatment,  525 

Intea-cranial  Aneurism  ....     529 

Causes,  529 ;  General  Pathology,  531 ;  Aneurisms  of 
Special  Arteries,  533 

DEGENERATIONS  OF  THE  BRAIN  .  .  .    541 

Chronic  Progressive  Softening  .  .  .     541 

Disseminated  or  Insular  Sclerosis       .  .  .     543 

Pathological  Anatomy,  545  ;  Symptoms,  547 ;  Pathology, 
553  ;  Diagnosis,  555  ;  Prognosis,  Treatment,  557 


CONTENTS. 

Disseminated  oe  Insular  Scleeosis  (continued) —  page 

Diffuse  Sclerosis    .....  558 

Miliary  Sclerosis  .....  560 

Associated  Palsy  of  the  Bulbar  Nertes     ,♦      .                .  562 
Chronic  (Degenerative),  564  ;  Sudden  (Apoplectiform)  574; 
Acute  (Inflammatory),  578 

Atrophy  of  the  Brain              ....  580 

Hypertrophy  of  the  Bealn     ....  £82 

Hydrocephalus           .....  584 

Acute      .                .                .                 .                .                 .  58  A 

Chronic  ......  584 

External,  584;  Internal,  585 


PART  V.— GENERAL  AND  FUNCTIONAL  DISEASES: 

Chorea.  .  591 

Etiology,  592  ;  Symptoms,  598  ;  Varieties,  610  ;  Pathological 
Anatomy,  611;  Pathology,  613;  Diagnosis,  619;  Treat- 
ment. G21 

Chronic  Adult  Chorea  .....  624 

Electrical  Chorea  .....  627 

Myoclonus  Multiplex     .....  629 

Saltatoric  Spasm  .....  631 

Habit  Spasm  .....  633 

Paraxysis  Agitans  .....     636 

Causes,  636;  Symptoms,  638;  Pathological  Anatomy,  650; 
Pathology,  651  ;  Diagnosis,  654 ;  Treatment,  656 
Other  Forms  of  Tremor  ....     657 

Wry-Neck  :  Torticollis    .....  659 

Fixed  Wry-Neck .-  Congenital  Torticollis   .  .  .  660 

Spasmodic  Wry-Neck  .....  660 
Symptoms,  663  ;  Treatment,  671 

Tetanus  .  .  .  .  .674 

Etiology,    675;  Symptoms,    680;    Pathology,    687;  Diagnosis, 
691 ;  Prognosis,  692  ;   Treatment,  693 

Tetany.  .  .  ...  .  .698 

Symptoms,  701 ;  Pathology,  706  ;  Diagnosis,  707  ;  Prognosis, 
70S  ;  Treatment,  708 
Tetanoid  Chorea  .....     709 

Occupation  Neuroses         .....     710 
Writing  Neuroses :   Writers'  Cramp  .  .  .711 

Symptoms,  715  ;   Pathology,  721  ;  Treatment,  726 
Other  Occupation  Neuroses  .  .  .  .     728 

Epilepsy  ......     730 

Etiology,   731 ;  Symptoms,   734  ;    Pathology,   753  ;    Diagnosis, 
756;  Prognosis,  760  ;   Treatment,  761 


CONTENTS. 


XI 


Convulsions  :  Eclampsia  .  .  . 

Infantile  Convulsions   .  .  , 

Symptoms,  770  ;  Treatment,  772 

Puerperal  Convulsions  .  . 

Symptoms,  774 

Ursemic  Convulsions     .  .  • 

Veetigo  .... 

Ocular  .... 

Aural,  Labyrinthine,  Meniere's  Disease 

-Symptoms,  785  ;  Treatment,  790 
Other  Forms  of  Vertigo 
Astasia-Abasia 

Neuealgia  .... 

Etiology,    795 ;     Symptoms,    798 ;    Varieties,    805  ; 

818  ;  Prognosis,  Treatment,  823 
Visceral  Neuralgias 


page 
768 
769 

773 

776 

777 
782 
782 

792 
794 

794 


Diagnosis, 


Metallic  Poisoning  .  .  .      ■  . 

Lead  Poisoning  . 

Symptoms,  945  ;  Pathological  Anatomy,  955  ;  Diagnosis,  960 ; 
Prognosis,  961 ;  Treatment,  962 
Arsenical  Poisoning      . 

Silver  Poisoning  . 

Mercurial  Poisoning     . 


832 


Migealne  :  Paeoxysmal  Headache  .  .  836 

Symptoms,  838 ;  Pathology,  849 ;  Diagnosis,  852  ;    Prognosis, 
853 ;  Treatment,  854 

Headache  ......     856 

Varieties,  859  ;  Treatment,  862 

Head-Pressure  and  Other  Cephalic  Sensations  .  .     863 

Facial  Hemiatrophy         .....     866 

Exophthalmic  Goitee       .....     871 
Symptoms,  874  ;  Pathology,  885  ;  Diagnosis,   891  ;  Treatment, 
892 

Paealysis  aetee  Acute  Diseases    ....     895 
Typhoid  Fever,  896  ;  Typhus  Fever,  Erysipelas,  897  ;   Variola, 
Measles,    898  ;    Scarlet  Fever,   Mumps,   Malaria,    Diarrhoea, 
Dysentery,  899  ;  Acute  Rheumatism,  Influenza,  900 

Diphtheeitic  Paealysis     .....     903 
Symptoms,  904;  Pathological  Anatomy,  911  ;   Pathology,  914; 
Diagnosis,  917;  Prognosis,  919;  Treatment,  920 

Hydeophobia      ......     922 

Rabies  in  Animals        .....     922 

Babies  in  Man  .....     924 

Symptoms,  926 ;   Pathology,  930  ;  Diagnosis,  936  ;  Prognosis, 
937  ;  Treatment,  938 


942 

943 


963 
967 
968 


xu 


CONTENTS. 


Alcoholism  .  .  . 

Acute  Alcoholism,  Delirium  Tremens 

Symptoms,  973  ;  Pathology,  976  ;  Diagnosis,  977  ;   Prognosis, 
977  ;  Treatment,  978 
Acute  Alcoholic  Insanity  . 

Chronic  Alcoholism      . 

Hysteria  ...... 

Etiology,  984 ;  Sym  >toms,  988  ;    Pathology,  1017  ;    Diagnosis, 
1019  ;  Prognosis,  1021  ;  Treatment,  1022 

Trance  and  Catalepsy 
Induced  Hypnotism 
Catalepsy 

Trance  or  Lethargy 
Narcolepsy     . 
African  Lethargy 

Hypochondriasis 
Neurasthenia 


INDEX 


TAGE 
970 

971 


980 
981 

984 


1030 
1031 
1032 
1034 
1038 
1039 

1040 

1045 

1051 


LIST    OE    ILLUSTRATIONS. 


.Fig.  pagk 

1.  Convolutions  and  Fissures  on  the  outer  surface  of  Right  Hemisphere         3 

2.  „                „                „           inner   (medial)  surface    of    Right 
Hemisphere    .                .                .  .  .3 

3.  Convolutions  within  the  Fissure  of  Sylvius          .  -  .6 
4    Relation  of  the  Convolutions  to  the  Skull            .  .  .7 

5.  Guiding  Lines  of  Reid            .                 .                .  .  .9 

6.  Relations  of  the  Fissures  and  Convolutions  to  the  Guiding  Lines      .         9 

7.  Layers  of  the  Cortex  Cerebri                  .                 .  .  .11 

8.  Human  Brain,  showing  Motor  Centres                   .  .  .15 

9.  10.  Position  of  Cortical  Centre  for  the  Leg           .  .  .17 

11.  „                      „              for  the  Arm          .  .  .18 

12.  „                      „              for  the  Face  and  Tongue     .  .       18 

13.  „          Cortical  Visual  Centres                   .  .  .21 

14.  „          Visual  and  Olfactory  Centres        .  .  .21 

15.  16.  Right  Hemisphere,  Embolism  of  Middle  Cerebral  Artery  (Sharkey)       23 

17.  Lesion  in  Left  Hemisphere  causing  Mind-blindness  .  .       23 

18.  Auditory  Centre  in  First  Temporal  Convolution  .  .  .24 

19.  Motor  Speech  Region  in  Left  Hemisphere            .  .  .25 

20.  Central  Ganglia  and  Internal  Capsule  .                .  .  .26 

21.  Crura  Cerebri          .                 .                 .                 .  .  .27 

22.  Pyramidal  Tract  of  Right  Hemisphere                  .  .  .28 

23.  Course  of  Motor  Tracts           .                .                .  .  .30 

24.  Section  of  the  Crus  (after  Wernicke)    .                 .  .  .30 

25.  Course  of  the  Motor  Tract     .                .                .  .  .31 

26.  Crura  Cerebri          .                 .                .                .  .  .32 

27.  Half  of  a  Section  through  the  Pons       .                 .  .  .33 

28.  Structure  of  the  Medulla  Oblongata      .                 .  .  .35 

29.  Section  through  the  Crus  (after  Wernicke)           .  .  .38 

30.  „       of  Lenticular  Nucleus  and  Internal  Capsule  .  .       41 

31.  Origin  of  Cranial  Nerves  (Henle)           .                 .  .  .43 

32.  Base  of  Skull,  showing  relative  positions  of  Nerves  (Henle)  .       44 

33.  Nerve  Nuclei  of  Medulla  Oblongata      .                 .  .  .45 

34.  Origin  of  Pneumogastric        .                 .                 .  .  .46 

35.  Pons  at  level  of  Glossopharyngeal  Nucleus          .  .  .46 

36.  37.  Origin  of  Auditory  Nerve                 .                 .  •  .48 

38.  Pons  at  level  of  Nuclei  of  Sixth  Nerves                .  *  .50 

39.  Origin  of  Fifth  Nerves           .                 .                 .  .  « .       50 

40.  41.  Nucleus  and  Origin  of  Fourth  Nerves             .  .  .52 


XIV 


LIST    OF    ILLUSTRATIONS. 


Fig. 

42.  Relation  of  Fields  of  Vision,  Retina,  and  Optic  Tracts 

43.  Nuclei  of  Cerebellum 

44.  Blood-supply  to  the  Central  Ganglia  (after  Duret) 

45.  46.  Area  of  Cortex  supplied  by  Anterior  Cerebral  Artery 

47.  Branches  of  Middle  Cerebral  Artery    . 

48.  Area  of  distribution  of  Branches  of  Middle  Cerebral  Artery 

49.  50.  Area  of  Cortex  supplied  by  Posterior  Cerebral  Artery . 

51.  Lesion  of  upper  part  of  Central  Convolutions      . 

52.  Partial  Disease  of  Central  Convolutions 

53.  Softening  in  the  left  side  of  the  Pons 

54.  Degeneration  of  Pyramidal  Tracts 

55.  Bilateral  Degeneration  of  Pyramidal  Tracts 

56.  Disease  of  the  Right  Pre-frontal  Lobe 

57.  Lesion  of  Lenticular  Nucleus,  &c. 

58.  Disease  of  posterior  part  of  Capsule  (Brissaud)   . 

59.  Lesion  of  Pons      .... 
60 — 62.  Voluntary  and  Emotional  Movements  of  the  Face 
63,  64.  Late  Rigidity  in  Hemiplegia 
65,  66.  Post-hemiplegic  Mobile  Spasm 

67.  Mobile  and  Fixed  Spasm 

68.  Probable  Course  of  Fibres  from  Motor  Speech-centre 

69.  Commencing  Optic  Neuritis 

70.  Optic  Neuritis  in  Cerebral  Tumour      . 

71.  Tumour  of  Right  Temporo-sphenoidal  Lobe 

72.  Limitation  of  Right  Field,  Orbital  Neuritis 
73 — 75.  Temporal  Hemianopia  . 

76.  Partial  Nasal  Hemianopia    . 

77.  Right  Hemianopia 

78.  79.  Left  Hemianopia  . 

80.  Partial  Left  Hemianopia 

81.  Partial  Right  Hemianopia   . 

82.  Left  Hemianopia 

83.  Concentric  Restriction  of  Fields  of  Vision 

84.  „  „         of  Field  of  Left  Eye 

85.  „  of  Fields 

86.  Action  of  Elevators  of  Right  ETe 

87.  „        Depressors  of  Right  Eye 

88.  Production  of  Diplopia  by  Erroneous  Projection 

89.  Paralysis  of  Left  External  Rectus 

90.  Paralysis  of  Right  Internal  Rectus 

91.  Diplopia  in  Paralysis  of  Right  Superior  Rectus 

92.  „  „  Inferior  Rectus   . 

93.  „  „  Superior  Oblique 

94.  Partial  Paralysis  of  Left  Third  Nerve 

95.  Paralysis  of  both  Third  Nerves 

96.  .,  Left  Third  Nerve 

97.  98.  Diagram  of  Mechanism  for  the  Movement  of  the  Eyes 
99.  Paralysis  of  the  Sixth  and  Facial  Nerves 

100.  Double  Ptosis       .... 

101.  Piogressive  Opthalmoplegia 


PAGE 

55 
57 
62 
62 
63 
64 
64 
6^ 
68 
69 
70 
70 
70 
72 
72 
72 
79 
83 
86 
87 
114 
133 
134 
145 
147 
148.  149 
149 
151 
151,  152 
153 
154 
154 
158 
159 
160 
169 
169 
173 
177 
178 
178 
178 
179 
180 
181 
182 
187 
188 
192 
197 


LIST   OF    ILLUSTRATIONS. 


XV 


FIG-  PAGE 

102.  Hysterical  Ptosis  ■  ■  .  •  .     201 

103,  104.  Facial  Paralysis  .  235,  238 

105.  Old  Paralysis  of  Eight  Side  of  Face    ....  242 

106.  Aneurism  of  Left  Vertebral  Artery     ....  250 

107.  Superficial  Softening  in  Ascending  Frontal  .  .  251 

108.  Bilateral  Facial  Spasm,  in  woman  aged  Gl  .  .  .  253 

109.  Total  Palsy  of  Vocal  Cords  .  .  .  [■  287 
110  Palsy  of  Left  Vocal  Cord     .                 .                .                .                [  287 

111.  Bilateral  Abductor  Palsy  of  Vocal  Cords             .                .                .  287 

112.  Wasting  of  Tongue               .  303 

113.  Tumour  of  Central  Convolution           ....  309 

114.  Haemorrhage,  causing  Paralysis  of  the  Tongue  and  Face   .                  .  309 

115.  Softening  of  Cortex               .....  311 

116.  Miliary  Aneurisms                 .....  385 

117.  Haemorrhage  into  Pons  .....  395 
118,119.  Meningeal  Haemorrhage  during  Birth  .  .  .417 
120,  121.  Birth  Palsy  of  Left  and  Right  Hemispheres               .                 .  418 

122.  Syphilitic  Disease  of  the  Basilar  and  Vertebral  Arteries     .  .  425 

123.  Embolism  of  Basilar  Artery  and  of  Left  Vertebral  .  .  428 

124.  Section  from  Cortex  of  Frontal  Lobe  in  Exanthematic  Typhus  .  466 

125.  Chronic  Disseminated  Sclerotic  Inflammation  of  Pons        .  .  469 

126.  127.  Abscess  of  Right  Temporal  Lobe  .  .  .  475 
128,  129.  Barker's  Guide  in  Trephining  for  Abscess  from  Ear  Disease  .  487 

130.  Tubercular  Tumour  of  the  Cerebellum  .  .  .    492 

131.  Infiltrating  Glioma  of  Cortex  .  .  „     494 

132.  133.  Infiltrating  Glioma  of  the  Pons  .  .  .  .495 

134.  Glioma  of  the  Pons  ...'•'.     495 

135.  Gliomata  of  Left  Hemisphere  ....     496 

136.  Tumour  compressing  the  Optic  Tract  .  .  .     497 

137.  Cancerous  Growth  in  the  Cortex  ....     498 

138.  Tumour  of  Corpora  Quadrigemina       ....    498 

139.  Growth  from  the  Occipital  Bone  compressing  the  Medulla  .     £ 01 

140.  Tumour  compressing  the  Pons  Varolii  .  .  .     501 

141.  Infiltrating  Tumour  of  the  Right  Frontal  Lobe  .  .502 

142.  Tubercle  in  the  Crus  .  .  .  .  .509 
143    Relations  of  the  Arteries  and  Nerves  at  the  Base  of  the  Brain  .     534 

144.  Insular  Sclerosis  .  .  .  .  .  .545 

145.  Miliary  Sclerosis  of  the  Brain  .  .  .  .562 

146.  Bulbar  Palsy.     Wasting  of  Tongue    .  .  .  .567 

147.  Sudden  Bulbar  Palsy  .  .  .  .  .575 

148.  Paralysis  Agitans  .....     639 

149.  Tracings  of  Various  Forms  of  Tremor  .  .     613 

150.  Paralysis  Agitans,  Posture  of  Hands  ....     645 

151.  „  ,,  Contraction  of  Fingers  .  .  .  6 15 
152—154.  Torticollis    .....             665,  667 

155.  Cramped  Method  of  holding  Pen         .  .  .  .716 

156.  Method  of  holding  Pen  in  Writers'  Cramp  .  .  .716 

157.  Handwriting  in  Writers'  Cramp  and  after  Recovery  .  .     716 

158.  Facial  Hemiatrophy  .....     868 

159.  Facial  Hemiatrophy  (SK-yrme)  ....     869 


XVI  LIST    OF   ILLUSTRATIONS. 

Fig.  page 

160.  Exophthalmic  Goitre  ;  early  stage       ....     875 

161.  „  „         (after  Wilks)      .  .  .  .876 

162.  „  .....     878 

163.  „  „       Acute  Mania        .  .  .  .881 

164.  Diphtheritic  Paralysis ;  Muscular  Fibres  .  ■  .     912 

165.  „  „  Changes  in  the  Anterior  Roots  (Meyer)        .     912 

166.  ,,  „  „  Phrenic  Nerve  (Meyer)         .     913 

167.  „  „  Motor  Nerve-cells  .  .  .914 

168.  Hydrophobia;  Perivascular  Sheath  in  Hypoglossal  Nucleus  .     931 

169.  ,,  Hypoglossal  Nucleus    ....     931 

170.  „  ,,           and  Pneumogastric  Nuclei      .                  .     932 

171.  „  Fibres  of  the  Hypoglossal  Nerve  .  .  932 
172 — 174.  Wrist-drop  from  Lead-poisoning                 .                 .              948.  949 

175.  "  Hysteria  Major  "  ;  First,  or  Epileptoid  Period  (Richer)  .  1004 

176,  177.  „  „  Second  Period  (Clownism)  .,  .  .  1004 
178,  179.  „  „  Third  Period  (Emotional  Attitudes)  (Richer)  .  1005 
180—182.  „            .,            Features  of  the  Attack  (Richer)        .         1006,  1007 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


PART    IV. 
DISEASES    OF    THE    BRAIN. 


INTRODUCTION". 

TEE  STRUCTURE   AND  FUNCTIONS   OF  THE  BRAIN. 

The  knowledge  we  possess  of  the  cerebral  structure  and  functions 
is  derived  from  various  sources.  Simple  dissection  of  the  brain  reveals 
only  the  coarser  outlines  of  its  anatomy,  and  is  apt  to  mislead  the 
investigator  who  endeavours,  by  its  aid  alone,  to  unravel  the  complex 
connection  of  the  several  parts.  By  the  aid  of  the  microscope  the 
structure  of  isolated  portions  can  be  ascertained,  but  the  difficulty 
and  even  impossibility  of  tracing  the  course  of  nerve-fibres,  where 
thousands  interlace,  limits  narrowly  the  results  to  be  obtained  from 
simple  microscopical  examination.  But  the  differentiation  effected  by 
processes  of  degeneration  on  the  one  hand,  and  of  development  on  the 
other,  has  enabled  many  facts  to  be  ascertained  which  are  of  the 
highest  importance,  and  which  must  otherwise  have  remained  unknown. 
The  close  correspondence  between  the  results  obtained  by  these  two 
methods,  the  study  of  development  and  of  degeneration,  not  only 
shows  their  high  value,  but  also  justifies  confidence  in  the  indications 
afforded  by  either,  where  the  two  cannot  be  combined.  The  credit  of 
discovering  the  fact  and  significance  of  secondary  degeneration  belongs 
to  Turck,  and  Flechsig  first  showed  the  value  of  the  structural  indi- 
cations of  development,  by  investigations  which  have  placed  many 
points  in  the  anatomy  of  the  brain  on  a  footing  far  firmer  than  any 
other  method  could  supply.  These  investigations  have  been  ably 
extended  by  Bechterew. 

The  functions  of  the  brain  have  been  ascertained  by  three  methods. 
First,  the  structural  arrangement  of  its  parts  affords  important 
suggestions  as  to  their  function — suggestions  which  are  valuable  in 
proportion  to  the  simplicity  of  the  structure,  and  the  distinctness  of 
its  connections.  For  instance,  a  group  of  nerve-cells  gives  origin  to 
the  fibres  of  a  cranial  nerve,  and  from  this  it  is  inferred  that  the 
VOL.  II.  1 


Z  BRAIN. 

function  of  these  cells  is  to  excite  the  nerve-fibres  if  the  nerve  is 
motor,  or  to  receive  the  impulses  which  traverse  them  if  the  nerve  is 
sensory.  Another  source  of  knowledge  is  the  result  of  experiments 
upon  animals,  in  which  portions  of  the  brain  are  removed,  or  de- 
stroyed, or  stimulated,  and  the  effects  are  observed.  The  results 
obtained  in  this  mauner  by  Hitzig,  Ferrier,  Munk,  and  others,  are 
of  very  great  importance;  so  far  as  the  human  brain  is  concerned 
they  are  suggestive,  often  highly  suggestive,  but  they  are  not  demon- 
strative,  and  the  conclusions  thus  reached  cannot  be  accepted  as 
certainly  true  of  man  except  in  so  far  as  they  receive  confirmation 
from  the  third  source  of  knowledge,  the  experiments  wrought  by- 
processes  of  disease,  by  accidental  violence,  or  surgical  procedure.  It 
is  to  these  that  we  have  to  look  for  exact  knowledge  and  certain  proof 
of  the  functions  of  the  several  parts  of  the  brain  of  man.  Unfortu- 
nately, the  conditions  of  disease  and  injury  are  usually  very  complex, 
and  their  manifestations  are  correspondingly  involved  and  difficult  to 
interpret.  Hence  our  knowledge  grows  but  slowly,  in  spite  of  the 
enormous  amount  of  careful  observation  which,  at  the  present  day,  is 
directed  to  this  subject  in  all  parts  of  the  world. 

The  following  account  of  the  structure  and  functions  of  the  brain 
does  not  profess  to  be  complete,  even  in  outline.  Its  object  is  to 
remind  the  student  of  the  facts  he  most  needs  to  know  in  order  to 
comprehend  the  symptoms  and  pathology  of  disease.  Unfortunately, 
our  knowledge  is  still  imperfect,  even  of  the  fundamental  facts.  Many 
questions  of  great  importance  are  still  unanswered,  while  to  others 
widely  different  answers  have  been  given  by  investigators  of  equal 
competence.  The  statements  here  made  on  such  points  are  the  result 
not  only  of  a  comparison  of  the  work  of  others,  but  also,  in  many 
instances,  of  an  independent  examination  of  the  point  at  issue.  The 
functions  of  the  brain  will  be  considered  very  briefly,  since  many  of 
them  must  be  discussed  more  fully  in  the  account  of  the  symptoms  of 
disease. 

The  few  points  in  the  anatomy  of  the  membranes  which  are  of 
medical  importance  will  be  most  conveniently  considered  in  the  section 
on  their  diseases. 


The  Cerebral  Cortex. 

The  anatomy  of  the  convolutions  of  the  brain  has  become  of  great 
practical  importance,  on  account  of  the  definite  localisation  of  func- 
tion found  to  obtain  in  certain  parts.  For  a  full  account  of  the  con- 
volutions the  reader  is  referred  to  works  on  Anatomy,  but  the  most 
important  facts  may  be  briefly  enumerated.  The  longitudinal  fissure 
separates  the  two  hemispheres.  In  each  half  cf  the  brain  three  fissures 
are  of  leading  importance  (see  Fig.  1),  the  fissures  of  Sylvius  and  of 
Eolando  on  the  outer  surface,  and  the  parietooccipital  fissure,  the 


STRUCTUEE    AND    FUNCTIONS. 


extremity  only  of  which  appears  on  the  convexity.  The  Sylvian 
fissure,  at  the  base,  separates  the  prominent  temporal  lobe  from  the 
orbital  surface  of  the  frontal  lobe,  and,  on  the  outer  surface,  divides 
into  a  very  short  anterior  limb  and  longer  posterior  limb ;  sometimes 


FROlll  L 


Par.OcE] 


L  0  B  £ 


Fig.  1. — Diagram  of  the  convolutions  and  fissures  on  the  outer  surface  of  the 
right  hemisphere.     The  fissures  are  indicated  by  italics. 

there  are  two  short  limbs,  one  anterior  and  the  other  vertical  (see 
Tigs.  1  and  3).  The  posterior  limb  separates  the  temporal  lobe  below 
from  the  parietal  lobe  above.     Just  above  the  bifurcation  of  the  fissure 


o_B^ 


F.  Tlclavdo 


TEMP 


Fig.  2. — Diagram  of  the  convolutions  and  fissures  on  the  inner  (medial) 
surface  of  the  right  hemisphere. 


of  Sylvius,  but  not  joining  it,  is  the  lower  extremity  of  the  fissure  of 
Rolando,  or  central  sulcus,  which  passes  upwards  and  backwards  to  the 


4  BRAIN. 

longitudinal  fissure,  and  separates  the  frontal  from  the  parietal  lobe. 
It  presents  in  its  course  two  bends,  the  superior  and  inferior  genu,  of 
which  the  latter,  roughly  speaking  opposite  the  upper  part  of  the 
middle  frontal  convolution,  is  an  important,  landmark.  The  parieto- 
occipital fissure  begins  at  the  longitudinal  fissure,  about  midway 
between  the  upper  end  of  the  fissure  of  Rolando  and  the  posterior 
extremity  of  the  hemisphere.  It  is  better  marked  on  the  medial 
than  on  the  outer  surface  of  the  hemisphere  ;  on  the  latter  it  extends 
only  for  a  short  distance  from  the  longitudinal  fissure.  It  marks  the 
boundary  between  the  parietal  and  occipital  lobes.  These  three 
fissures  are  the  chief  landmarks  on  the  outer  surface,  and  are  our 
guides  in  identifying  the  various  convolutions.  On  the  inner  or 
medial  aspect  (Fig.  2)  the  parieto-occipital  fissure,  at  its  lower  ex- 
tremity, joins  another  sulcus  which  extends  backwards  to  the  posterior 
extremity  of  the  brain,  the  calcarine  fissure,  and  the  two  bound  a 
wedge-shaped  area,  the  cunens.  In  the  anterior  half  of  this  inner 
surface,  the  calloso-marginal  fissure  runs  parallel  with  the  corpus  cal- 
losum,  midway  between  it  and  the  edge  of  the  hemisphere,  to  which 
the  posterior  extremity  of  this  fissure  turns  up,  behind  the  upper  end 
of  the  fissure  of  Rolando.  Between  this  upcurved  end  and  the  cuneus 
is  an  area  termed  the  pre-cuneus,  or,  from  its  shape,  the  quadrate 
lobule. 

The  fissure  of  Rolando  runs  between  two  convolutions  which  have 
the  same  direction  as  the  fissure.  These  are  the  ascending  frontal  and 
ascending  parietal  convolutions.  These  two  gyri  are  of  great  impor- 
tance, because  they  contain  the  chief  so-called  "motor"  centres^ 
They  are  sometimes  termed  the  "central  convolutions,"  "anterior" 
and  "  posterior."  They  unite  below  the  lower  end  of  the  fissure  of 
Rolando,  and  the  region  that  occupies  the  bifurcation  of  the  fissure  of 
Sylvius  is  often  termed  the  "  operculum."  The  ascending  frontal 
is  bounded  by  the  pre-central  sulcus,  usually  interrupted  by  the  origin 
of  one  or  two  of  the  remaining  frontal  convolutions,  topper,  middle,. 
and  lower ;  or  first,  second,  and  third.  The  highest  is  at  the  margin 
of  the  longitudinal  fissure ;  the  lowest  curves  round  the  anterior  limb 
of  the  fissure  of  Sylvius.  The  upper  part  of  the  ascending  parietal 
convolution  blends  with  the  upper  part  of  the  parietal  lobe  in  the 
superior  parietal  lobule,  also  called  the  parietal  lobule  ;  this  also  forms 
part  of  the  motor  region,  and  so  does  the  medial  aspect  of  these  two 
central  convolutions,  the  paracentral  lobule,  it  is  termed,  in  front  of  the 
upcurved  end  of  the  calloso-marginal  fissure.  The  lower  part  of  the 
parietal  lobe,  behind  the  ascending  parietal  convolution,  is  termed  the 
inferior  parietal  lobule,  and  is  separated  from  the  superior  lobule  by 
the  interparietal,  also  called  the  intraparietal,  fissure. 

The  lowest  parietal  convolution,  which  bounds,  above,  the  posterior 
limb  of  the  fissure  of  Sylvius,  is  termed  the  supra-marginal  convolu- 
tion. In  some  brains  this  constitutes  almost  the  whole  of  the  inferior 
parietal  lobule.     By  some  authorities  (Turner,  &c.)  the  supra-marginal 


STRUCTURE    AND    FUNCTIONS.  5 

gyrus  is  regarded  as  ceasing  above  the  extremity  of  the  upturned  end 
of  the  fissure  of  Sylvius  ;  by  others  it  is  regarded  as  passing  round 
this,  so  that  the  gyrus  immediately  behind  the  upturned  portion  of 
the  fissure  is  included  in  the  name.  Behind  this  upturned  fissure  is 
the  angular  gyrus,  which  extends  back  to  the  occipital  lobe,  upwards 
to  the  intra-parietal  sulcus,  and  downwards  is  continuous  with  the  first 
and  second  temporal  convolutions.  Its  posterior  limit  is  somewhat 
arbitrary,  corresponding  to  a  line  drawn  across  from  the  parieto- 
occipital fissure.  Its  anterior  limit  varies  according  to  the  area 
assigned  to  the  supra-marginal  convolution.* 

The  convolutions  passing  from  the  parietal  to  the  occipital  lobes  on 
the  outer  surface  are  called  "  annectant ;"  the  highest  of  these  is  at 
the  outer  extremity  of  the  short  parieto-occipital  fissure. 

In  the  occipital  lobe  three  short  convolutions  may  often  be  distin- 
guished,— upper,  middle,  and  lower.  The  upper  one  is  continuous  with 
the  superior  parietal  lobule  by  the  first  annectant  gyrus.  These  occipital 
convolutions  are  often  not  distinctly  separate.  In  the  temporal  lobe 
two  or  three  antero-posterior  convolutions  can  be  distinguished  on  the 
outer  surface.  Of  these  the  upper,  or  first,  forms  the  inferior  boundary 
to  the  fissure  of  Sylvius,  and  is  continuous  behind  with  the  supra- 
marginal  or  the  angular  convolution,  or  with  both,  according  to  the 
sense  in  which  these  words  are  used.  The  fissure  below  this  convolution 
is  termed  the  parallel  fissure,  because  it  is  parallel  with  the  fissure  of 
•Sylvius.  The  lower  convolution  or  convolutions  (if  two  can  be  dis- 
tinguished) are  continuous  with  the  occipital  lobe. 

On  the  medial  surface  of  the  temporal  lobe  (Fig.  2)  two  or  three 
similar  convolutions  are  visible ;  and  of  these  the  upper  one  is  the 
uncinate  gyrus,  so  called  because  its  anterior  extremity  is  shaped  like 

*  The  importance  attached  to  the  angular  convolution  renders  it  desirable  to 
point  out  the  different  senses  in  which  the  word  is  used.  The  term  was  taken  from 
the  "pli  courbe  "  of  Gratiolet,  applied  by  him  to  the  convolution  in  the  brain  of  the 
ape  which  winds  round  the  top  of  the  fissure  of  Sylvius,  and,  as  a  simple  gyrus,  is 
limited  behind  by  the  parieto-occipital  fissure,  which  extends,  in  the  ape's  brain,  far  on 
the  outer  surface  of  the  hemisphere.  But  in  applying  the  term  to  the  more  complex 
brain  of  man,  Gratiolet  restricted  it  to  the  posterior  part  of  the  region  between  the 
extremity  of  the  fissure  of  Sylvius  and  the  occipital  lobe.  The  term  is  now  used  in 
four  senses.  (1)  The  whole  region  from  the  end  of  the  fissure  of  Sylvius  to  the 
occipital  lobe.  (2)  The  posterior  two  thirds  of  this  region,  a  small  sulcus,  parallel 
with  the  upturned  fissure  of  Sylvius,  being  taken  as  the  anterior  limit  of  the  angular 
and  posterior  limit  of  the  supra-marginal,  which  is  thus  regarded  as  passing  round  the 
fissure  of  Sylvius.  In  this  sense  the  parallel  fissure  passes  into  the  angular  gyrus. 
(3)  The  posterior  third  of  this  region;  the  anterior  limit  being  the  parallel  fissure, 
to  which  the  supra-marginal  will  then  extend.  (4)  The  term  is  sometimes  used  (and 
the  corresponding  "pli  courbe"  by  French  writers)  to  include  not  only  the  whole  of 
this  region,  but  also  that  part  of  the  supra-marginal  gyrus  which  lies  in  front  of  the 
«xtremity  of  the  fissure  of  Sylvius.  This  makes  it  correspond  to  the  whole  region 
into  which  the  pli  courbe  of  the  ape  has  developed  in  the  human  brain;  but  it  is 
inconsistent  with  the  application  of  the  word  to  the  human  brain  by  Gratiolet  himself 
and  most  other  authorities. 


6  BRAIN. 

a  hook.  Beneath  the  calcarine  fissure  is  the  lingual  gyrus.  In  the  rest 
of  the  medial  surface  the  gyrus  fornicatus  lies  next  to  the  corpus 
callosum,  but  only  constitutes  a  well-marked  convolution  in  the  ante- 
rior half  of  the  brain,  where  the  calloso-marginal  fissure  separates  it 
from  the  marginal  convolution,  which  is,  for  the  most  part,  the  medial 
aspect  of  the  highest  frontal  convolution.  The  other  divisions  of  the 
medial  surface  have  been  already  enumerated.  Within  the  fissure 
of  Sylvius  lie  the  small  convolutions  of  the  island  of  Reil,  or  insula 
(Fig.  3),  four  or  five  in  number  (i  to  v,  Fig.  3),  which  spread  out  like  a 
fan.  Behind  the  insula,  but  still  entirely  within  the  fissure  of  Sylvius, 
two  or  three  convolutions  connect  the  first  temporal 'with  the  parietal 
lobe.  They  have  been  termed  the  retro-insular  or  temporoparietal  convo- 
lutions (r  i,  Fig.  3).  Neither  these  convolutions  nor  those  of  the  insula 


':■>:.  ORB  ITAU 


'•~~^<^- 


FiG.  3. — Convolutions  within  the  fissure  of  Sylvius.  F  S  a  its  anterior 
and  F  S  v  its  vertical,  and  F  S  p  the  extremity  of  its  posterior  limb. 
I — v,  the  short  gvri  of  the  insula  ;  R  I,  retro-insular  convolutions 
connecting  the  temporal  and  parietal  lobes. 

are  visible  until  the  lips  of  the  Sylvian  fissure  are  separated.  Hence 
they  often  escape  examination,  and  this  is  probably  one  reason  why 
little  is  known  of  the  effect  of  their  isolated  disease.  It  will  be 
observed  that  the  boundary  between  the  frontal  and  parietal  Lobes  also 
separates  the  two  "  ascending  "  convolutions,  which  have  been  found 
to  have  functions  at  once  similar,  important,  and  unlike  those  of  most 
other  parts  of  the  brain.  Hence  it  is  often  convenient  to  distinguish 
that  part  of  the  frontal  lobe  which  lies  in  front  of  the  ascending  con- 
volution as  the  "  pre-frontal  lobe." 

Relation"  of  the  Cortex  to  the  Skull. — The  correspondence 
between  certain  parts  of  the  surface  of  the  brain  and  of  the  skull  has 
been  carefully  investigated,  especially  by  Broca,  Kefftler,  Turner,. 
Championniere,  Fere,  Hare,  Poirier,  Le  Fort,  Reid,  Horsley,  and 
Cunningham,  and  rules  have  been  formulated  by  which  the  position 


STRUCTURE    AND    FUNCTIONS.  7 

of  the  various  fissures  and  convolutions  may  he  determined.  The 
general  relation  of  the  brain  to  the  bones  of  the  skull  is  shown  in  Fig,  4. 
It  presents  some  degree  of  variation  in  different  individuals,*  but  this 
is  seldom  enough  to  have  been  found  important.  Beneath  the  frontal 
bone  lies  nearly  all  the  lowest  frontal,  five  sixths  of  the  middle,  and 
about  three  quarters  of  the  upper  frontal  convolutions.  The  temporal 
bone  covers  the  temporal  lobe  except  its  posterior  fifth  and  anterior 
extremity.  The  major  part  of  the  occipital  lobe  lies  under  the  occipital 
bone.     The  rest  of  the  cerebral  cortex  lies  beneath  the  parietal  bone. 


33J- 


Fig.  4. — Dingram  of  the  relation  of  the  convolutions  to  the  skull. 
F  1,  2,  and  3,  upper,  middle,  and  lower  frontal  convolutions;  A  F,  AP, 
ascending  frontal  and  parietal ;  S  P,  sup.  parietal  lobule ;  Ang, 
angular  gyrus;  Oc  L,  occipital  lobe;  T  1,  2,  3,  the  temporal  convo- 
lutions ;  P  0  F,  parieto-otcipital  fissure ;  F  Sy  and  F  Sy  P,  fissure 
of  Sylvius  and  its  posterior  lirnb.f 


Horsley's  Rules. — My  colleague,  Professor  Victor  Horsley,  who  has  had  so 
much  practical  experience  in  the  surgery  of  the  brain,  employs  a-  method  of 
finding  the  position  of  the  important  centres  of  the  brain,  of  which  he  has 
published  an  account  in  the  '  International  Journal  of  Medical  Science '  for 
April,  1887.     From  this  the  following  abstract  is  taken : 

The  chief  landmarks  on  the  surface  of  the  skull  are  (1)  the  parietal  eminence 
and  (2)  the  curved  temporal  ridge,  which  is  really  double ;  a  lower  one  which  is 
best  marked  and  limits  the  attachment  of  the  temporal  muscle,  and  an  upper  one 
to  which  the  temporal  fascia  is  attached.  The  lower  one  can  be  best  found  by 
making  the  patient  contract  the  muscle  firmly  ;  the  upper  one  marks  the  sudden 

*  See  Anderson  and  Makins,  (  Journ.  Anat.  and  Phys.,'  1889. 
t  In  this  figure  the  highest  part  of  the  parieto-occipital  fissure  should  be  repre- 
sented as  lying  at  or  a  little  above  the  apex  of  the  famMnidal  suture. 


8  BKAIN. 

change  in  the  slope  of  the  skull  to  the  vertical  direction.  (3)  The  coronal  suture, 
which  can  generally  be  felt  just  above  the  place  where  the  temporal  ridge  crosses 
it  (this  crossing  is  termed  by  Broca  the  stepbanion).  If  the  upper  part  cannot 
be  felt,  its  position  can  be  ascertained  by  finding  its  junction  with  the  sagittal 
suture. 

The  parieto-squamosal  suture  lies  beneath  the  temporal  muscle  :  the  highest 
point  of  its  curve  is  in  a  vertical  line  passing  just  in  front  of  the  articulation  of 
the  lower  jaw,  and  it  is  there  two  thirds  of  the  distance  from  the  zygoma  to  the 
temporal  ridge. 

The  short  junction  of  the  anterior  inferior  corner  of  the  parietal  bone  with 
the  wing  of  the  sphenoid  (corresponding  nearly  to  the  division  of  the  Sylvian 
fissure)  is  about  halfway  between  the  stephanion  and  the  upper  border  of  the 
zygoma.  This  junction,  the  pterion  of  Broca,  is  shaped  like  an  H>  the  hori- 
zontal bar  of  which  corresponds  to  the  upper  border  of  the  sphenoidal  wing, 
and  it  is  opposite  the  hinder  end  of  the  same  that  the  division  point  of  the 
fissure  of  Sylvius  lies. 

The  upper  end  of  the  fissure  of  Bolando  is  best  found  by  the  plan  of 
Professor  Thane.  Measure  the  distance  along  the  middle  line  from  the  root  of 
the  nose  to  the  occipital  protuberance,  and  find  the  middle  point  of  this  distance  ; 
half  an  inch  behind  this  point  is  the  upper  extremity  of  the  fissure  of  Bolando. 
The  fissure  makes  an  angle  with  the  middle  line  of  67°.  Professor  Horsley 
used  at  first  a  long  strip  of  soft  metal,  from  which  projects  another  piece  at  this 
an°de.  When  this  strip  is  laid  along  the  middle  line  of  the  head,  with  the 
junction  of  the  two  parts  over  the  spot  mentioned,  the  arm  corresponds  in  direc- 
tion to  that  of  the  upper  two  thirds  of  the  fissure  of  Bolando.  In  its  lower 
third  the  fissure  is  rather  more  vertical. 

Dr.  Claud  "Wilson  subsequently  slightly  modified  Mr.  Horsley's  instrument, 
60  that  it  consisted  of  two  pieces,  one  at  a  fixed  angle  of  67°  to  the  other,  but 
movable.  Further,  it  was  marked  off  into  two  series  of  divisions,  the  posterior 
series,  corresponding  to  the  occipital  protuberance,  being  lettered  with  capital 
letters,  the  anterior  being  lettered  with  the  same  letters  small.  With  one  of  the 
capital  letters,  e.  g.  B,  over  the  occipital  protuberance,  the  corresponding  small 
letter  marked  the  situation  in  the  particular  case  of  the  upper  end  of  the  fissure 
of  Bolando,  and  on  running  the  movable  limb  along  the  horizontal  one  the 
former  corresponded  in  situation  and  direction  with  that  sulcus. 

Mr.  Horsley  has  introduced  more  recently  an  important  modification  of  this 
instrument.  From  measurements  made  on  a  series  of  specimens  prepared  by 
Professor  Cunningham  of  Dublin,  he  found  that  the  direction  of  the  fissure  of 
Bolando  had  apparently  a  definite  relation  to  the  relative  breadth  of  the  head. 
Thus  in  a  dolicho-cephalic  individual  the  angle  formed  by  the  fissure  of 
Bolando  with  the  longitudinal  fissure  was  acute,  while  in  the  brachy-cephalic, 
on  the  other  hand,  it  more  and  more  nearly  became  a  right  angle.  Such  varia- 
tions must  of  course  be  provided  for  if  accuracy  is  to  be  attained  in  surgical 
procedure,  and  Mr.  Horsley  now  uses  an  instrument  in  which  the  limb, 
marking  out  the  fissure  of  Bolando,  can  be  placed  at  a  varying  angle  and  fixed 
goniometrically  to  the  limb  which  corresponds  to  the  longitudinal  fissure.  The 
variation  cf  this  angle  depends  upon  the  character  of  the  skull,  whether 
dolicho-cephalic  or  brachy-cephalic,  and  a  measure  of  this  is  obtained  by  taking 
the  cephalic  index  in  the  manner  which  has  been  made  familiar  by  anthro- 
pometric observations. 

Th^  anterior  limb  of  the  fissure  of  Sylvius  runs  upwards  from  the  parieto- 
sphenoidal  junction  above  mentioned.     The  posterior  limb  passes  backwards 


STRUCTURE    AND    FUNCTIONS. 


9 


and  upwards  just  above  the  ascending  part  of  the  parieto-temporal  suture,  and 
from  the  highest  part  of  this  it  curves  upwards  towards  the  centre  of  the 
parietal  eminence.     This  is  only  true  for  the  adult. 

The  lower  half  of  the  pre-central  sulcus  is  parallel  to  and  behind  the  coronal 
suture.  The  interparietal  sulcus  lies,  in  its  ascending  part,  midway  between 
the  line  of  the  fissure  of  Eolando  and  the  parietal  eminence,  and  then  passes 
backwards  midway  between  the  latter  and  the  middle  line  of  the  skull. 

The  ascending  frontal  convolution  begins  below  beneath  the  anterior  inferior 
angle  of  the  parietal  bone,  in  front  of  the  prolonged  line  of  the  fissure  of 
Eolando,  between  this  and  the  prolonged  line  of  the  lower  part  of  the  pre-central 
sulcus  ;  in  front  of  the  latter  will  be  the  root  of  the  lower  frontal ;  behind  the 
ascending  frontal,  the  root  of  the  ascending  parietal.* 

Ileid's  Rules. — The  most  important  of  Reid's  rules  are  the  following:  some 
additions  are  enclosed  in  brackets.  As  a  base  is  taken  a  line  running  from 
the  inferior  margin  of  the  orbit  (Fig.  5)  through  the  middle  of  the  auditory 
meatus.  The  posterior  limit  of  the  fissure  of  Sylvius  lies  beneath  the  hinder 
three  fifths  of  a  line  drawn  from  the  external  angular  process  of  the  frontal 
bone  to  a  point  three  quarters  of  an  inch  below  the  most  prominent  part  of  the 
parietal  bone  (this  may  be  termed  the  Sylvian  line).     The  anterior  limb  of  the 


Fig.  5. — Guiding  lines  of  Eeid. 


Fig.  6. — Relations  of  the  fissures  and  con- 
volutions to  the  guiding  lines,  f 


fissure  ascends  from  this  line  above  the  middle  of  the  zygoma.  The  temporal 
ridge  corresponds  nearly  to  the  fissure  between  the  middle  and  lowest  frontal 
convolutions.  If  the  Sylvian  line  is  prolonged  to  the  sagittal  suture,  it  will 
give  the  position  of  the  parietooccipital  fissure  (and  the  occipital  lobe,  half -vision 
centre,  lies  between  this  and  the  base  line).     A  perpendicular  from  the  base  line, 


*  On  this  subject.  Professor  Horsley  has  recently  contributed  a  chapter  in  Pro- 
fessor Cunningham's  memoir  on  "  The  Surface  Anatomy  of  the  Primate  Cerebrum  " 
(Cunningham  Memoir  VII,  Royal  Irish  Acad.,  1892).  To  this  reference  may  be 
trade  for  further  details. 

f  I  am  indebted  to  Professor  Reid  for  permission  to  reproduce  these  figures. 


10  BKAIN. 

at  the  depression  in  front  of  the  auditory  meatus,  cuts  the  Sylvian  line  where 
the  fissure  of  Rolando,  if  prolonged"  would  join  the  Sylvian  fissure,  and  the 
position  of  the  fissure  of  Rolando  is  under  a  line  drawn  from  this  point  to  the 
place  at  which  the  sagittal  suture  is  cut  hy  a  perpendicular  drawn  to  the  hase  line 
drawn  from  the  posterior  border  of  the  mastoid  process.  The  central  convolu- 
tions occupy  about  an  inch  on  each  side  of  the  Rolandic  line.  The  position  of 
the  centres  for  the  leg,  arm,  and  face  can  thus  readily  be  ascertained,  since  they 
lie  on  each  side  of  the  fissure  of  Rolando.  The  angular  gyrus  lies  immediately 
behind  the  most  prominent  part  of  the  parietal  eminence.  The  first  temporal 
convolution  lies  below  the  Sylvian  line,  over  the  ear  and  mastoid  process. 

Structure  of  the  Cortex.— The  nerve-fibres  of  the  white  substance  radiate 
into  the  cortex,  passing  between  the  nerve-cells,  and  in  places  separating  these 
into  vertical  groups.  The  cells  are  of  various  forms  and  sizes,  certain  of  which 
predominate  at  different  depths  from  the  surface,  thus  permitting  a  distinction 
into  layers.  Each  layer  contains  many  kinds  of  cells,  but  those  which  are  in 
greatest  number  give  to  the  layer  its  distinctive  character.  Considerable  varia- 
tions exist  in  different  parts  of  the  brain  in  the  number,  characters,  and  relative 
thickness  of  the  layers,  and  their  precise  division  has  been  the  subject  of  much 
discussion.*  There  is  especially  a  marked  difference  between  the  characters  of 
the  cortex  in  the  central  convolutions  (ascending  frontal,  ascending  parietal, 
and  paracentral  lobule)  and  in  the  rest  of  the  outer  surface  of  the  hemisphere. 
It  may  be  said  generally  that  the  three  layers  next  the  surface  present  nearly 
the  same  characters  over  the  greater  part  of  the  cortex,  varying,  however,  in 
thickness.  The  deepest  layer,  next  the  white  substance,  is  also  very  uniform  in 
its  character  ;  the  chief  variations  are  in  the  elements  which  intervene  between 
the  three  superficial  layers  and  the  deepest  layer. 

In  the  central  convolutions  (as  the  ascending  frontal)  the  layers  present  the 
cell-forms  shown  in  the  first  column  in  Fig.  7.  Above,  next  the  surface,  is  a 
narrow  superficial  layer  containing  few  cells,  and  those  of  doubtful  nature, 
chiefly  small  corpuscles,  more  or  less  rounded.  Similar  corpuscles  are  also 
scattered  through  all  the  layers.  This  superficial  stratum  contains  also  many 
delicate  nerve-fibres  (Remak,  Lockhart  Clarke,  Exner).  Beneath  this  is  a  layer 
of  smcdl  pyramidal  cells  densely  massed,  with  a  few  nuclear  elements.  The 
cells  have  the  apex  of  the  pyramid  turned  towards  the  surface.  The  next  layer 
is  composed  of  large  pyramidal  cells,  less  densely  massed,  and  paitially  sepa- 
rated into  columns  by  the  bundles  of  nerve-fibres.  The  cells  in  the  upper  part 
of  the  layer  are  little  larger  than  those  of  the  second  layer,  but  they  increase  in 
size  in  the  deeper  parts.  The  apex  of  each  is  turned  towards  the  surface,  and 
from  it  a  long  process  may  be  traced.  From  the  centre  of  the  base  another 
process  extends,  continuous,  it  is  said,  with  the  axis-cylinder  of  a  nerve-fibre, 
while  from  the  angles  blanching  processes  are  given  off.  The  small  pyramidal 
cells  occur  also,  in  fewer  number,  throughout  this  layer,  and  at  some  parts  of 
the  brain  they  are  more  numerous  in  the  deepest  part  of  the  layer.  The  next 
layer  is  characterised  by  nerve-cells  which  are  irregular  in  shape,  and  often 
triangular.  Many  of  them  resemble  the  motor  nerve-cells  of  the  spinal  cord, 
and  hence  it  has  been  proposed  by  Bevan  Lewis  to  call  this  layer  the  ganglion- 
cell  layer.     The  cells  vary  much  in  size.     Some  are  small  angular  elements,  the 

*  They  were  studied  first  by  Baillarger,  thirty  years  ago;  subsequently  by 
Lockhart  Clarke,  Meynert.  and  others;  and,  more  recently,  they  have  been  investi- 
gated with  much  care  by  Betz,  Bevan  Lewis,  Golgi,  Kolliker,  and  Ramon  y  Cajal. 


STRUCTURE    AND    FUNCTIONS. 


11 


size  of  the  small  pyramidal  cells 
of  the  second  layer  ;  others  are  as 
large  as  the  large  pyramidal  cells 
of  the  third  layer  ;-but  both  differ 
from  the  cells  of  the  second  and 
third  layer  in  being  very  rarely 
distinctly  pyramidal  in  form,  and 
in  being  less  regularly  placed. 
Moreover  in  this  layer  some  cells 
are  met  with  which  exceed  the 
size  of  the  largest  pyramidal  cells ; 
some  are  even  three  times  the 
size  of  the  latter.  These  are  the 
"  giant-cells  "  of  Betz,  and  were 
once  regarded  as  pathological,  but 
every  gradation  is  seen  between 
them  and  the  ordinary  ganglion- 
cells  of  the  layer.  The  largest 
cells  occur  in  groups  of  two  to 
five,  and  are  almost  confined  to 
the  central  region ;  while  the 
smaller  ganglion-cells  of  this 
layer  are  met  with  over  the 
greater  part  of  the  surface  of  the 
brain.  Beneath  this  stratum  is 
a  layer  in  which,  with  a  few 
angular  cells,  there  are  many 
fusiform  cells.  Hence  it  is  called 
the  spindle-cell  layer.  It.  is  the 
deepest  layer  of  the  cortex,  and 
beneath  it  is  the  white  substance 
of  the  hemisphere,  among  the 
fibres  of  which  are  many  nuclei 
and  a  few  angular  and  spindle- 
cells,  especiall}7  near  the  cortex. 
Thus  the  type  here  is  five  lami- 
nated. 

In  the  region  of  the  brain 
behind  the  central  convolutions 
(and  also  in  the  anterior  part  of 
the  frontal  lobe)  the  structure  of 
the  cortex  more  or  less  resembles 
that  shown  in  the  second  section 
in  Fig.  7,  which  is  from  the  first 
annectant  gyrus.  It  will  be  seen 
that  the  first  three  layers,  super- 
ficial, small  pyramid,  and  large 
pyramid  layers,  closely  resemble 
those  of  the  other  section,  and  so 
also  does  the  deepest  or  spindle- 
celled  layer.  The  ganglion-cell 
layer  is  rather  narrow,  and  con- 


JstxnJiy  Frontal  Tirst  Annectant 


Large  Pyramid 
Layer 


ill 


Fig.  7. —  Diagrammatic  sketch  of  the  layers, 
of  the  cortex  cerebri.  The  drawings  were 
made  from  sections  of  the  ascending  frontal 
and  first  annectant  convolutions  (the  latter 
near  the  extremity  of  the  parieto-occipital 
fissure).  The  sections  were  kindly  furnished 
me,  as  representative  of  the  so-called  motor 
and  sensory  types,  by  Dr.  Bevan  Lewis. 


12  BRAIN. 

tains  no  very  large  cells.  Above  it,  and  between  it  and  tbe  large  pyramid 
layer,  is  a  stratum  of  small  round  or  angular  granule-like  elements  with  a  few 
rather  larger,  but  still  small,  angular  cells.  It  has  been  called  the  granule 
layer.  At  the  extremity  of  the  occipital  lobe  this  granule  layer  is  considerably 
larger,  and  the  pyramidal  cells  are  much  less  developed,  while  in  the  cornu 
ammonis  the  latter  are  alone  found.  The  claustrum  is  composed  of  fusiform 
cells,  and  hence  is  regarded  as  a  detached  part  of  the  deepest  layer. 

We  can  merely  surmise  the  functional  significance  of  the  several  varieties  of 
cells.  It  is  important  to  note  that  the  transition  from  one  type  of  structure  to 
another  is  everywhere  gradual,  and  that  (with  the  exception  of  the  very  large 
ganglion-cells)  each  form  of  cell  can  be  found  in  almost  all  parts  of  the  brain. 
The  localisation  of  the  largest  ganglion-cells  in  the  so-called  motor  regions,  and 
the  analogy  between  these  and  the  motor  cells  of  the  cord,  make  it  highly  pro- 
bable that  they  are  motor  in  function.  It  has  been  conjectured  that  the  large 
pyramidal  cells  are  also  motor,  but  from  the  wide  extent  of  this  formation  it  is 
possible  that  the  function  of  these  cells  varies  according  to  their  connections. 
The  preponderance  of  the  granule-cells  at  the  posterior  portion  of  the  brain,  and 
their  similarity  to  the  cells  of  the  posterior  cornu  of  the  spinal  cord,  has  sug- 
gested that  they  are  sensory  in  function. 

Functional  Regions  of  the  Cortex. — Doubt  was  formerly  enter- 
tained as  to  the  existence  of  differentiation  of  function  in  different 
parts  of  the  cortex,  but  recent  researches  have  established  the  existence 
of  a  differentiation  which  has  almost  revolutionised  cerebral  physiology, 
and  has  vastly  extended  the  range  of  cerebral  diagnosis.  The  first 
step  of  the  new  discovery  was  constituted  by  the  clinical  and  patho- 
logical investigations  of  Hughlings  Jackson,  which  suggested  the 
existence,  on  each  side  of  the  fissure  of  .Rolando,  of  special  centres 
for  the  movements  of  the  leg,  arm,  and  face.  In  Germany,  Hitzig 
and  Fritsch  discovered  experimentally  that  the  cortex  cerebri  was 
•excitable  by  artificial  stimulation,  and  they  succeeded  in  mapping  out 
in  the  dog  the  centres  for  the  movements  of  the  limbs  and  head. 
These  observations  led  to  the  experiments  of  Ferrier,  which  resulted 
in  the  demonstration  of  the  existence  in  the  cortex  of  the  lower 
animals  of  well-defined  regions,  stimulation  of  which  caused  separate 
movements,  or  evidence  of  special  sense  excitation,  while  the  destruc- 
tion of  the  same  parts  caused  indications  of  a  loss  of  the  correspond- 
ing function.  Hence  he  came  to  the  conclusion  that  these  regions 
■constitute  actual  motor  and  sensory  centres.  Many  other  investiga- 
tions of  the  same  character  have  since  been  made,  of  which  those  of 
Munk  are  especially  important.  The  original  observations  of 
Hughlings  Jackson  left  little  doubt  that  the  general  facts,  learned 
from  experiments  on  animals,  are  true  of  man ;  and  this  conclusion 
has  been  to  a  large  extent  confirmed  by  pathological  and  clinical 
observations  directed  to  the  verification  on  man  of  the  experimental 
results.  To  this  verification  the  labours  of  Charcot  and  his 
coadjutors  have  largely  contributed.  But  the  verification  has  already 
made  it  probable  that  some  differences  exist  between  the  brain  of 
man  and  of   other  animals  (even  of  monkeys),  and  that  the  con- 


STEUOTUBB    AB    FUNCTIONS.  13 

elusions    from    the    latter    cannot    be    simply   transferred    to    the 
former. 

Cortical  Centres  in  tke  Monkey. — Before  considering  the  indications 
of  the  position  of  the  various  centres  in  the  cortex  of  the  human  brain,  it  may 
he  well  to  enumerate  the  chief  functional  regions  ascertained  by  Ferrier  and 
others  in  the  brain  of  the  monkey. 

Motor  Centres. — Superior  parietal  lobule  (except  the  part  adjacent  to 
the  fissure  of  Rolando) :  movement  of  the  leg  and  foot,  flexion  of  the  hip, 
extension  of  the  knee,  flexion  of  the  ankle. 

Highest  and  adjacent  parts  of  the  ascending  frontal  and  parietal  convolu- 
tions, close  to  the  margin  of  the  hemisphere,  together  with  the  root  of  first 
frontal:  flexion  and  outward  rotation  of  thigh,  rotation  inwards  of  leg,  flexion 
of  toes,  as  in  scratching  abdomen  with  foot.  (Horsley  and  Schafer*  obtained 
movements  of  the  leg  also  from  the  medial  aspect  of  the  convolutions  on  each 
side  oE  the  extremity  of  the  fissure  of  Rolando.  Horsley  and  Beevor  found 
movement  of  the  great  toe  chiefly  represented  in  the  upper  extremity  of  the 
ascending  frontal,  and  of  the  small  toes  at  the  extreme  posterior  part  of  the 
parietal  lobule.) 

Adjacent  parts  of  ascending  frontal  and  parietal,  outside  the  last  centre  but 
still  opposite  the  highest  frontal  convolution :  adduction  and  extension  of  arm, 
pronation  of  hand. 

Ascending  frontal  and  base  of  the  highest  frontal :  extension  of  elbow, 
movement  forwards  at  shoulder,  and  synchronous  movement  of  leg.  (Horsley 
and  Schafer  obtained  movements  of  the  arm  from  the  medial  aspect  of  the 
posterior  half  of  the  highest  frontal.) 

Ascending  frontal,  opposite  upper  part  of  middle  frontal :  supination  of 
hand  and  flexion  of  forearm. 

Middle  three  fifths  of  ascending  parietal :  movements  of  hand,  especially 
clenching  of  fist.f 

The  arm  area  in  the  monkey  is  separated  from  the  leg  area  by  a  small  but 
constant  sulcus  which  is  believed  to  correspond  to  the  superior  pre-central  sulcus 
in  man.  The  lower  limit  is  a  horizontal  line  drawn  from  the  extremity  of  the 
intra-parietal  sulcus  passing  through  the  inferior  genu  of  the  fissure  of  Rolando. 
The  same  relation  is  found  to  hold  in  the  case  of  the  orang,  and  in  both  the 
orang  and  the  monkey  the  thumb  centre  is  specially  localised  in  the  region  of 
this  line. 

Ascending  frontal,  opposite  lower  half  of  middle  frontal:  elevation  and 
retraction  of  angle  of  mouth. 

*  '  Proc.  Roy.  Soc.,'  18S5. 

f  Horsley  and  Beevor  ('  Phil.  Trans.,'  1887,  1889)  found  that  the  representation 
of  the  arm  is  as  follows  : — In  the  highest  part  of  the  arm  region  of  the  two  central 
convolutions,  opposite  the  upper  frontal  sulcus,  the  shoulder  movements  are  repre- 
sented ;  next,  below,  come  the  movements  of  the  elbow  behind  and  of  the  wrist  in 
front,  while  in  the  lowest  part  the  movements  of  the  finders  are  represented  in  front, 
and  of  the  thumb  behind.  But  this  is  only  the  maximum  representation  of  the 
several  parts,  in  which  the  special  movement  is  produced  by  the  weakest  currents. 
There  is  scarcely  any  part  in  which  movements  of  the  elbow  and  wrist  are  not 
produced,  or  in  which  they  are  produced  alone.  Hence  the  experimenters  conclude 
that  the  representation  of  the  movement  of  these  parts  is  subordinate  to  that  of  the 
shoulder  on  the  one  hand  and  of  the  digits  on  the  other.  In  the  orang,  the  repre- 
sentation of  the  lower  limb  instead  of  being,  as  in  the  monkey,  horizontal,  is  vertical, 
the  hallux  being  represented  above  and  the  hip  below  ('  Phil.  Trans.,'  1890). 


14  BRAIN. 

Ascending  frontal,  opposite  highest  part  of  third  frontal :  elevation  of  upper 
lip  and  ala  of  nose. 

Lowest  part  of  ascending  parietal:  retraction  of  angle  of  mouth  by  platysina. 

Lowest  part  of  ascending  frontal:  movements  of  lips  and  tongue  and  in  the 
anterior  part,  closure  of  the  vocal  cords.* 

Posterior  half  of  upper  and  middle  frontal  convolutions :  lateral  movement 
of  head  and  eyes,  with  elevation  of  eyelids. 

{Medial  aspect  of  top  of  ascending  frontal,  i.  e.  corresponding  region  of  the 
marginal  convolution,  movement  of  the  trunk. — Horsley  and  Schafer.) 

Sensory  Centres. — Stimulation  of  the  angular  convolution  caused  a 
movement  of  the  eyes  to  the  opposite  side,  suggestive  of  a  visual  sensation. 
Extirpation  of  the  angular  gyrus  caused  amblyopia  of  the  opposite  eye,  more  or 
less  transient,  and  destruction  of  this  convolution  in  both  hemispheres  caused 
permanent  blindness.  (Munk  found  that  hemianopia  was  produced  by  destruction 
of  the  occipital  lobe,  and  Ferrier  found  that  destruction  of  the  occipital  lobe 
and  angular  gyrus  caused  not  only  transient  amblyopia  of  the  opposite  eye,  but 
also  permanent  hemianopia.  He  failed  to  obtain  any  affection  of  vision  by 
extirpation  of  the  occipital  lobe  only,  even  on  both  sides.  Nevertheless  human 
pathology,  especially  the  observations  of  Monakow  and  Henschen,  has  fully 
confirmed  the  correctness  of  Munk's  conclusion.  Horsley  and  Schaferf  found 
that  destruction  of  one  occipital  lobe  produced  hemiopic  disturbance  of  vision, 
so  far  confirming  Munk's  conclusion  ;  but  the  imperfect  vision  which  remained 
after  destruction  of  both  occipital  lobes  seemed  to  them  to  indicate  the 
existence  of  visual  function  elsewhere,  probably  in  the  angular  gyrus.  The 
subsequent  experiments  of  Schafer  and  Sanger  BrownJ  seem  to  confirm  Munk's 
conclusion.) 

Stimulation  of  the  anterior  part  of  the  uncinate  convolution  caused  movement 
of  the  nostril  suggestive  of  a  sensation  of  smell  on  the  same  side.  Isolated 
extirpation  of  these  regions  is  impossible,  but  the  destruction  of  it,  together  with 
other  parts,  always  caused  loss  of  smell. 

Stimulation  of  the  superior  temporo-sphenoidal  convolution  caused  a  move- 
ment suggestive  of  an  auditory  sensation  on  the  opposite  side,  and  destruction 
of  this  convolution  caused  deafness  on  the  opposite  side. 

Destruction  of  the  hippocampal  region  (gyrus  hippocampi  and  hippocampus) 
seemed  to  cause  partial  loss  of  sensibility  to  touch  and  pain  on  the  opposite  side. 
(Horsley  and  Schafer  found  that  extensive  lesions  of  the  gyrus  fornicatus  had  a 
similar  effect.  Munk's  experiments  point  to  the  outer  surface,  and  especially 
the  central  region,  as  that  in  which  cutaneous  sensibility  is  chiefly  represented.) 
The  experiments  of  Hitzig  and  Fritsch  and  Horsley's  clinical  observations 
apparently  show  that  slight  tactile  sensibility  and  the  muscular  sense  are 
represented  in  the  so-called  motor  region. 

Cortical  Centres  in  the  Human  Brain. — The  evidence  we  possess 
regarding  the  cortical  centres  in  the  human  brain  is  derived  chiefly 
from  the  comparison  of  the  effects  of  disease  observed  during  life,  with 
its  position  ascertained  after  death.  It  is  probable,  however,  that 
brain  surgery  may  indirectly  increase  considerably  the  facts  at  our 

*  This  is  the  centre  for  the  vocal  cord  in  the  monkey,  accoruing  to  Horsley  and 
Semon  ;  Deierine  says  it  is  so  also  in  man.     ('Compt.  Rend./  1891,  No.  8.) 
f  '  Phil.  Trans.,'  1888. 
t  Ibid.,  18S8. 


STRUCTURE    AND    FUNCTIONS. 


15 


disposal.  The  evidence  at  present  available  shows  that  there  is  a 
general  correspondence  between  the  cortical  centres  of  man  and  those 
of  the  monkey.  It  is  afforded  by  cases  in  which  small  lesions  have 
caused  definite  loss  of  function,  motor  or  sensory,  or  definite  excita- 
tion of  function,  and  especially  by  the  effects  of  operations  and  the 
use  of  the  facts  as  indications  for  these.  The  irritation  symptoms 
are  of  chief  significance  in  the  case  of  the  motor  function,  and  are 
constituted  by  local  spasm,  or  more  commonly  by  convulsion  begin- 
ning in  or  limited  to,  one  part.  But  such  convulsion  may  be  caused 
by  disease  adjacent  to  as  well  as  by  that  which  is  in,  a  cortical 
centre,  and  therefore  such  cases  afford  less  precise  and  certain  evi- 
dence than  do  those  in  which  there  is  local  destruction  of  tissue  and 
local  paralysis. 


J>c 


FlG.  8. — Diagram  of  the  human  hrain,  to  which  is  transferred  the  motor 
centres  found  by  Horsley  in  the  brain  of  the  bonnet  monkey  (Beevor 
and  Horsley,  '  Phil.  Trans.,'  vol.  181,  1890,  p.  81,  fig.  7).  The  diagram 
corresponds  with  Figs.  1  and  2.  The  position  of  the  centres  has  been 
for  the  most  part  verified  by  Horsley  in  his  operations.  The  asterisks 
indicate  the  centre  for  the  tongue. 

It  is  only  under  certain  conditions,  however,  that  even  destroying 
lesions  can  be  taken  as  evidence  of  functional  localisation.  Those 
conditions  have  been  rightly  insisted  on  by  Nothnagel  in  his  work*  on 
this  subject,  a  work  which  is  a  model  of  scientific  method.  It  is  only 
the  lasting  symptoms  which  can  be  regarded  as  related  to  the  damaged 
region  of  the  brain,  because  an  acute  lesion  frequently  causes,  for  a 
time,  symptoms  of  much  wider  range  than  strictly  correspond  to  the 
destruction,  Such  wide  symptoms  are  due  to  pressure,  secondary 
vascular  disturbance,  or  irritative  inhibition.  Hence  sufficient  time 
must  be  allowed  to  elapse  for  these  "  indirect  "  effects  to  pass  away 
before  any  inference  can  be  drawn  ;  that  is,  only  such  symptoms  as 
have  lasted  for  some  weeks  can  be  regarded  as  having  real  significance, 
and  cases  of  shorter  course  are  of  small  value. 

Negative  evidence  is  also  important — the  occurrence  of  lesions  in 

*  '  Topische  Diag.  der  Gehirnkrankheiten,'  Berlin,  1S79. 


16  BRAIN. 

certain  parts  without  the  production  of  certain  symptoms.  ,Bufc 
another  condition  must  be  observed  in  the  reception  of  this  evidence. 
The  nerve-structures  are  remarkably  tolerant  of  morbid  processes  that 
develop  gradually.  Tumours  or  abscesses  may  form  iu  the  position 
of  structures  that  are  known  to  have  a  certain  function,  and  there 
may  be  no  symptoms  of  disturbance  of  that  function,  or  such  symptoms 
may  be  slight,  even  when  the  structures  are  apparently  destroyed  by 
the  mo-bid  processes.  In  these  cases  the  nerve-elements  are  displaced 
and  not  destroyed  ;  any  damage  they  have  suffered  has  been  so  slowly 
produced  that  it  has  not  deranged  their  function.  Hence  the  negative 
evidence  afforded  by  such  cases  is  of  almost  no  value.  On  the  other 
hand,  these,  and  other  lesions  which  cause  pressure  or  irritation,  often 
produce  symptoms  of  much  wider  extent  than  corresponds  to  the 
position  of  the  lesion  or  to  its  direct  influence, — effects  which  are 
analogous  in  nature  to  the  "  indirect "  initial  consequences  of  an  acute 
lesion.  Hence  the  positive  evidence  afforded  by  irritating  and  com- 
pressing lesions  can  only  be  accepted  with  reserve.  Neglect  of  these 
considerations  has  deprived  of  almost  all  value  one  of  the  most 
laborious  investigations  into  this  problem — that  of  Exner.* 

There  are  some  functions  of  the  cortex  that  elude  localisation  for 
another  reason,  because  their  loss  is  quickly  conpensated  by  the  other 
hemisphere.  It  appears  that  one-sided  movements  are  represented  in 
both  hemispheres,  and  can  be  excited  from  either,  in  proportion  as  they 
are  habitually  associated  on  the  two  sides.  This  law,  first  stated  by 
Broadbent,  is  of  extreme  importance,  and  we  shall  have  to  return  to  it 
many  times.  The  above  statement  of  it  is  perhaps  only  part  of  the 
truth,  but  it  enables  us  to  understand  the  absence  of  any  evidence  as 
to  the  position  of  the  centres  for  certain  movements.  Before  the 
indirect  effects  of  a  lesion  have  passed  away,  and  the  persistent  sym- 
ptoms can  be  admitted  "into  court,"  the  loss  of  the  movements 
referred  to  has  passed  away  because  the  other  hemisphere  has  supplied 
the  lost  function.  It  is  so,  for  instance,  in  the  case  of  lateral  move- 
ment of  the  head  and  eyes,  the  movement  of  the  muscles  of  mastica- 
tion, and  many  movements  of  the  trunk. 

The  evidence  at  present  available  consists  of  a  large  number  of 
facts,  ascertained  by  various  observers,  many  of  which  have  been 
collected  and  carefully  compared  by  Nothnagel,  Charcot  and  Pitres,f 
and  Allen  Starr.  J 

Motor  Centres. — There  is  conclusive  evidence  that  the  two  ascending 
convolutions  have  the  same  special  relation  to  voluntary  motion  as  in 
the  monkey.  It  is  also  certain  that  the  paracentral  lobule  on  the 
median  aspect  of  these  convolutions  has  a  similar  function,  and  that 
the  motor  region  extends  through  part  at  least  of  the  superior  parietal 

*  '  Untersuch.  u.  d.  Localisation  der  Grosshirnrinde,'  Wien,  1S81. 
f  In  a  valuable  series  of  papers  in  the  '  Revue  de  Med.,'  1883. 
J  In  critical  and  analytical    collections  of  cases  in  the  'American  Journal  of 
Medical  Science'  and  other  American  periodicals  during  the  last  three  or  four  years.. 


STRUCTURE    AND    FUNCTIONS. 


17 


lobule,  and  perhaps  on  to  the  root  of  the  highest  frontal  convolution. 
Destructive  lesions  in  these  parts  cause  paralysis  on  the  opposite  side, 
while  irritating  disease  causes  convulsion  of  corresponding  situation. 
Lesions  elsewhere  in  the  cortex  cause  no  persistent  paralysis.  There 
is  at  present  no  direct  evidence  that  the  motor  region  in  man  extends 
beyond  the  ascending  frontal,  with  the  possible  exception  of  the  root 
of  the  first  frontal. 

It  is  from  this  motor  region  that  the  fibres  arise  which,  as  we  shall 
see,  pass  down  through  the  white  substance  into  the  anterior  pyramids 
of  the  medulla,  and  the  pyramidal  tracts  of  the  spinal  cord.  Through 
these  fibres  the  nerve  impulses  pass  that  ultimately  excite  the  muscles. 
Lesions  of  the  cortex  in  this  region  cause  a  descending  degeneration  of 
these  pyramidal  fibres. 

We  can  distinguish  in  these  convolutions  regions  related  to  the  leg, 
arm,  face,  and  tongue,  which  have  the  same  relative  position  as  in 
animals. 

The  centre  for  the  leg  occupies  the  highest  part  of  the  motor  region, 
namely,  the  ascending  frontal  and  parietal  convolutions,  adjacent  to 
the  longitudinal  fissure.  We  do  not  at  present  know  how  far  back 
it  extends  in  the  superior  parietal  lobule,  or  how  far  outwards  it 
extends  on  the  ascending  frontal.*     It  does  not  seem  to  extend  further 


Figs.  9  and  10.—  Position  of  the  cortical  centre  for  the  leg.  It  is 
doubtful,  however,  whether  the  centre  extends  so  far  hack,  in  the  superior 
parietal  lobule  (S  P),  as  is  here  represented  on  the  outer  surface. 


than  the  upper  frontal  sulcus,  perhaps  not  so  far.  There  mav  be 
individual  variations  in  the  area  occupied  by  the  leg  centre.  It 
certainly  occupies  also  the  paracentral  lobule  on  the  inner  surface. 
We  do  not  know  how  far  the  representation  of  separate  movements 
corresponds  to  the  arrangement  in  animals,  but  in  many  cases  of 
convulsion  beginning  in  the  foot,  the  disease  has  been  in  or  near 
the  junction  of  the  highest  frontal  and  ascending  frontal  convolu- 
tions. Moreover  evidence  of  the  representation  of  movements  of  the 
great  toe  in  front  of  the  highest  part  of  the  fissure  of  Rolando  is 

*  See  Dr.  Seguin's  case  (c  Journ.  of  Nerv.  and  Ment.  Dis.,'  1887).  A  woman,  the 
subject  of  cancer,  had  crural  monoplegia,  the  result  of  a  growth  seven  eighths  by 
five  eighths  of  an  inch,  subcortical,  with  the  posterior  end  on  a  vertical  level  with 
the  posterior  end  of  the  calloso-marginal  fissure.  Transversely  it  was  about  half 
an  inch  from  the  mesial  surface  (Dr.  Hughlings  Jackson,  '  Trans.  Clin.  Soc ,'  1887). 
VOL.    II.  l> 


18 


BRAIN. 


shown  by  a  case  in  which  convulsions  beginning  in  the  toe  were  due 
to  a  cicatrix  in  this  situation,  and  the  removal  of  the  part  by  Horsley 
left  paralysis  of  the  toe  only.* 

The  arm  centre  (Fig.  11)  appears  to  occupy  the  middle  third  of 
these  convolutions,  but  extends  higher  up  the  ascending  frontal  than 
the  ascending  parietal,  perhaps  reaching  almost  to  tbe  edge  of  the 
hemisphere.  A  small  lesion  very  near  the  longitudinal  fissure  has 
paralysed  the  arm.  It  is  probable  that  this  centre  overlaps  that  for 
the  leor. 


Fig.  11. — Position  of  the  arm. 


Fig.  12. — Position  of  the  centre  for  the 
face  and  tongue. 


The  centre  for  the  movement  of  the  face  (Fig.  12)  lies  in  the  lower 
third  of  the  ascending  frontal.  It  is  probable,  but  not  yet  proved,  that 
it  extends  on  to  the  ascending  parietal. f  The  centre  for  the  movement 
of  the  angles  of  the  mouth  lies  opposite  the  fissure  between  the  middle 
and  lower  frontal  convolutions.  J  The  lips  and  tongue  are  apparently 
represented  together  in  the  lowest  part  of  the  ascending  frontal,  and 
perhaps  in  the  adjacent  root  of  the  third  frontal.  The  orbicularis  oris 
and  tbe  transverse  fibres  of  the  tongue  habitually  act  together  ;  hence 
we  cannot  separate  the  centres  for  the  face  and  tongue. § 

We  have  no  sure  evidence  at  present  as  to  the  position  of  the  centre 
for  the  movement  of  the  head  and  eyes  (said  to  occupy,  in  the  monkey, 
parts  of  the  first  and  second  frontal)  ;  it  must  be  of  great  importance. 
The  effect  of  its  activity  determines  our  recognition  of  the  relation  of 
the  body  to  external  objects,  especially  to  those  that  are  seen.  It  is 
only  the  relation  of  these  to  one  another  that  we  can  learn  from  the/ 
field  of  vision  alone  ;  the  centre  for  the  trunk  muscles  to  be  placed 

*  Horsley,  'Int.  Journal  of  Med.  Science,'  April,  1887. 

t  All  parts  of  the  face  were  paralysed  by  a  lesion  which  involved  the  right  of  the 
second  frontal  and  adjacent  part  of  the  ascending  frontal,  but  below  the  cortex 
extended  to  the  first  and  third  frontal  ('Mill.  Journ.  Nerv.  and  Mental  Dis./ 
1887). 

J  See  the  conclusive  case  of  Dr.  Berkeley,  of  Baltimore,  figured  in  the  chapter 
on  facial  spasm. 

§  It  is  probable  that  the  movements  of  the  jaw  are  also  represented  in  this  region. 
In  the  course  of  an  operation  on  man,  Horsley  found  that  stimulation  of  the 
ascending  frontal,  at  the  junction  of  the  middle  and  upper  third  of  the  facial  region, 
caused  a  lateral  movement  of  the  jaw  as  well  as  of  the  angle  of  the  mouth. 


STRUCTURE    AND    FUNCTIONS.  19 

(according  to  the  expei'iments  of  Horsley  and  Schafer)  on  the  inner 
surface  of  the  hemisphere  (see  p.  14)  still  needs  verification.  The 
reason  for  this  uncertainty  has  heen  already  mentioned  ;  compensation 
occurs  so  readily  that  the  loss  of  movement  quickly  passes  away.* 
It  has  been  thought  that  there  is  a  centre  for  the  movement  of  the 
upper  eyelid  in  the  angular  or  lower  parietal  lobule  (Landouzy  and 
Grrasset) ;  an  old  lesion  has  been  found  in  the  angular  gyrus  in  a  case 
of  ptosis  of  long  duration. f  Wernicke  has  concluded  from  Munk's 
researches  that  the  neck  I'egion  is  represented  in  the  part  of  the  frontal 
lobe  which  lies  in  front  of  the  middle  of  the  anterior  central  con- 
volution, and  a  case  published  by  Fraenkel,J  in  which  there  was 
excessive  rigidity  of  the  neck  muscles  would  seem  to  bear  out  this 
conclusion,  as  examination  showed  the  existence  of  a  large  clot 
covering  the  foot  of  the  second  and  the  adjacent  part  of  the  third 
left  frontal  convolution  immediately  in  front  of  the  anterior  central 
convolution. 

There  has  been  much  discussion  regarding  the  precise  nature  of  these 
centres,  and  opinion  is  still  divided  on  the  matter.  It  is  certain,  how- 
ever, that  movements  are  produced  by  their  stimulation  in  m.m  as  well 
as  in  animals.  §  It  is  certain  also  that  the  fibres  which  conduct  motor 
impulses  to  the  coi*d  spring  from  them,  and  pass  directly  downwards. 
Hence  it  is  difficult  to  believe  that  any  considerable  amount  of  error 
can  be  involved  in  designating  the  region  "  motor,"  especially  from  the 
standpoint  of  practical  medicine.  We  need  not,  therefore,  conceive  that 
these  parts  subserve  no  other  functiou  (we  shall  presently  see  reason 
for  believing  that  they  have  sensory  as  well  as  motor  functions).  It 
is  instructive,  in  this  connection,  to  note  that  in  this  part  are  found 
the  largest  ganglion-cells  met  with  in  the  cortex,  cells  comparable  to, 
though  exceeding  in  size,  the  certainly  motor  cells  of  the  anterior 
cornu  of  the  spinal  cord.|| 

*  It  is  in  the  highest  degree  probable  that  the  position  of  the  centres  corresponds 
to  that  in  the  monkey,  and  this  is  supported  by  an  interesting  case  recorded  by  Horsley 
('Int.  J.  of  Med.  Science/  April,  1887),  which  is  not,  however,  quite  conclusive. 

t  Lemoine,  '  Rev.  de  Med.,'  1887.  This  harmonises  with  the  sensory  localisation, 
since  the  upper  lid  is  raised  for  intent  vision. 

X  '  Charite  Annalen,'  1886. 

§  First  demonstrated  by  Bartholow,  and  since  abundantly  confirmed  in  the  course 
of  surgical  procedure. 

||  A  theory  of  the  nature  of  the  so-called  motor  centres,  which  has  received  wide 
acceptance  in  Germany,  is  that  of  Munk.  This  theory  regards  tbem  as  essentially 
sensory;  the  movements  which  result  from  their  activity  are  due  to  the  fact  that 
the  nerve  processes  in  them  represent  "conceptions  of  movements"  composed  of  the 
cutaneous  and  muscular  sensations  and  sensations  of  active  innervation.  These  are 
regarded  as  essentially  sensory  conceptions,  and  hence  Munk  terras  this  region  the 
"Sense-sphere"  (Fuhlsphare).  An  objection  to  this  view  is  that  the  "sense  of 
innervation,"  one  element  of  the  threefold  "conception  of  movement,"  is  a  sense  of 
something  which  is  not  itself  sensory,  and  which  is  commonly  termed  motor,  and 
that  destruction  of  this  region  causes  loss  of  this  "motor"  function  oui  oi  all  pro- 
portion to  any  demonstrable  sensory  loss. 


20  BRAIN. 

Sensory  Centres. — Our  knowledge  of  the  position  of  the  centres  for 
sensation  of  the  limbs  and  trunk  is  far  less  precise  than  is  that  of  the 
motor  centres.  According  to  Flechsig  the  fibres  of  the  sensory  path 
of  the  internal  capsule  pass  towards  the  outer  surface  of  the  cortex, 
towards  the  region  which,  roughly  speaking,  lies  beneath  the  parietal 
bone,  i.  e.  the  central  convolutions  and  the  parietal  lobe.  The  meagre 
facts  of  pathology,  as  far  as  they  go,  are  in  harmony  with  this  view. 
One  case  is  shown  in  Fig.  15.  In  another  case  complete  left-sided 
loss  of  sensibility,  including  the  eye  and  other  special  senses,  resulted 
from  a  layer  of  softening  at  aud  just  beneath  the  surface  of  the 
greater  part  of  the  convexity  of  the  right  hemisphere,  the  medial 
aspect  and  internal  capsule  being  unaffected.*  The  view  that  the 
central  convolutions  have  some  sensory  function,  as  well  as  a  motor 
function,  is  supported  by  the  facts  that  there  is  often  slight  blunting 
of  sensibility  on  the  extremity  of  a  limb  paralysed  by  disease  in  this 
region,  aud  that  in  convulsions  due  to  irritating  lesions  in  this  situa- 
tion a  sensory  aura  very  often  precedes  the  motor  spasm.  It  is  quite 
possible  that  the  sensory  region  extends  also  to  the  medial  surface  of 
the  hemisphere,  just  as  does  the  motor  region,  but  all  the  facts  hitherto 
observed  are  opposed  to  the  inference  drawn  by  Ferrier  from  the 
experiments  on  animals,  that  any  part  of  the  medial  surface  has  an 
exclusive  or  even  a  preponderant  relation  to  cutaneous  sensibility. 
One  reason  why  we  have  so  little  evidence  of  the  seat  of  this  function 
is  that  extensive  compensation  is  possible.  Thus  a  unilateral  lesion 
in  childhood,  however  extensive,  scarcely  ever  causes  permanent  loss 
of  sensation. 

Smell. — The  indication  of  experiment  is  that  there  is  a  centre  for 
smell  at  the  anterior  extremity  of  the  uncinate  convolution  on  the 
medial  surface  of  the  temporal  lobe,  related  to  the  olfactory  nerve  of 
the  same  side.f  This  is  supported,  as  regards  man,  by  the  facts  that 
some  fibres  of  the  olfactory  nerve  can  be  traced  towards  this  region, 
and  that  olfactory  symptoms  have  been  observed  in  a  few  cases 
of  disease  of  this  part.  Thus  epileptic  fits  beginning  with  an  olfac- 
tory aura  were  associated  in  one  case  with  softening  in  this  region. J 
But  it  is  probable  that  other  fibres,  or  fibres  from  this  centre,  cross 
the  middle  line  (perhaps  in  the  anterior  commissure)  and  go  to  some 
part  of  the  cortex  of  the  opposite  hemisphere,  since  there  are  cases  in 
which  organic  disease  of  one  hemisphere  has  caused  loss  of  the  sense 
of  smell,  in  addition  to  that  of  the  other  special  senses,  on  the  oppo- 
site side.§ 

*  Demange,  '  Revue  de  Med.,'  May,  1883,  p.  391.  A  collection  of  clinical  facts 
pointing  to  the  parietal  and  central  regions  as  the  chief  sensory  region  is  given  by 
Allen  Starr,  '  Journal  of  Nervous  and  Mental  Diseases,'  1S84-,  p.  327. 

f  See  case  of  Dr.  Churton,  Leeds,  'Brit.  Med.  Journ./  1887. 

*  McLane  Hamilton,  'New  York  Med.  Journal,'  June,  1882;  also  Hughlings 
Jackson  and  Beevor,  '  Brain,'  vol.  xii;  p.  304. 

§  Such  a  case,  with  autopsy,  showing  softening  of  the  hinder  part  of  the  internal 
capsule,  is  recorded  by  Fere, '  Arch,  de  Neurologie,'  1885.     I  Lave  seen  several  cases 


STRUCTURE    AND    FUNCTIONS. 


21 


Vision. — Numerous  observations  bave  established  beyond  question 
the  fact  tbat  hemianopia  results  frorn  disease  of  tbe  occipital  lobe, 
which  thus  constitutes  a  centre  for  the  fibres  from  the  same-named 
half  of  each  retina,  and  receives  impressions  from  the  opposite  half  of 
each  Held  of  vision.  The  impressions  from  the  retinae  reach  it  by  the 
optic  tract,  and  probably  by  the  optic  thalamus,  and  by  fibres  from  the 
thalamus  through  the  white  substance  of  the  occipital  lobe.  Fuller 
details  of  this  path  are  given  in  the  account  of  the  origin  of  the  optic 
nerves.  We  do  not  know  the  exact  position  of  the  visual  centres  in 
the  occipital  lobe.  Hemianopia  has  resulted  from  disease  of  the  apes 
of  the  lobe,  the  outer  surface,  and  the  medial  surface,  but  in  some  eases 
of  partial  lesion  the  white  fibres  of  the  optic  path  may  have  been  in- 
volved. Complete  hemianopia  has  most  frequently  been  produced  by 
disease  of  the  apex  of  the  lobe,  and  especially  of  the  cuneus.     Munk 


Fig.  13. — Cortical  visual  centres  on  the 
outer  surface  of  the  hemisphere.  The 
darker  shading  indicates  the  region  of 
the  half-vision  centre  (the  precise  limi- 
tation of  which  is  not  yet  known)  ;  the 
lighter  shading  is  that  of  the  supposed 
higher  visual  centre. 


Fig.  14. — Inner  aspect  of  the  right 
hemisphere.  Prohable  position  ot  the 
visual  centre  in  the  occipital  lobe  and 
of  the  olfactory  centre  in  the  uncinate 
gyrus  (U). 


believes  that,  in  animals,  there  is  a  serial  surface  representation  of 
the  half-field  in  the  occipital  cortex,  the  anterior  half  corresponding 
to  the  upper  quadrant  and  the  posterior  half  to  the  lower  quadrant. 
Since  small  cortical  lesions  cause  incomplete  hemianopia,  it  is  probable 
that  in  man  also  there  is  such  a  projection  of  the  field  as  Munk  de- 
scribes, but  it  is  not  probable  that  the  projection  occupies  the  whole 
occipital  region.*  There  must  be  a  representation  of  the  colour  fields  in 
the  cortex,  distinct  from  that  for  light  and  objects,  since  colour  hemi- 
anopia has  been  met  with  as  an  isolated  symptom.     (See  "  Diseases  of 

during  life  in  which  smell  was  implicated.  See  also  Fasola,  '  Riv.  Sper.  di  Fren.,' 
18S6;   and  Anderson,  'Brain,'  vol.  ix,  p.  390. 

*  An  important  case  has  heen  recorded  by  Delepine  ('Trans.  Path.  Soc.,'  1890). 
The  patient  had  had  right  homonymous  hemianopia  for  eight  months,  and  contrac- 
tion of  the  remaining  fields.  On  the  right  side  of  the  right  field,  however  (which 
was  otherwise  blind),  there  was  a  persistent  marginal  circle  of  vision.  Post  mortem 
there  was  softening  in  the  left  cuneus  and  middle  occipital  convolution.  The  inner 
aspect  of  the  cuneus  was  also  affected,  except  the  postcro- superior  portion,  and  tho 
interesting  question  presents  itself  whether  this  part  which  escaped  had  a  relation 
to  the  persistent  marginal  circle  of  vision  in  the  right,  otherwise  blind,  field. 


22  BliAlN. 

the  Optic  Nerve.")  Wilbrand*  assumes  that  all  impressions  are  con- 
ducted first  to  the  apical  region,  because  disease  there  causes  total 
loss,  and  that  there  is  a  re-representation  of  the  colour  Lalf -field  in 
front  of  tbis.f 

But  disease  sometimes  causes,  not  hemianopia,  but  "crossed 
amblyopia,"  i.  e.  dimness  of  sight  in  the  opposite  eye,  generally  -with 
concentric  diminution  of  the  field.J  The  theory  which  best  explains 
the  fact  is  that  on  the  outer  surface,  in  front  of  the  occipital  lobe, 
there  is  a  higher  visual  centre  in  which  the  half-fields  are  combined, 
and  the  whole  opposite  field  is  represented.  Such  a  centre,  in  animals, 
is  localised  by  Ferrier  in  the  angular  gyrus  (in  which  term  he  includes 
the  extremity  of  the  supra-marginal  convolution).  Pathological  evi- 
dence in  man  points  to  some  part  of  the  same  region  as  the  seat  of  this 
centre.  In  the  very  few  post-mortem  examinations  in  cases  with 
"crossed  amblyopia"  the  posterior  and  inferior  part  of  the  parietal 
lobe,  i.  e.  the  angular  gyrus,  in  its  widest  sense,  has  been  involved  in 
the  disease.  In  the  case  nieutioned  on  p.  20,  recorded  by  Demange, 
the  loss  of  sight  of  the  left  eye  was  an  early  symptom,  and 
the  softening  of  this  region  appeared  older  than  that  elsewhere. 
Another  instructive  case,  recorded  by  Dr.  Sharkey,  is  shown  in  Figs. 
15  and  16.  It  would  seem  that  the  field  of  the  same  side  is  also 
represented  in  this  centre,  since  the  amblyopia  in  the  opposite  eye  is 
usually  accompanied  by  a  slight  restriction  of  the  field  of  the  eye  on 
the  same  side.  Thus  the  centre  must  be  assumed  to  represent  the 
whole  of  both  fields,  but  that  of  the  opposite  side  in  a  far  higher 
degree  than  the  field  on  the  same  side.  This  assumption  enables  us 
to  understand  another  curious  fact,  viz.  that  the  "crossed  amblyopia" 
generally  lessens  after  a  time  (while  hemianopia  is  usually  persistent). 
,If  the  higher  centre  in  each  hemisphere  is  connected  with  both 
retina?,  it  is  conceivable  that  the  loss  caused  by  disease  of  one  hemi- 
sphere may  be  compensated  by  the  function  of  the  other  hemisphere. 
Hence  we  can  understand  that  atrophy  of  this  region,  congenital  or 
dating  from  early  life,  may  be  unaccompanied  by  any  recognised  loss 
of  sight. §  The  visual  p>ath  will  be  considered  in  connection  with  the 
optic  nerves. || 

*  '  Ophth.  Beit,  zur  Diag.  d.  Gehirnkr.,'  1884. 

f  Varying  impairment  in  extent  of  vision  in  a  patient  found  to  have  glioma  in 
angular  gyrus  (Anderson,  'Trans.  Ophthal.  Soc.,'  1890). 

X  I  have  seen  several  such  cases,  and  others  have  been  recorded,  some  by  Ferrier 
('  Brain/  vol.  iii,  p.  456).  Of  course  all  ocular  causes  of  amblyopia  are  excluded. 
(See  chapter  on  Affections  of  Sight.) 

§  As  in  a  curious  case  recorded  by  Dr.  Sharkey  ('lled.-Chir.  Trans.,'  vol.  lxvi, 
1883,  p.  293). 

j|  Dr.  Beevor  has  found  that  in  the  marmoset  monkey  there  are  no  fibres  from 
the  corpus  callosum  to  the  cortex  hounding  the  calcarine  fissure.  This  part  of  the 
cortex  is  analogous  to  the  visual  centre  in  man,  and  if  such  an  arrangement  is  also 
present  there,  it  m'ght  throw  some  light  on  the  persistence  of  heinb'pia  after  lesion 
of  this  p.irt. 


STRUCTURE    AND    FUNCTIONS. 


23 


r^, 

vk  \ 


Cortical  lesions  in  dogs  that  do  not  cause  loss  of  sight  may  abolish 

or  impair  the  power  of 

recognising  the  nature 

of     seen     objects,     al- 
though    they    can    be 

recognised      at      once 

when  some  other  sense 

is     employed  ;     the 

condition      has      been 

termed  mind-blindness 

(Munk*).     The  power 

thus   lost  seems  to  be 

subserved     by      struc- 
tures in   or    near   the 

higher    visual     centre, 

but     the     position     of 

the  lesion  has  not  yet 

been     ascertained     in 

any  case  in  which  the 

loss    was    considerable 

and    persistent.       The 

loss  of  course  includes 

the       recognition       of 

words,  and  the  latter 
may  occur  without  in- 
ability to  recognise  ob- 
jects in  general.  Mind- 
blindness  was  pro- 
duced by  the  lesion 
indicated  in  Fig.  17, 
but  this  case,  while  it 
agrees  with  the  pro- 
bable localisation,  was 
too  brief  in  duration 
to  constitute  actual 
proof  of  the  seat  of 
disease  on  which  the 
symptom  depends,  f 
The     subject    is    con- 


Fig.  15. — Aspect  of  right  hemisphere,  and  Fig.  16 
probable  area  of  the  lesion,  in  a  case  of  embolism  of 
the  right  middle  cerebral  artery  (Sharkey,  '  Med.- 
Chir.  Trans.,'  1884,  p.  265).  The  immediate  effect 
of  the  lesion  was  left  hemiplegia  and  hemianes- 
thesia, with  almost  complete  blindness  of  the  left 
eve,  and  loss  of  hearing  and  taste  on  the  left  side. 
Four  weeks  after  the  illuess  there  was  marked  im- 
provement in  the  special  senses,  and,  a  little  later, 
in  the  hemiansesthesia.  Six  and  a  half  weeks  after 
the  onset  the  special  senses  were  normal,  the  leg 
had  regained  .much  power,  and  a  fortnight  later 
sensation  was  normal.  The  paralysis  of  the  arm 
continued  until  death,  seven  years  later. 


*  'Deut.  med.Wochensch./ 
1877,  No.  13;  and 'Arch.  f. 
Anat.  u.  Phys./  1878,  p.  162. 
■f  The  same  statement  ap- 
plies to  a  case  of  depressed 
fracture  of  the  skull  in  this 
region,  in  which  mind-blindness  existed  for  two  weeks  (McEwen, 
Journal/  Aug.,  1888). 


Fig.  17. — Position  of  lesion  in  the  left  hemisphere 
(angular  gyrus),  which  caused  complete  mind-blind- 
ness during  the  short  time  the  patient  lived.  (Chauf- 
fard,  'Rev.  de  Med./  1881,  p.  940.) 


'Brit.  Med. 


24 


BRAIN. 


Kio-.  18. — Position  of  the  auditory  centre 
in  the  first  temporal  convolution. 


sidered  further  in  the  sections  on  "  Affections  of  Speech,"  and  "  Dis- 
eases of  the  Optic  Nerves."     The  theory  remains  the  most  probable. 

Auditory  Centre. — Pathology  on  the  whole  supports  the  indication 
of  experiment,  which  places  the  auditory  centre  in  the  middle  of 
the  first  temporo-sphenoidal  convolution  (Fig.  18).     This  convolution 

has  been  found  atrophied  in 
cases  of  congenital  deafness.* 
Destruction  of  this  region  has 
been  accompanied  by  loss  of 
hearing  in  the  opposite  ear,  al- 
though the  loss  has  not  been  per- 
manent. An  instance  is  the  case 
figured  on  the  last  page  (Fig. 
15).  In  a  case  under  my  obser- 
vation of  extensive  tumour,  in 
which  the  oldest  part  was  beneath 
this  convolution,  convulsions  preceded  by  an  auditory  aura,  referred 
to  the  opposite  ear,  were  a  very  early  symptom.  In  another  case  a 
tumour  in  the  position  of  the  letters  P  Sy  in  Fig.  18  caused  unilateral 
convulsions,  preceded  by  a  loud  noise,  as  of  machinery.  The  convolu- 
tion on  each  side  would  appear,  therefore,  to  be  related  to  the  opposite 
auditory  nerve.  It  is  important  to  note  that  the  loss  is  not  permanent, 
and  this  may  explain  another  fact,  that,  in  many  cases  in  which  the 
symptoms  lasted  for  some  time,  the  absence  of  deafness  has  been 
noted  during  life,  although  this  convolution  was  found  destroyed  after 
death.f  Hence  it  would  seem  that  perfect  compensation  is  possible, 
presumably  by  the  corresponding  centre  of  the  opposite  side.  The 
complete  deafness  present  at  first  in  the  case  shown  at  Fig.  15  passed 
■  away  completely  at  the  end  of  six  weeks.  Thus  each  auditory  nerve 
must  be  structurally  connected  with  both  hemispheres,  although  only 
the  connection  with  the  opposite  hemisphere  is  habitually  in  functional 
action. 

A  condition  of  "mind-deafness"  has  apparently  been  caused  in 
animals  by  destruction  of  the  first  temporal  convolution  (Munk).  An 
,  analogous  condition  is  met  with  not  infrequently  in  man  when  this 
convolution  on  the  left  side  is  diseased,  but  it  has  been  observed 
rather  in  connection  with  the  perception  of  words  than  of  sounds  iu 
general.     (See  "  Affections  of  Speech.") 

Of  the  cortical  representation  of  taste  we  know  nothing.  The  percep- 
tion of  flavours  is  related  to  the  olfactory,  not  to  the  gustatory  nerve; 
but  in  epileptic  warning,  flavour  and  smell  are  always  distinct,  and  it 
is  probable  that  a  rearrangement  obtains  in  the  cortex. 

Speech. — The  relation  of  certain  parts  of  the  cortex  to  speech  pro- 
cesses   can    be   better  understood   when  these    processes   have    been 

*  Fletcher,  Beach,  and  others. 

f  As  in  si  case  of  softening  recorded  by  Ball,  '  New  York  Arch,  of  Med.,'  April, 
1881. 


STRUCTURE    AND    FUNCTIONS. 


25 


considered  in  detail.  The  centres  concerned  in  articulate  speech  are  in 
the  posterior  extremity  of  the  lowest  frontal  convolution,  and  the 
adjacent  part  of  the  ascending  frontal,  in  the  left  hemisphere.  They 
correspond,  in  part  at  least,  to 
the  centres  for  the  movements 
(lips  and  tongue)  by  which  ar- 
ticulation is  effected.  The  per- 
ception of  beard  words  is  sub- 
served by  the  centre  for  hearing 
iii  the  first  temporal,  or  by 
structures  adjacent  to  it.  There 
may  be  loss  of  the  power  of 
understanding  heard  words 
without  deafness.  The  com- 
prehension of  seen  words  is  a 
difficult  and  complex  subject,  which  will  be  considered  in  the  chapter 
on  affections  of  speech. 

Psychical  Processes. — It  is  presumed  that  mental  processes  are  sub- 
served by  those  parts  of  the  cortex  that  have  no  known  motor  or  sen- 
sory function,  and  especially  by  the  pre-frontal  lobes.  Many  cases 
are  on  record  in  which  considerable  mental  change  was  produced  by 
extensive  disease  in  this  part,  especially  great  when  the  disease  was 
bilateral.  Small  lesions,  however,  may  cause  no  symptoms,  perhaps 
because  there  is  considerable  capacity  for  functional  compensation. 
It  would  probably,  however,  be  wrong  to  regard  mental  processes 
as  exclusively  related  to  the  parts  which  are  not  known  to  have  other 
functions,  since  the  motor  and  sensory  regions  must  also  subserve 
mental  operations. 


Fig.  19. — Position  of  the  motor  speech 
region  in  the  left  hemisphere. 


The  Connecting  Tracts,  Central  Ganglia,  &c. 

The  next  subject  of  medical  importance  is  the  course  of  the  fibres 
that  unite  the  various  parts,  and  establish  a  connection  with  the  spinal 
cord.  The  course  of  these  fibres  has  been  only  partially  unravelled, 
and  the  difficulty  of  the  task  is  increased  by  the  fact  that  many  of  the 
tracts  are  interrupted  in  places  by  grey  matter.  This  interruption 
'arrests  the  progress  of  secondary  degeneration,  which  is  so  great  an 
aid  in  tracing  the  course  of  interlacing  fibres. 

The  centrum  ovale  of  the  hemisphere  consists  of  medullated  nerve- 
fibres,  of  which  three  classes  have  been  distinguished  according  to 
their  course: — (1)  Fibres  that  pass  between  and  connect  different 
convolutions  in  the  same  hemisphere;  amongst  these  is  a  special  set 
which  passes  between  the  occipital  and  frontal  lobes,  in  the  inner  part 
of  the  hemisphere,  crossing  the  fibres  to  the  corpus  callosutn,  in  the 
congenital  absence  of  which  it  becomes  very  distinct.*     It  may  sub- 

*   Burdaeh,  Meynert,  Onufrowicz  ('A.  f.  Psych.,'  xviii). 


26  BRAIN. 

serve  movement  of  the  head  and  eyes  to  the  opposite  side  when  a 
visual  impression  passes  thence  to  the  train.  (2)  Fibres  that  pass 
inwards  to  the  corpus  callosum,  and  for  the  most  part  connect 
corresponding  regions  in  the  cortex  of  the  two  hemispheres.*  Probably 
the  fibres  between  the  leg  centres  are  at  the  bach  of  the  corpus  callosum, 
those  between  the  arm  and  trunk  centres  in  the  middle,  and  those 
between  the  head  and  eye  centres  in  the  fore-part. f  (3)  Fibres  that 
pass  to  the  central  ganglia  or  crus  cerebri.  The  last-named  converge 
from  all  parts  of  the  cortex  to  the  inner  and  lower  region  of  the 
hemisphere,  where  the  central  ganglia  he  and  the  crus  leaves  the 
brain.  If  traced  upwards  from  the  crus  and  ganglia  they  radiate 
towards  the  cortex,  and  the  radiation  of  the  two  hemispheres  has  been 
compared  to  a  crown,  and  termed  the  "  corona  radiata."  This  ex- 
pression is  not  now  much  used,  but  a  limited  application  of  the  term 
is  current  and  convenient :  special  groups  of  these  fibres  are  termed 
'"radiations,"  as  the  "pyramidal  radiation,"  "optic  radiation,"  &c. ; 
while  the  fibres  that  thus  radiate  are  sometimes  termed  "  coronal." 

The  crus  cerebri,  it  will  be  remembered,  enters  the  inner  side  of  the 
hemisphere,  spreading  out  beneath  the  optic  thalamus  and  caudate 

nucleus,  and  its  fibres  ascend 
sgg        ^.v..  in  a  layer  beneath  these  gan- 

V   ;         A  glia  on  the  inner  side   and 

>— _^__^_)  the  lenticular  nucleus  on  the 

I  /0&&!Jf   '■       '•'_-      ./\  .  ..  1  -     y  outer    side.      This   layer   is 

i>    :::  /'-,  /  Z^y^yf^X  termed    the    "internal  cap- 

Vo  './   z  i     -  S)         sule,"  because  it  bounds  in- 

ternally the  lenticular  nu- 
cleus. In  a  horizontal  sec- 
tion through  these  ganglia 
(Fig.  20)  it  is  seen  that  the 
anterior  and  posterior  parts 
of  the  capsule  have  not  quite 
the  same  direction ;  the  an- 
terior part,  between  the  body 

of  the  caudate  nucleus  and 
Fig  20.— Diagram  of  horizontal  section  through    .-,      ,  ,     -  ,,      ipnHnilor 

the  central  ganglia  and  internal  capsule.  tne  lore-P^  0I  tne  lenticular 

nucleus,  joins  at  an  angle 
the  posterior  part  between  the  optic  thalamus  and  the  hinder  part  of 
the  lenticular  nucleus.     These  are  called  the  anterior  and  posterior 

*  This  opinion  has  been  confirmed  by  almost  all  modern  investigations,  with  the 
exception  of  those  of  Dr.  D.  J.  Hamilton  ('  Journ.  of  Anat.,'  xix,  p.  385),  whose 
theory  is  scarcely  to  be  reconciled  with  the  certain  facts  of  pathology,  and  whose 
evidence,  from  comparative  anatomy,  has  been  contested  by  Beevor  ('  Brain,'  1886), 
while  the  older  view  has  been  experimentally  confirmed  by  Schafer  and  Mott 
(•'  Brain,'  viii,  1890).  Stimulation  of  the  surface  of  the  corpus  callosum  excited  the 
motor  centres  of  both  hemispheres ;  of  one  only  when  they  had  been  destroyed  in 
the  other. 

t  Schafer  and  Mott,  loc.  cit. 


STRUCTURE    AND    FUNCTIONS. 


"limbs"  of  the  capsule,  and  the  angle  at  which  tney  join  is  called 
its  "elbow"  or  "knee."*  In  an  experimental  investigation  into 
the  excitability  of  the  fibres  of  the  internal  capsule  in  the  monkey ,f 
Beevor  and  Horsley  found  that  the  fibres  were  arranged  from 
before  backwards  in  the  same  order  as  the  foci  of  representation 
in  the  excitable  part  of  the  cortex  taken  along  lines  drawn  at 
right  angles  to  the  direction  of  the  fissure  of  Eolando;  that  the 
arrangement  of  fibres  in  the  different  segments  of  each  great 
division  was  the  same  as  prevails  in  the  cortex,  and  that  the  character 
of  each  movement  was  represented  in  the  capsule  as  in  the  cortex. 
The  extent  of  the  lenticular  nucleus  from  front  to  back  corresponds 
to  both  the  caudate  nucleus  and  optic  thalamus  together,  but  the 
slender  tail  of  the  caudate  nucleus  extends  as  far  back  as  the  posterior 
extremity  of  the  lenticular  nucleus,  curving  down  into  the  roof  of  the 
descending  cornu  of  the  lateral  ventricle.  The  two  parts  of  the 
corpus  striatum  (caudate  aud  lenticular  nuclei)  are  connected  at  their 
anterior  and  posterior  extremities  by  slender  tracts  of  grey  matter, 
which  pass  between  the  fibres  of  the  capsule ;  elsewhere  these  fibres 
separate  the  two  ganglia.  In  the  lenticular  nucleus,  as  seen  in 
transverse  section,  three  parts  can  be  distinguished  by  a  difference  in 
tint— the  inner,  middle,  and  outer,  or  first,  second,  and  third,  the  last 
being  by  far  the  largest  (see  p.  41). 

A  section  through  the  crura  cerebri  above  the  pons  (Fig.  21)  shows 
them   connected   above   by 


the  corpora  quadrigemina. 
The  cms  proper  is  separated 
into  two  parts,  anterior 
(ventral)  and  posterior 
(dorsal), |  by  the  "  locus 
niger ;  "  the  lower  or  ante- 
rior  is  called  the  crusta,  the 
upper  or  posterior  the  teg- 
mentum. The  crusta  is  also 
called  the  "pes  "  or  "  basis," 
and  the  former  ("  Fuss  ")  is 
the  termusualy  employed  in 
Germany  ;  but  neither  of  these  words  lends  itself  to  the  English  system 
of  terminology,  and  it  is  better  to  use  the  older  term  "  crusta  "  and  its 
adjective  "  crustal."  The  tegmentum  is  much  greyer  than  the  crusta, 
because  it  contains  many  nerve-cells  mingled  with  the  fibres,  while  the 
crusta  consists  almost  exclusively  of  nerve-fibres.      The  tegmentum 

*  Such  a  bend  (as  in  a  pipe)  is  termed  a  "  knee  "  in  Germany,  an  "  elbow  "  in  tbis 
country.     It  is  perhaps  better  to  term  the  junction  the  "angle"  of  the  capsule. 

t  '  Phil.  Trans.,'  1890. 

X  Although  the  direction  of  the  pons  and  crura  is  nearer  the  horizontal  than  the 
vertical,  it  is  convenient  to  retain  the  terms  anterior  aud  posterior  in  the  same 
significance  as  in  reference  to  the  cord — the  more  so  because  the  fibres  from  the  crus 
again  assume  an  ascending  course  when  they  enter  the  hemisphere. 


Fig.  21.- 


-Diagram  of  section  of  crura  cerebri. 
aq,  aqueduct  of  Sylvius. 


28 


BRAIN. 


varies  in  tint  in  different  parts  of  its  section.  Near  the  middle  line 
is  a  round  or  oval  area,  greyer  thau  the  rest,  and  often  reddish  grey. 
It  is  the  "  red  nucleus,"  or  "  tegmental  nucleus."  To  the  outer  side 
of  the  red  nucleus,  and  just  above  the  outer  part  of  the  locus  niger, 
a  paler  curved  band  is  seen,  largest  at  its  inner  extremity.  This  is  the 
fillet,  an  important  tract  of  fibres,  which  extends  np  from  the  lowest 
part  of  the  pons,  aud  occupies  there  also  the  same  relative  position, 
the  lowest  part  of  the  tegmentum.  Above  the  red  nucleus  is  a  small 
triangular  white  area,  near  the  middle  line,  the  section  of  a  compact 
bundle  of  "  posterior  longitudinal  "  or  "  posterior  horizontal"  fibres. 
In  a  section  through  the  middle  of  the  pons  (Fig.  27,  p.  33)  the  dis- 
tinction between  the  two  parts,  crustal  and  tegmental,  is  still  indicated 
by  the  position  of  the  fillet  in  the  lowest  layer  of  the  tegmentum.  The 
crustal  portion  below  (i.  e.  in  front  of)  the  fillet  is  here  increased  in 
bulk  by  the  transverse  fibres  from  the  middle 
peduncle  of  the  cerebellum  and  by  much  scat- 
tered gi'ey  matter.  In  the  tegmentum  the  pos- 
terior longitudinal  bundles  are  still  seen  near  the 
middle  line  and  close  to  the  floor  of  the  fourth 
ventricle.  Between  them  and  the  fillet  is  an  area 
consisting  of  interlacing  bundles  of  fibres,  trans- 
verse and  longitudinal,  the  "  reticular  forma- 
tion." In  the  tegmental  part  of  the  pons  there 
are  also  various  collections  of  grey  matter  from 
which  certain  cranial  nerves  take  origin.  These  lie 
chiefly  in  the  upper  part,  near  the  floor  of  the 
fourth  ventricle,  and  will  be  subsequently  de- 
scribed. 

Our  knowledge  of  the  course  of  the  motor 
path  is  more  complete  than  that  of  any  other  set 
of  fibres.  The  relations  of  the  spinal  portion  of 
this  path  have  been  described  in  the  account  of 
the  anatomy  of  the  spinal  cord  (vol.  i,  p.  172). 
We  have  seen  that  it  there  occupies  the  two  pyra- 
midal tracts,  anterior  or  direct,  aud  lateral  or 
crossed.  The  precision  with  which  their  limits 
are  indicated  by  secondary  degeneration  enables 
us  to  trace  their  course  with  equal  certainty  in 
the  brain.  The  degeneration  has  revealed  also 
the  remarkable  fact  that  the  pyramidal  fibres 
extend  fron  the  central  convolutions  to  the  spinal 
Fig.  22.— Diagram  of  cord  -without  any  interruption  by  grey  matter. 
SrdSTactftlofPytr£  Tracing  their  course  up  from  the  cord  (Fig.  22), 
right  hemisphere.  we  find  that  each  lateral  tract  crosses  the  middle 

line  in  the  medulla,  and,  uniting  with  the  anterior 
or  direct  tract,  forms  the  "  anterior  pyramid  ;  "  from  this  the  name  is 
taken  by  which  the  fibres  are  known  throughout  their  course.   Entering 


STRUCTURE    AND    FUNCTIONS.  29 

the  pons  the  two  pyramids  are  covered  by  the  superficial  layer  of 
transverse  fibres,  and  divide  into  a  series  of  bundles.  Thus  divided, 
they  course  up  through  the  crustal  portion  of  the  pons,  lying  between 
tbe  superficial  and  deep  layers  of  transverse  fibres,  and  surrounded  by 
much  grey  matter,  with  which,  however,  their  fibres  have  no  connec- 
tion. Above  the  pons  the  bundles  again  unite,  and  in  the  crus 
cerebri  the  pyramidal  fibres  lie  together,  and  occupy  the  middle  two 
fifths  of  the  crusta,  extending  from  tbe  surface  below  almost,  but  not 
quite,  to  the  substantia  nigra  above.  Passing  beneath  the  optic 
thalamus,  they  ascend  between  it  and  the  lenticular  nucleus,  as  part  of 
the  internal  capsule.  They  occupy  the  anterior  two  thirds  of  its 
posterior  limb,  the  hinder  third  containing  the  sensory  path*  Above 
the  lenticular  nucleus  they  radiate  through  the  white  substance  of  the 
hemisphere  to  that  part  of  the  cortex  in  which  experimental  stimula- 
tion causes  movement  in  the  limbs,  viz.  the  two  central  convolutions 
with  the  superior  parietal  lobule  and  paracentral  lobule.  The  motor 
impulses  originating  in  these  convolutions  appear  to  be  conducted 
directly  to  the  grey  matter  of  the  spinal  cord  by  these  fibres,  without 
the  intervention  of  any  nerve-cells,  either  of  the  central  ganglia  or  tbe 
pons.  If  these  convolutions  are  destroyed,  the  fibres  degenerate  down 
to  the  lowest  part  of  the  cord.  Some  fibres  from  the  motor  cortex 
pass  into  the  narrow  "  external  capsule,"  outside  the  lenticular 
nucleus,  into  which  their  degeneration  can  be  traced.  Their  further 
course  is  unknown. 

The  "motor  "  convolutions  contain  also  centres  for  the  movements 
exerted  through  some  of  the  motor  cranial  nerves — movements  of  the 
jaw,  face,  and  tongue.  Tbe  fibres  from  these  centres  pass  from  the 
cortex  with  tbe  pyramidal  fibres.  The  centres  for  the  face  and  tongue 
are  lowest  in  the  cortex  (as  we  have  seen),  and  their  path  lies  corre- 
spondingly below  that  of  the  limbs  in  the  centrum  ovale.  But  the 
change  from  the  vertical  to  an  antero-posterior  relation,  in  the  internal 
capsule,  brings  the  fibres  for  the  face  and  tongue  in  front  of  tbose  for 
the  limbs,  and  they  occupy  the  bend  or  angle  of  the  capsule  (Fig.  23). 
In  the  crusta  they  occupy  a  corresponding  position  on  the  inner  (medial) 
side  of  the  pyramidal  fibres  (Brissaud,  Raymond  and  Artaud),  tbe 
change  in  direction  of  the  crus  having  brought  to  the  inner  side  that 
which  was  anterior  in  the  capsule  and  inferior  in  the  cortex.  It  is 
probable  tbat,  in  the  pons,  the  fibres  for  the  cranial  nerves  continue 
with  the  pyramidal  fibres,  lying  on  the  inner  side  of  the  latter ;  hence 
the  face  and  limbs  may  be  paralysed  together  by  a  small  lesion  in  the 
upper  part  of  the  pons.  When  these  fibres  approach  the  level  of 
their  nuclei,  they  leave  the  neighbourhood  of  the  pyramidal  tract,  and, 
crossing  the  middle  line,  pass  to  the  nucleus  from  which  the  cranial 
nerve  takes  origin. 

*  Perhaps  not  exclusively,  however.  A  few  fibres  of  the  motor  path  have  heen  found 
in  the  hinder  third  (Mannkopf,  '  Zeitsch.  f.  kl.  Med.,'  1884,  Sup.).  It  is  possible, 
however,  that  these  fibres  belong,  not  to  the  pyramidal  tract,  but  to  the  fillet  (q.  v.). 


30 


BKAIN. 


Fig.  23. — Diagram  to  show  the  relative  position  of  the  several  motor  tracts 
in  their  course  from  the  cortex  to  the  cms.  The  section  through  the  con- 
volutions is  vertical;  that  through  the  internal  capsule,  I  C,  horizontal ; 
that  through  the  crus  is  agnin  vertical;  CN,  caudate  nucleus,  0  TH,  optic 
thalamus,  L  2  and  L  3,  the  middle  and  outer  parts  oK  the  lenticular  nucleus; 
/,  a,  I,  face,  arm,  and  leg  fibres.  The  words  in  italics  indicate  the  corre- 
sponding cortical  centres. 


FlG.  24.— Diagram  of  section  of  the  crus  (modified  from  Wernicke).  L  F,  U  F, 
upper  and  lower  fillet;  C  Q  A,  anterior  corp.  quad.;  Aq,  aqueduct; 
III,  nucleus  of  third  nerve  (3);  P  H,  posterior  horizontal  fibres;  c  p, 
brnchium  of  the  post.  corp.  quad.;  R  N,  red  nucleus;  S  N,  substantia 
nigra ;  0  G  I,  internal  geniculate  body ;  T  0  C,  temporo-occipital  cerebellar 
fibres;  Py,  pyramidal  fibres;  F  C,  fronto-cerebellar  fibres;  C  C,  caudate 
cerebellar  fibres ;  t,  inner  fibres  of  crusta  to  tegmentum. 


STRUCTURE    AND    FUNCTIONS. 


31 


Thus,  of  the  white  fibres  that  constitute  the  crusta,  or  lower  half  of 
the  crus  cerebri,  less  than  half  belong  to  the  pyramidal  tracts.  What 
are  the  other  crustal  fibres  ?  They  lie  partly  on  the  outer  side  of  the 
pyramidal  fibres  (t  o  c,  Fig.  24),  partly  on  the  inner  (medial)  side 
(f  c),  partly  above  (c  c),  between  the  pyramidal  fibres  and  the  sub- 
stantia nigra.     Only  those  on  the  inner  (medial)  side  of  the  pyramidal 


PlG.  25. — Diagram  of  the  course  of  the  motor  tract  as  shown  in  a  diagram- 
matic horizontal  section  through  the  cerebral  hemisphere,  pons,  and  medulla. 
Fr,  frontal  lobe;  Oc,  occipital  lobe;  A  F,  ascending  frontal,  and  A  P, 
ascending  parietal,  convolutions;  P  C  F,  pre-central  fissure  in  front  of  the 
ascending  frontal  convolution;  I P  F,  interparietal  fissure.  A  section  of 
the  crura  is  lettered  on  the  left  side:  S  N,  substantia  nigra;  Py,  region 
occupied  by  the  pyramidal  fibres  (motor  tract),  which  on  the  right  are 
shown  as  continuous  lines,  converging  in  the  white  substance  of  the  hemi- 
sphere, to  pass  through  the  posterior  limb  of  I  C,  the  internal  capsule  (the 
elbow  of  which  is  shown  at  *) — through  the  crus  and  pons,  and  to  divide 
in  the  medulla  into  the  decussating  lateral  pyramidal  tract  (Ipt)  and  the 
direct  anterior  pyramidal  tract  (apt). 

tract  pass  up  into  the  internal  capsule.  The  change  in  the  direction 
of  the  crus  brings  these  inner  fibres  in  front  of  those  of  the  pyramidal 
tract,  and  they  form  the  anterior  limb  of  the  capsule  (Fig.  25).  They 
radiate  to  the  cortex  of  the  "pre  frontal  lobe,"  i.e.  that  part  of  the 
brain  which  lies  in  front  of  the  central  convolutions.  From  the  crus 
they  pass  downwai'ds  into  the  pons.     They  degenerate  downwards,  and 


82 


BKA1N. 


have  been  found  degenerated  in  many  cases  of  disease  of  the  anterior 
part  of  the  capsule  and  in  extensive  softening  of  the  cortex.*  Hence 
we  may  assume  that  they  conduct  downwards,  but  their  degeneration 
stops  in  the  pons,  apparently  because  they  end  in  the  grey  matter 
which  is  so  abundant  in  the  crustal  portion.  This  grey  matter  also 
receives  fibres  from  the  middle  cerebellar  peduncles,  and  these  fibres 
probably  decussate  in  the  middle  line  before  entering  the  nerve-cells 
(Lallemont).  They  seem  to  continue  the  path  constituted  by  the 
inner  crustal  fibres.  Thus  each  pre-frontal  lobe  is  specially  connected, 
not  only,  as  we  have  seen,  with  the  occipital  cortex  of  its  own  side, 
but  also  with  the  opposite  cerebellar  hemisphere,  and  chiefly  with  its 
lateral  and  posterior  regions.  When  the  cerebellum  is  congenitally 
absent,  these  fibres,  the  crustal  grey  matter  of  the  pons,  and  the 
anterior  limb  of  the  internal  capsule  are  absent  (Flechsig).  In 
animals  the  grey  matter  atrophies  if  the  cerebellum  is  excised.f 

One  small  bundle  of  fibres  in  the  inner  part  of  the  crusta  (t,  Fig.  24), 
lying  close  to  the  medial  surface,  differs  from  the  rest.  As  it  descends, 
it  passes  backwards  into  the  tegmentum,  and  joins  the  fillet.  Its 
further  relations  have  not  been  traced. 

The  crustal  fibres  that  lie  outside  the  pyramidal  tractj  (t-o-c,  Fig. 
25)  do  not  enter  the  internal  capsule.  They  leave  the  other  fibres  when 
the  crus  enters  the  hemisphere,  and  pass  partly  beneath  the  lenti- 
cular nucleus,  partly  between  its  posterior  extremity  and  the  outer  geni- 
culate body,  to  radiate  towards  the  cortex  of  the  occipital  and  temporal 

lobes.  Downwards  they  pass  into 
the  crustal  portion  of  the  pons 
and  then  end  in  the  grey  mat- 
ter, just  as  do  the  inner  fibres, 
and  are  probably,  in  like  man- 
ner, connected  with  the  cerebellar 
hemisphere,  chiefly,  Flechsig 
thinks,  with  the  upper  surface, 
near  the  middle  lobe.  These 
fibres  are  also  wanting  when  the 
Fig.  26.— Crura  cerebri ;  positi.  n  of  the  cerebellum  is  absent.  Flechsig 
fronto- cerebellar  (Pr-C),  pyramidal  (Pyr)i    ,i  i  .  xi    x*xi         i  j.    i 

and    temporo-occipital    cerebellar    fibres    thought  that  they  do  not  dege- 
(T-O-C)  on  the  surface.  nerate    downwards,   but   it   ap- 

'  pears  certain  that  they  do, 
since  they  have  been  found  degenerated  in  several  cases  of  dis- 
ease of  the  occipital  and  temporal  cortex.  §     It  was  formerly  believed 

*  Rossolymo,  'Neur.  Cent.,'  1886. 

f  Marchi,  *  Rivist.  sperim.  de  freniat.,'  1886. 

X  Sometimes  called  "  Tiirek's  bundle,"  but  to  be  carefully  distinguished  from 
"  'lurch's  column  "  in  the  cord. 

§  Bechterew,  'Cent,  f.  Nervenh.,'  1886,  p.  635.  See  also  under  "Secondary 
Degenerations;"  also  Kreuser  ('Allg.  Zeitschr.  f.  Psych.,' xlviii)  relates  a  case  in 
which  there  was  absence  of  the  occipital  lobe  on  one  side,  and  amongst  other  changes 


STRUCTURE    AND    FUNCTIONS. 


33 


that  these  fibres  enter  the  internal  capsule  and  constitute  its  pos- 
terior extremity,  which  is  known  to  he  the  chief  sensory  path,  and 
this  statement  is  still  made  in  some  text-hooks.  But  Flechsig,  by 
developmental  investigations,  has  shown  that  this  is  an  error,  and 
his  conclusions  have  been  confirmed  by  pathology.  As  the  fibres 
separate  from  the  pyramidal  tract,  their  place  is  taken  by  sensory  fibres 
from  the  tegmentum,  and  thus  the  extremity  of  the  capsule  is  formed. 
The  last  part  of  the  crusta  to  be  considered  is  the  thin  layer  of  fibres 
which  lies  above  the  pyramidal  tract,  between  it  and  the  substantia 
nigra.  According  to  Flechsig,  these  arise,  above,  from  the  corpus 
striatum  (caudate  nucleus,  and  outer  part  of  the  lenticular  nucleus), 
and  they  seem  to  end,  below,  in  the  pons,  probably  in  the  crustal  grey 
matter,  as  do  the  other  fibres  just  described.  They  degenerate  down- 
wards, and  cannot  be  traced  beyond  the  pons.  They  may  thus  counect 
the  corpus  striatum  and  cerebellum,  in  the  same  way  as  the  inner 
group  connects  the  pre-frontal  lobe  and  cei-ebellum.  Some  of  them 
may  be  connected  with  the  grey  matter  of  the  substantia  nigra. 

Thus,  of  all  the  fibres  of  the  spinal  cord,  the  pyramidal  tracts  alone 
find  a  place  in  the  crusta  of  the  cerebral  peduncle.  It  may  be  noted, 
moreover,  that  these  are  the  only  long  spinal  fibres  that  degenerate 
downwards.  The  other  fibres  of  the  cord  are  either  short  fibres 
or  degenerate  upwards,  and  are  connected  with  the  cerebellum  or 
with  the  tegmentum  of  the  cms.  Their  connections  are  at  present 
very  imperfectly  known,  but 
are  of  great  importance.    The  /*">'■*.* 

sensory  path  must  be  sought     „      ..*•■- --..,''     -  ;  .     -Hu 

in   some   of   these  fibres;  it     ^    •  ^>,    <?v  >■ 

certainly  lies  in  the  tegmen-  s  ■  ;■{■■■■  i,"'lMUE  ..ui-r  :  ■;  .  QS%', 
turn  of  the  cms,  and  proba-  5:  ■-■  ;F°;' -/''■'  r,t  '  Ja  r\  >"' .  r  ^% 
bly  passes  to  the  cms  by  the 
tegmental  region  of  the  pons. 
In  the  tegmental  region  of 
the  pons,  as  we  have  already 
seen,  three  chief  groups  of 
fibres  may  be  distinguished, 
(Fig.  27),  the  small  bundle 
of  "  posterior  longitudinal 
fibres,"  the  «■  fillet,"  and  the 
extensive  "  reticular  forma- 
tion." We  have  to  consider 
the  connection  of  the  remain- 
ing tracts  of  the  cord  with 
these  structures  and  with  the 

cerebellum,   and  also  the  relation  of  these   tegmental  fibres  to  the 
cerebral  hemispheres. 

there  was  descending  degeneration  in  the  lateral  part  of  the  crus,  which  could  be 
followed  down  to  the  pons,  where  it  gradually  disappeared. 

VOL.  II.  3 


t 


y 


Fig.  '11.—  Diagram  of   one  half  of  a  section 
through  the  middle  of  the  pons.     S  o,  supe- 
rior olivary  body;    V as,  ascending  root,  Vm, 
.middle  nucleus,   V  motor,  motor  nucleus  of 
the  fifth  nerve. 


34  BRAIN. 

Most  of  the  white  columns  of  the  cord  become  occupied  by  grey 
matter  when  they  reach  the  medulla  oblongata.  Their  fibres  probably 
end  in  the  cells  of  this  grey  matter,  from  which  other  fibres  proceed 
aud  continue  the  functional  conducting  path  of  the  spinal  tracts. 
Nerve-cells  arrest  secondary  degeneration  ;  and  hence  most  ascending 
degenerations  of  the  cord,  as,  for  instance,  that  of  the  posterior  median 
columns,  stop  in  the  medulla.  This  very  much  increases  the  difficulty 
of  tracing  the  connection  of  these  fibres. 

One  tract  passes  up  to  the  cerebellum  without  interruption,  the 
direct  cerebellar  tract.  Its  fibres  pass  in  the  restiform  body,  and  reach 
the  middle  lobe  of  the  cerebellum  ;  they  cross  the  middle  line,  and  end 
in  the  opposite  side  of  this  lobe.  They  degenerate,  and  doubtless 
conduct,  upwards,  and  probably  conduct  centripetal  impressions  from 
the  muscles  of  the  lower  part  of  the  trunk  to  the  co-ordinating 
mechanism  in  the  cerebellum  (see  vol.  i,  pp.  170  and  181).  A  few 
fibres  from  the  direct  cerebellar  tract  pass  up  into  the  pons. 

The  postero-median  column  (col.  of  Groll)  is  sometimes  termed,  at 
the  medulla,  the  "funiculus  gracilis,"  sometimes  the  "posterior 
pyramid."  Its  fibres,  or  at  least  most  of  them,  end  in  the  grey  matter 
which  occupies  this  region  of  the  medulla,  the  "  post-pyramidal 
nucleus,"  or,  better,  "postero-median  nucleus  "  (Fig.  28,  p.  m.  n.). 
Here  ascending  degeneration  stops.  The  postero -external  column 
("funiculus  cuneatus,"  "col.  of  Burdach  ")  is  also  occupied  by  grey 
matter,  the  " postero-external  nucleus"  (p.  e.  n.).  From  the  cells 
of  these  nuclei  other  fibres  continue  the  upward  path.  Those  from 
the  two  nuclei  are  so  blended  that  their  distinction  is  scarcely  possible, 
and  the  difficulty  in  tracing  them  is  increased  by  the  circumstance  that 
their  course  is  circuitous.  Many  fibres  from  both  these  nuclei  course 
forwards  to  the  neighbourhood  of  the  olivary  bodies.  A  large  num- 
ber of  them  cross  the  middle  line,  in  front  of  the  central  canal,  form- 
ing a  decussation  analogous  to  that  of  the  pyramidal  fibres,  but  higher 
up  the  medulla  ;  it  is  of  course  wholly  unconnected  with  the  pyramids, 
but  it  has  been  rather  unfortunately  termed  the  "  superior  pyramidal 
decussation."  These  fibres  turn  upwards  between  the  two  olivary 
bodies  ("  interolivary  layer,"  i.  o.  z..)  and  between  them  and  the 
anterior  pyramids.  Some  are  probably  connected  with  the  cells  of 
the  olivary  bodies.  From  the  olivary  bodies  many  fibres  pass  to  the 
cerebellum  by  the  restiform  body,  and  these  may  establish  a  connection 
between  the  posterior  columns  and  the  cerebellum,  perhaps  by 
fibres  which  are  not  connected  with  the  cells  of  the  olivary  body. 
The  "  interolivary  layer,"  a  little  higher  up,  forms  the  commencement 
of  the  fillet,  which  has  been  already  mentioned,  and  the  fillet  is  thus 
connected  with  the  posterior  columns.  Other  fibres  from  these  pos- 
terior nuclei  pass  to  the  reticular  formation,  which  increases  in  size  as 
the  posterior  columns  lessen  in  size.  Thus  the  posterior  columns  are 
probably  connected  with  the  reticular  formation,  with  the  fillet,  and 
with  the  cerebellum. 


STRUCTURE    AND    FUNCTIONS. 


35 


The  olivary  body  bears  a  close 
corpus  dentatum  of  the  cerebellum, 
and  many  fibres  pass  between  the 
two.  The  connection  is  crossed, 
congenital  atrophy  or  long-stand- 
ing disease  of  one  cerebellar  hemi- 
sphere is  associated  with  atrophy 
of  the  opposite  olivary  body,  and 
experimental  removal  of  one  hemi- 
sphere in  animals  causes  a  similar 
atrophy. 

Although  the  ^esti form  body  (in- 
ferior cerebellar  peduncle)  appears 
to  be  formed  from  the  lateral 
column  of  the  cord,  its  external 
relation  does  not  indicate  its  real 
connections. '  Of  the  elements  of 
the  lateral  column,  only  the  direct 
cerebellar  tract  enters  the  resti- 
form  body.  The  pyramidal  tract 
leaves  the  lateral  column  to  cross 
to  the  opposite  anterior  pyramid, 
and  in  the  remaining  part  of  the 
lateral  column  grey  matter  ap- 
pears (just  as  it  does  in  the  pos- 
terior columns),  the  "lateral  nu- 
cleus." This  lies  in  front  of  a  grey 
mass  into  which  the  caput  cornu 
posterioris  (c.  c.  p.)  has  expanded, 
the  "grey  tubercle  of  Rolando" 
(t  R).  The  lateral  nucleus  higher 
up  is  continuous  with  the  reticular 
formation,   most   of  the  fibres  of 

Fig.  28. — Diagrams  of  the  structure  of 
the  medulla  oblongata.  A,  lower,  and 
B,  upper  part  of  decussation  of  the 
pyrHmids ;  C,  at  the  lowest  of  the  olivary 
bodies;  D,  at  the  apex,  and  E,  at  the 
middle  of  the  calamus  scriptorius.  A, 
anterior,  L,  lateral  column  of  cord;  A. P., 
ant.  pyramid;  R,  restiform  body;  a.  c, 
ant.  cornu ;  t  R,  tubercle  of  Rolando ; 
c.  c.p.,  caput  cornu  posterioris;  d.  c.  t., 
direct  cerebellar  tract ;  Hi/,  hypoglossal 
nerve;  ky.  nu.,  its  nucleus;  01,  olivary 
body;  p.  m.  c,  post.  med.  col.;  p.  e.  c, 
post.  ext.  col.;  p.  m.  n.,  post.  med. 
nucleus;  p.  e.  «.,  post.  ext.  nucleus; 
Sp.  A.,  spinal  accessory  nerve ;  sp.  a.  nu., 
its  nucleus;*  c, slender  column;  V.as., 
ascending  root  of  the  fifth  nerve. 


resemblance  in  structure  to  the 


fi.mn. 


AF    r.  /P     J.O.L. 


36  BKA1N. 

which  spring  from  the  nucleus.  Fibres  also  pass  from  the  lateral 
nucleus  and  reticular  formation  to  the  restiform  body  and  cerebellum, 
but  the  direction  in  which  they  conduct  is  uncertain.  Flechsig  thinks 
that  they  may  conduct  from  the  cerebellum  to  the  reticular  forma- 
tion. Besides  these  two  sets  of  fibres,  the  restiform  body  contains 
also  the  fibres  from  the  opposite  olivary  body  to  the  cerebellum, 
which  we  have  aheady  considered. 

The  autero-lateral  ascending  tract  seems  to  pass  to  the  reticular 
formation,  but  its  fibres  are  most  likely  interrupted  by  the  grey  matter 
of  the  lateral  nucleus.  We  have  seen  that  the  posterior  columns  are 
also  connected  with  the  reticular  formation.  It  is  probable  that 
the  upward  sensory  path  passes,  in  part  at  least  (and  perhaps 
chiefiv),  by  this  structure,  which  can  be  traced  through  the  pons 
into  the  tegmentum  of  the  crus,  in  which  the  sensory  path  certainly 
lies. 

The  fillet  or  lemniscus,  as  we  have  seen,  is  a  layer  of  fibres  that  lies 
between  the  crustal  and  tegmental  portions  of  the  pons,  on  the  anterior 
(ventral)  side  of  the  reticular  formation.  It  extends  through  the  crus 
cerebri,  where,  however,  it  moves  outwards,  and  lies  in  the  outer  part 
of  the  tegmentum.  There  is  still  much  difference  of  opinion  regardiuo- 
the  connections  of  its  fibres,  in  spite  of  the  fact  that  these  have  been 
the  subject  of  an  immense  amount  of  recent  investigation.*  It  is  clear, 
however,  it  contains  several  different  sets  of  fibres.  Below,  the  fillet 
arises,  as  already  stated  (p  34),  in  the  interolivary  layer,  formed  of 
the  arciform  fibres  which  proceed  from  the  nuclei  of  the  opposite  pos- 
terior columns,  median  and  external ;  part  of  the  fillet  thus  appears 
to  be  a  continuation  of  the  path  of  these  columns,  and  is  conjectured 
by  Spitzka  to  conduct  chiefly  centripetal  impressions  from  the  muscles. 
Many  of  the  fibres,  however,  degenerate  downwards ;  others  seem  to- 
degenerate  upwards.  In  a  case  in  which  the  fillet  was  destroyed  on 
the  left  side  of  the  pons  by  an  old  haemorrhage,  Spitzka  traced  the 
descending  degeneration  through  the  interolivary  layer  to  the  opposite 
nuclei  of  the  posterior  columns.  But  in  another  case  of  focal  lesion 
an  extensive  ascending  degeneration  of  the  same  part  of  the  fillet  was 
found  by  Meyer. f  A  few  fibres  also  seem  to  pass  to  the  lateral 
column  of  the  cord.  Among  the  different  sets  of  fibres  in  the  fillet 
we  may  distinguish  the  following  upward  connections: — (1)  Many 
fibres  pass  by  the  red  nucleus,  and  are  associated  with  fibres  from 
this  and  from  the  opposite  cerebellar  peduncle,  in  what  is  termed  the 
"  lenticular  loop,"  a  set  of  fibres  which,  beneath  the  optic  thalamus, 
turn  outwards  and  pass  transversely  through  the  internal  capsule,  to 

*  The  most  important  recent  writings  on  the  suhjcch  are  those  of  Flechsig  ('  Plan 
des  Menschliehen  Gehirns  ') ;  Flechsig  and  Becliterew  (abstract  by  Flechsig  in  the 
'' Neurologisches  Centralblatt,  1885,  p.  356);  Monakow  (ib.,  p.  265);  Wernicke 
(' Gehirakrankheiten,'  Bd.  i);  Spitzka  ('New  York  Med.  Record,'  lb84,  Nos.  15 — 
18)  ;  and  A.  Bruce  ('  The  Mid  and  Hind  Braiu,'  1892). 

t  '  Arch,  f .  Psych.,'  xvii,  p.  439. 


STRUCTURE    AND    FUNCTIONS.  37 

•end  in  the  lenticular  nucleus*  (Fig.  29).  (2)  Some  fibres  pass,  in  the 
pons,  into  the  reticular  formation.  (3)  Some  fibres  go  to  the  posterior 
corpus  quadrigeminum.  Some  of  these  end  below  in  the  superior 
olivary  body.  (4)  Other  fibres  end  in  a  collection  of  grey  matter 
lying  outside  the  junction  of  the  two  corpora  quadrigemina,  the 
«  nucleus  lemnisci "  of  Flechsig  and  Bechterew.  (5)  Fibres  pass  up 
to  the  posterior  part  of  the  internal  capsule,  and  radiate  with  these 
capsular  fibres  to  the  central  and  parietal  cortex.  Most  of  them  are 
said  to  be  connected  with  the  posterior  median  nucleus.  It  appears 
probable,  however,  that  they  degenerate  downwards  (Monakow, 
Spitzka). 

The  reticular  formation  contains  numerous  longitudinal  fibres,  the 
downward  connection  of  which,  with  the  lateral  column  and  posterior 
columns,  has  been  already  described.  It  also  receives  fibres  from  the 
nerve-nuclei  of  the  pons.  At  the  upper  part  of  the  pons  it  rapidly 
lessens  in  size,  and  many  of  its  fibres  go  to  the  upper  corpus  quadri- 
geminum,f  and  from  this  again  fibres  proceed  to  the  posterior  part  of 
the  internal  capsule  and  tegmental  radiation.  The  fibres  that  do  not 
go  to  the  corpus  quadrigeminum  pass  upwards  to  the  optic  thalamus, 
and  perhaps  to  the  posterior  part  of  the  internal  capsule  and 
tegmental  radiation;  a  few  go  to  the  grey  matter  lining  the  third 
ventricle. 

The  third  group  of  longitudinal  fibres  in  the  tegmental  portion  of 
the  pons  is  that  termed  the  posterior  longitudinal  fibres,  lying  near  the 
posterior  surface  and  middle  line  (Figs.  24,  29,  39) .  This  group  contains 
fibres  of  different  size.  The  finer  are  continuous  below  with  some  of 
those  of  the  anterior  column  of  the  cord,  and  above  pass  to  the 
central  grey  substance  that  lines  the  third  ventricle  (Flechsig).  The 
eoarser  fibres  extend  only  from  the  nucleus  of  the  third  and  fourth 
nerves  above  to  the  level  of  the  nucleus  of  the  sixth  below,  perhaps 
also  of  the  seventh, J  and  connect  these  nuclei.  Some  of  the  fibres 
decussate,  and  they  no  doubt  subserve  the  complex  associated  action  of 
the  eyeball  muscles,  their  relation  to  which  will  be  considered  later. 

In  the  lower  part  of  the  pons,  above  the  olivary  body,  is  a  small 
body,  with  somewhat  sinuous  outline,  the  superior  olivary  body.  It 
lies  in  the  anterior  part  of  the  tegmentum,  and  its  important  connec- 
tions have  been  traced  by  Bechterew.  §  According  to  him,  fibres  pass 
up  from  it  to  the  fillet  and  central  grey  substance  of  the  posterior 
quadi-igeminal  bodies  ;  other  fibres  pass  to  the  nucleus  of  the  sixth 
nerve,  the  anterior  auditory  nucleus,  the  cerebellum  (roof  nucleus  in 

*  In  a  case  of  absence  of  the  cerebellum,  examined  by  Flecbsig,  the  red  nucleus 
and  fibres  from  the  superior  cerebellar  peduncle  were  absent,  and  the  fillet  fibres  in 
the  lenticular  loop  were  very  distinct. 

f  A  few  of  these  reticular  fibres,  that  lie  close  to  the  fillet,  are  by  some  authori- 
ties regarded  as  belonging  to  this  structure. 

%  See  Turner  and  Tooth,  'Brain/  1892,  and  Mendel,  '  Neur.^Cent.,'  1S87,  p.  537. 

§  '  Wratsch,'  No.  32,  1885 ;  '  Cent.  f.  Nervenheilk.,'  1886,  p!  587. 


38  BRAIN. 

the  middle  lobe),  and  to  the  lateral  column  of  the  spinal  cord.  This 
connection  suggests  that  the  body  has  important  central  functions, 
and  it  may  be  through  it  that  an  auditory  impression  causes  a  lateral 
movement  of  the  eyes  and  head,  the  former  through  the  nucleus  of 
the  sixth,  the  latter  through  the  lateral  column  of  the  cord.  The  con- 
nection with  the  cerebellum  may  be  one  path  by  which  disease  or 
stimulation  of  the  cerebellum  influences  ocular  movements.  The 
corpora  quadrigemina  are  probably  concerned  in  the  movements  of  the 
eyes,  and  the  fibres  from  them  to  the  supeiior  olivary  body  belong  to 
that  part  of  the  fillet  which,  according  to  Flechsig,  degenerates  and 
conducts  downwards. 

Beneath  the  corpora  quadrigemina  the  tegmentum  receives  a  con- 
siderable accession  of  fibres  from  the  passage  into  it  of  the  superior 
cerebellar  peduncle,  the  fibres  of  which  come  chiefly  from  the  dentate 
nucleus.  They  may  be  connected,  through  this,  with  the  fibres  from 
the  olivary  body,  and  also  with  the  cortex  of  the  cerebellum.  Iu  the 
tegmentum  these  fibres  cross  the  middle  line,  and  are  connected  with 
the  opposite  red  nucleus,  which  is  absent,  with  the  fibres  of  this 
peduncle,  in  congenital  absence  of  the  cerebellum  (Flechsig).  Thus 
the  red  nucleus  may  be  connected  with  the  olivary  body  of  the  same 
side  by  means  of  the  opposite  dentate  nucleus.  Proceeding  upwards 
from  the  red  nucleus,  the  fibres  divide  into  two  groups  :  one  passes 
forwards  and  outwards  to  the  lenticular  loop,  and  thus  to  the  lenticular 


Fig.  29. — Diagram  of  a  section  through  the  crus,  &c,  in  front  of  the  corp. 
quad.  PC,  posterior  commissure;  Aq,  aqueduct  of  Sylvius;  P  L,  poste- 
rior longitudinal  fibres.:  HI,  third  nerve;  L  B,  Luy's  body;  OPT,  optic 
tract.     (Modified  from  Wernicke.) 

nucleus  (Fig.  29)  ;  the  other  courses  backwards  and  outwards,  partly 
into  the  basal  part  of  the  optic  thalamus,  partly  into  the  posterior 
part  of  the  internal  capsule  and  tegmental  radiation.     Those  fibres 


STRUCTURE    AND    FUNCTIONS.  39 

which,  enter  the  thalamus   perhaps  merely   pass   through  it  to  the 
capsule. 

Thus  the  chief  destination  of  the  tegmentum,  including  the  superior 
cerebellar  peduncle,  is  twofold — the  lenticular  nucleus,  and  the  cortex 
of  the  hemisphere  by  the  tegmental  radiation.  Fibres  go  to  each  of 
these  from  the  fillet  and  the  cerebellar  peduncle,  and  other  fibres  of 
the  fillet,  together  with  those  of  the  reticular  formation,  ultimately 
reach  the  tegmental  radiation.  As  before  stated,  the  sensory  path 
certainly  lies  in  the  tegmental  radiation  where  this  begins  in  the  hind- 
most regicn  of  the  internal  capsule.  It  is  also  practically  certain  that 
most  forms  of  sensation  from  the  limbs  pass  through  the  tegmentum 
of  the  pons,  and  it  is  probable  that  the  path  is  different  for  the 
different  forms  of  sensibility.  It  may  be  assumed  that  no  sensory 
impressions  pass  in  the  larger  division  of  the  fillet  (which  is  connected 
above  with  the  lenticular  nucleus)  since  the  fibres  degenerate  down- 
wards, nor  by  the  posterior  longitudinal  bundles,  which  are  not  con- 
nected with  the  tegmental  radiation.  There  remain,  then,  as  possible 
paths  only  the  upper  smaller  division  of  the  fillet  and  the  longitudinal 
fibres  of  the  reticular  formation.  It  has  been  conjectured  that  some 
forms  of  sensibility,  e.  g.  visceral  sensibility  and  muscular  sensibility, 
may  pass  through  the  cerebellum  and  superior  cerebellar  peduncles. 
But  the  perceptions  of  posture  and  movement  are  very  complex. 
They  depend  in  part  on  afferent  impression  from  the  muscles,  tendons 
ligaments,  and  joints,  which  are  perceived  as  sensations,  or  can  be  so 
perceived  by  attention.  The  path  of  these  is  probably  through  the 
pons,  and  some  facts  recently  ascertained  suggest  that  they  pass  up 
in  that  part  of  the  reticular  formation  and  fillet  which  is  nearest  the 
raphe.*  But  the  perceptions  of  posture  and  movement  are  probably 
also  due  in  considerable  degree  to  the  activity  of  the  motor  cells  of 
the  cortex,  under  the  influence  of  impulses  that  proceed  from  the 
middle  lobe  of  the  cerebellum,  and  are  due  to  its  activity  under  the 
influence  of  impulses  from  the  muscles,  the  semicircular  canals,  &c. 
On  this  hypothesis  we  can  understand  the  origin  of  perceptions  of 
posture  and  of  movement  which  are  not  true  sensations  ;  active  states 
of  the  cortical  motor  cells  must  correspond  to  the  states  of  the  muscles 
in  passive  as  well  as  in  active  movement  (see  vol.  i,  p.  12).  It  is, 
moreover,  noteworthy,  in  connection  with  the  passage  of  the  true 
sensory  impulses  by  the  fillet,  that  a  connection  of  this  with  the 
middle  lobe  of  the  cerebellum  (by  fibres  of  the  middle  peduncle)  has 
been  lately  described. f 

The  posterior  third  of  the  internal  capsule  contains  not  only  the 
sensory  path  from  the  limbs,  but  also  the  optic  path,  and  it  also  con- 
tains the  paths  for  the  other  special  senses ;  those  for  hearing  and 
taste  ascend  to  it  from  the  pons  in  the  tegmentum.     How  the  path  for 

*  Senator,  CA.  f.  Psych./  xi,  p.  725,  and  xiv,  p.  663 ;  Goldscheider,  'Char.  Ann.,' 
xvi,  1891,  p.  162. 

f  Marclii,  '  Riv.  sper.  di  fren.,  &c.,'  1891. 


40  1MA1N. 

smell  reaches  it  is  at  present  unknowu.  This  is  the  "  sensory  cross- 
way  "  of  Charcot,  in  which  a  lesion  causes  hemiansesthesia,  hemianopia, 
and  loss  of  the  other  special  senses,  all  on  the  side  opposite  to  the  lesion. 

Central  Ganglia. — The  corpus  striatum  and  optic  thalamus  present 
considerable  differences  in  their  connections,  and  these  probably  indi- 
cate fundamental  differences  in  function,  although  we  are  still  almost 
entirely  in  the  dark  as  to  the  nature  of  their  function. 

The  grey  matter  of  which  the  optic  thalamus  is  composed  consists 
of  fine  nerve-cells,  among  which  narrow  tracts  of  fibres  pass.  At  the 
surface  is  a  layer  of  white  fibres,  the  "  zonal  stratum,"  and  outside 
this  again  a  very  thiu  layer  of  gelatinous  grey  matter,  continuous  with 
that  lining  the  third  ventricle  and  surrounding  the  central  canal  of 
the  cord.  It  is  the  union  of  this  layer  on  the  two  thalami  that  con- 
stitutes the  posterior  commissure.  Tlie  posterior  extremity  of  the 
thalamus  is  distinguished  as  the  "pulvinar,"  and  between  the  extremi- 
ties of  the  two  thalami  lie  the  anterior  corpora  quadrigemina.  The 
grey  matter  of  which  the  thalamus  is  composed  is  divided  by  a  thin 
stratum  of  white  fibres  (internal  medullary  lamina)  into  an  external  and 
an  internal  nucleus,  and  the  lamina  divides  anteriorly  into  two,  which 
join  the  capsular  layer,  and  with  it  enclose  a  small  anterior  nucleus. 
The  most  important  connections  of  the  thalamus  are  with  the  cortex, 
the  optic  tracts,  and  the  tegmentum  of  the  crus.  It  is  connected  with 
all  parts  of  the  cortex  by  fibres  that  pass  from  it  to  the  internal  cap- 
sule and  corona  radiata,  of  which  they  form  a  large  part.  They  pass 
to  all  parts  of  the  cortex ;  those  from  the  pulvinar  go  to  the  occipital 
lobe,  and  constitute  part  of  the  "  optic  radiation  "  of  G-ratiolet.  It  is 
probable  that  most  of  these  fibres  conduct  from  the  thalamus  ;  never- 
theless some  fibres  from  the  central  convolutions  to  the  thalamus  have 
been  found  to  degenerate  downwards.*  Fibres  also  pass  between  the 
thalamus  and  lenticular  nucleus,  but  we  do  not  know  whether  they 
end  in  the  lenticular  nucleus,  or  merely  pass  through  it  to  the  cortex. 

The  connection  of  the  thalamus  and  optic  tract  will  be  described  in 
the  account  of  the  latter.  The  chief  downward  connection  of  the 
thalamus  is  with  the  tegmentum.  This  may  be  said  to  end  beneath 
the  posterior  part  of  the  thalamus,  in  what  has  been  termed  the 
"  subthalamic  region,"  in  which  are  certain  collections  of  grey  matter. 
Many  fibres  pass  to  the  thalamus  from  the  superior  cerebellar 
peduncle,  going  through  the  red  nucleus.  The  extent  of  the  connec- 
tion of  the  thalamus  with  the  fillet  and  the  reticular  formation  is  a 
subject  on  which  there  is  much  difference  of  opinion.  Wernicke  finds 
the  chief  origin  of  the  fillet  in  the  thalamus,  while  Flechsig  could  trace 
no  connection  between  them. 

Corpus  Striatum. — The  caudate  nucleus  is  more  uniform  in  structure 
than  is  the  lenticular  nucleus.  In  the  latter  two  narrow  laminae  of 
white  fibres,  almost  vertical  in  direction,  divide  the  grey  substance 
*  Maunkopf,  '  Zeitsch.  f.  kl.  Med.,5  18S4,  Bd.  vii,  Sup. 


STRUCTURE    AND    FUNCTIONS.  41 

into  three  zones,  inner,  middle,  and  outer  (Fig.  29).     In  consequence 

of  the  shape  of  the  nucleus,  the  outer  zone  is  the  most  extensive,  both 

in  the  antero-posterior  and  vertical  direction  ;  and  it  is  also  darker  in 

tint  than  the  other  parts.     Each  part  of  the  corpus  striatum  consists  of 

nerve-cells,  large  and  small,  and 

interlacing  fibres.     The  fibres 

are  far  more  numerous  in  the 

lenticular  than  in  the  caudate 

nucleus  ;    hut   it    is    probable 

that    many    of    these    merely 

pass  through  the  former,  while      -;   ']  /      a^  '  <-^%    2      Y  < 

the  fibres  that  enter  the  cau-  ,!  .     LE>i1Jc'l '/ !"AR  '•■'    Jj  i5       V- 

■date  nucleus  are  connected  with        •    -  :     <    J  . .    n       UJ  "     ,  £ -.) 

its  cells.     Moreover  the  outer     ~~\  ;      .,;      ?°f*:'Q'     '■''?  '/  /^'. 

part  of  the  lenticular  nucleus        -      '"-\    ^^*^x '■  x'iC  "c'-^ 

i  OPTIC      3  S~7r-'.'-5.±J   ^  *     - 

actually  blends  with  the  cau-        —i2ZL*y      ^J:j:'^~  *m         l***°ae" 
date  nucleus  in  front  by  tracts    p^_  w.-Di^mrf  a  transverse  section  of 
of     grey     matter    which     pass        the  lenticular  nucleus  and  internal  capsule, 
through  the  internal   capsule.        I.  n>  m>  indicate  the  three  parts  of  the 
m      ,,  . ,        cj.li  nucleus;  ant.com.,  section  of  the  bundle 

ATo  the  outer  side  of  the  len-  of  fibres  o£  the  anteri0r  commissure  to  the 
ticular  nucleus  is  the  white  temporo-sphenoidal  lobe, 
layer  of  the  "  external  cap- 
sule," and  the  grey  lamina  of  the  "claustrum."  According  to 
Kowalewsky*  all  three  limbs  of  the  lenticular  nucleus  receive  fibres 
from  the  internal  capsule  and  corona  radiata,  while  the  external  cap- 
sular fibres  are  connected  with  some  if  not  all  those  limbs.  Further, 
all  these  limbs  are  connected  with  each  other,  and  he  regards  the 
lenticular  and  caudate  nuclei  as  together  forming  one  ganglion, 
divided  into  two  by  the  internal  capsule. 

It  is  doubtful  whether  the  corpus  striatum  has  any  connection  with 
the  cortex,  and  the  old  hypothesis  that  its  cells  interrupt  the  fibres 
which  conduct  motor  impulses  seems  to  be  altogether  wrong.  Mey- 
nert  thought  that  many  fibres  pass  from  the  caudate  nucleus  to  the 
cortex ;  but  the  researches  of  Wernicke  and  Others  make  this  connec- 
tion very  doubtful.  It  is  extremely  difficult  to  ascertain  whether  the 
lenticular  nucleus  is  connected  with  the  cortex,  on  account  of  the 
number  of  fibres  that  pass  through  it  and  do  not  end  in  it.  Fibres, 
however,  pass  from  the  caudate  nucleus  to  the  internal  capsule,  and 
others  pass  to  the  crus  through  the  lenticular  nucleus.  These  caudate 
fibres  seem  to  end,  as  we  have  seen,  in  the  pons,  and  to  be  con- 
nected, through  the  pontine  grey  matter,  with  the  fibres  of  the  middle 
cerebellar  peduncles.  The  lenticular  nucleus  differs  from  the  caudate 
nucleus  in  being  extensively  connected  with  the  tegmentum  of  the 
eras  cerebri  by  many  fibres,  and  especially  by  those  of  the  lenticular 
loop.  It  is  also  connected  in  a  similar  manner  with  the  superior 
cerebellar  peduncle.  The  connection  of  the  corpus  striatum  with  the 
*  '  K.  Akad.  der  Wissensch./  1882. 


42  BKA1N. 

cerebellum  is  thus  very  considerable.  When  the  cerebellum  is  absent, 
the  corpus  striatum  is  reduced  to  a  third  of  its  uormal  size.  Flechsig 
aud  Wernicke  consider  that  it  must  be  regarded  as  a  central  organ, 
analogous  to  the  cortex.  The  latter  has  also  pointed  out  that — the 
lenticular  nucleus  being  continuous  with  the  grey  matter  of  the 
anterior  perforated  spot,  and  this  being  continuous  with  the  cortex — 
the  grey  matter  of  the  corpus  striatum  may  even  be  conceived  to  be 
homologous  with  that  of  the  cortex.  The  "  amygdala  "  of  the  temporo- 
sphenoidal  lobe  is  an  instance  of  the  development  of  the  cortical  grey 
matter  into  the  white  substance  to  such  an  extent  as  to  appeal", 
in  some  sections,  as  if  it  were  a  central  mass. 

The  Corpora  quadrigemina  are  masses  of  grey  matter  mingled  with 
fibres,  which  lie  over  the  aqueduct  of  Sylvius  aud  the  tegmentum 
of  the  crus  cerebri.  A  process  or  "brachiuin  "  extends  forward  from 
each,  and  contains  white  fibres,  which  proceed  from  a  superficial 
layer  immediately  beneath  the  convex  surface.  The  process  from 
the  anterior  tubercle  sends  fibres  to  the  external  geniculate  body,  and, 
by  the  posterior  portion  of  the  internal  capsule,  to  the  tegmental  or 
optic  radiation.  That  of  the  posterior  tubercle  goes  to  the  internal 
geniculate  body,  aud  is  thus  connected,  according  to  Von  GJ-udden,  with 
the  commissural  fibres  of  the  optic  tract,  which  at  the  optic  chiasma 
turn  back,  along  the  opposite  optic  tract,  to  the  opposite  internal 
geniculate  body  and  corpora  quadrigemina. 

The  quadrigeminal  bodies  receive  many  fibres  from  the  teg- 
mentum, chiefly  from  the  reticulate  formation,  and,  according  to  some 
authorities,  from  the  fillet.  From  the  grey  matter  of  the  corpora 
quadrigemina  fibres  pass  directly  to  the  subjacent  nucleus  of  the  third 
nerves  (Meynert). 

We  have  no  direct  evidence  of  the  function  of  these  ganglia.  The 
results  of  experiment  are  difficult  to  interpret,  and  these  bodies 
appear  to  have  a  higher  relative  importance  in  animals.  In  man  they 
are  scarcely  ever  the  seat  of  isolated  disease.  It  is  not  probable  that 
they  are  directly  concerned  in  the  function  of  vision.  Stimulation  of 
either  the  anterior  or  posterior  causes  dilatation  of  the  pupils,  first  of 
that  on  the  side  opposite  to  the  tubercle  stimulated;  while  further 
stimulation  causes  tonic  and  tetanic  spasm,  ending  in  opisthotonos, 
and  stimulation  of  the  posterior  causes  the  animal  to  cry  out  (Perrier 
and  others).  The  relation  to  the  optic  nerve  and  oculo-motor  nuclei, 
and  likewise  some  of  the  results  of  experiment,  strongly  suggest  that 
these  bodies  are  concerned  in  the  adjustment  of  ocular  movements  to 
visual  impressions.  The  spasm  produced  by  their  stimulation  must 
be  of  reflex  origin,  and  suggests  important  connections;  but  of  the 
nature  of  these  we  have  at  present  no  evideuce. 


STBUOTURHJ    AND    FUNCTIONS. 


43 


Origin  of  the  Cranial  Nerves. 

The  surface  attachment  of  the  cranial  nerves  is  too  well  known  to 
need  repetition  here.  Their  relative  position  is  shown  in  the  accom- 
panying figure  (Fig.  31),  and  is  of  considerable  importance  because  it 
determines  the  grouping  of  nerve  palsies  in  diseases  of  the  base  of  the 
brain.  The  nerves  that  arise  nearest  the  middle  line,  and  are  there- 
fore most  readily  affected  on  both  sides  by  a  single  lesion,  are  the 
third  nerves.  The  two  sixth  nerves  are  also  near  together,  and  so  are 
the  two  hypoglossal  nerves,  but  the  latter  are  seldom  both  affected  by 
disease  outside  the  medulla  because  each  passes  outwards,  and  they 
are  separated  by  the  prominent  anterior  pyramids.  The  two  sixth 
nerves  suffer,  on  the  other  hand,  with  great  frequency,  because  they 
have  a  long  course,  not  far 
apart,  over  the  most  pro- 
minent part  of  the  pons, 
and  they  are  readily  af- 
fected by  distant  pressure. 
The  nerves  that  are  farthest 
apart,  and  are  least  fre- 
quently damaged  together 
by  a  basal  lesion,  are  the 
two  fifth  nerves. 

With  regard  to  the  rela- 
tive position  of  the  nerves, 
the  fifth  occupies  a  com- 
paratively isolated  posi- 
tion at  its  surface  attach- 
ment :  the  sixth  nerve  is 
the  nearest,  and  is  most 
frequently  associated  with 
it  in  paralysis.  As  the 
fifth  nerve  enters  the  dura 
mater  the  third  and  fourth 
nerves  are  also  near  it 
(Fig.  32).  The  contiguity 
of  the  facial  and  auditory, 
and  also  that  of  the  glosso- 
pharyngeal, vagus,  and 
spinal  accessory,  are  well 

known.  It  should  be  especially  noted  that  the  hypoglossal  passes 
outwards  close  to  the  spinal  accessory,  and  hence  these  two  nerves 
not  unf'requently  suffer  together,  and  palsy  of  the  tongue  is  then 
conjoined  with  that  of  the  vocal  cord  on  the  same  side. 

The  deep  origin  of  these  nerves  (with  the  exception  of  the  first  two) 
is  from  a  series  of  tracts  of  grey  matter  which  are  situated  in  front  of 


Fig.  31. — Origin  of  the  cranial  nerves  (indicated 
by  the  roman  numerals).  Th,  thalamus;  t  c, 
tuber  cinereum;  h,  pituitary  body  ("hypo- 
physis cerebri ") ;  P,  peduncle ;  P  V,  pons 
Varolii;  a,  corpora  albicantia;  Ce,  cerebellum ; 
pa,  anterior  pyramid  ;  o,  olivary  body.  (After 
Henle.) 


44 


JBKA1N. 


the  central  cavity  of  the  mesencephalon,  and  extend  from  the  level 
of  the  anterior  corpora  quadrigerniua  ahove  to  that  of  the  decussation 
of  the  pyramids  below.  Above  and  below,  these  tracts  lie  near  the 
middle  line,  but  beneath  the  floor  of  the  fourth  ventricle  they  exteud 
almost  from  one  side  of  the  floor  to  the  other.  Most  of  the  nuclei 
are  situated  between  the  reticular  formation  and  the  floor  of  the 
ventricle,  but  some  lie  on  the  outer  side  of  the  reticular  formation. 


-AT 


FlG.  32. — Base  of  the  skull,  showing  the  relative  positions  of  the  nerves  (1 — 
XII)  as  they  enter  the  dura  mater,  which  has  been  removed  on  the  right 
side  from  the  Gasserian  ganglion,  V*  ;  f  c  b,  cut  edge  of  falx  cerebelli ;  H, 
pedicle  of  pituitary  body  or  hvpophysis  cerebri;  T,  cut  edge  of  tentorium. 
(After  Henle.) 

It  is  probable  that  the  upward  path  from  those  nuclei  that  are  sensory 
in  function  lies  in  the  reticular  formation,  while  that  from  the  brain 
to  the  motor  nuclei  runs  chiefly  with  the  pyramidal  tracts,  as  we 
have  already  seen.  The  tracts  of  grey  matter  which  constitute  these 
nuclei  are,  for  the  most  part,  of  small  transverse  sectional  area,  but 
of  considerable  length. 

The  hypoglossal  nucleus  (Figs.  28,  34,  35)  is  situated  close  to  the 
middle  line,  and  extends  from   just  above  the   decussation  of  the 


STRUCTURE    AND    FUNCTIONS. 


45 


pyramids  to  the  calamus  scriptorius  of  the  fourth  ventricle,  at  the 
point  of  which  it  lies  beneath  the  prominence  that  adjoins  the  raphe. 
Below,  it  is  situated  in  front  of  the  central  canal.  The  nerve-fibres 
pass  from  it  through  the  inner  part  of  the  reticular  formation  and 
olivary  body,  and  then  curve  outwards  between  the  latter  and  the 
anterior  pyramid.  Besides  the  chief  hypoglossal  nucleus  there  is  also 
the  small-celled  nucleus  of  Roller,  nucleus  centralis,  which  lies  ventrally 
to  the  chief  nucleus  and  surrounds  its  root-bundles.  There  are  also 
some  large  cells  lying  among  the  roots  of  the  nerve  and  probably 
reinforcing  them,  constituting  the  so-called  nucleus  accessorius  of 
Duval.  The  nuclear  origin  of  the 
fibres  for  the  palate  and  vocal 
cords  running  in  the  spinal  acces- 
sory nerve  may  possibly  be  in  the 
lower  part  of  the  hypoglossal  nu- 
cleus.* 

Accessory,  vagus,  and  glosso-pTia- 
ryngeal. — A  group  of  nerve-cells  be- 
hind the  hypoglossal  nucleus,  and 
behiud  the  level  of  the  canal,  is  the 
lower    part   of    the    nucleus    of   the 

spinal  accessory   nervef  (Fig.  28,  sp. 

a.  nu.),  and  from  it  the  fibres  course 

outwards  (Sp.  A)  through  the  lateral 

part  of   the  medulla.     As  the  canal 

opens    out  into  the  fourth  ventricle, 

this    nucleus    passes    to    the    outer 

side    of    the    hypoglossal,     and    the 

fibres  pass  forwards  between  the  reti- 
cular  formation    and    the    restiform 

body.     The  nucleus  is  the  lowest  part 

of  a  tract  of  grey  matter,  the  upper 

part  of  which  lies  beneath  the  floor 

(at  the    "  ala   cinerea")    outside  the 

eminentia    teres,    and    gives    origin, 

above  the  upper  fibres  of  the  spinal 

accessory,  to  the  fibres  of  the  pneumo- 

gastric,  and  then  to  those  of  the  glosso- 
pharyngeal.    The  filaments  of  origin 

of   these   nerves    form    a   continuous 

series,  and  it  is  scarcely  possible  to 

say  where  one  ends  and  another  begins.     They  all  have    a  similar 

course  to  the  surface,  emerging  beside  the  prominence  of  the  resti- 


FiG.  33. — Diagram  of  the  relative 
position  of  the  nerve  nuclei  beneath 
the  floor  of  the  fourth  ventricle. 
Ill,  third  nerve  nucleus;  IV, 
fourth;  V  s,  middle  sensory  nu- 
cleus of  the  filth;  V  m,  motor 
nucleus  of  fifth;  VI,  sixth;  F, 
facial ;  An,  auditory ;  H,  hypo- 
glossal ;  V  a,  vago-accessorial  nu- 
cleus, the  upper  part  giving  origin 
to  the  pneumogastric,  the  lower 
to  the  highest  fibres  of  the  spinal 
accessory.  Where  one  nucleus  lies 
beneath  another  its  outline  is  in- 
dicated by  a  dotted  line. 


*  Lockhart  Clarke,  '  Phil.  Trans.,'  1868. 

f  The  lower  fibres  of  the  nerve  arise,  not  from  the  spinal  accessory  nucleus,  but 
from  the  anterior  cornu  of  the  upper  cervical  cord.  These  fibres  supply  the  muscles 
of  the  neck. 


46 


BKA1N. 


form  body,  and  all  pass  through  a  group  of  longitudinal  fibres,  more 
or  less  oval  in  transverse  section,  the  ascending  root  of  the  fifth 
nerve   (Fig.   34,  Y  asc).      ]So  other  nerve-roots   pass  through  this 


Fig.  34. 


Fig.  35. 


CB"!  „_»— « 


Fig.  34. — Origin  of  pneumogastric.  Hy,  hypoglossal  nucleus;  Png,  chief  nucleus 
of  pneumogastric ;  An,  i  e,  lowest  part  of  internal  and  (so-called)  external  auditory 
nuclei ;  V  asc,  ascending  root  of  fifth ;  X,  nucleus  of  unknown  function  in  front  of 
reticular  formation  (eet.  poem.)  ;  x,  fibres  passing  forwards  from  the  neighbour- 
hood of  the  vagal  nucleus. 

FlG.  35. — Diagram  of  half-section  of  pons  at  the  level  of  the  glossopharyngeal 
nucleus,  Gl.Fh.;  Hy,  hypoglossal  nucleus.  The  other  lettering  is  the  same  as  in 
Fig.  34. 

bundle.  It  may  be  noted  that  the  fibres  of  the  spinal  accessory  which 
arise  from  the  medulla  are  those  that  innervate  the  muscles  of  the 
larynx,  and  are  thus  associated  in  origin  with  the  fibres  of  the  great 
respiratory  nerve,  the  vagus. 

Moreover,  in  this  relation,  another  connection  of  these  nerves  is 
important.  To  the  outer  side  of  these  nuclei,  and  of  the  fibres  pro- 
ceeding from  them,  is  another  baindle  of  longitudinal  fibres,  rounded 
in  section  and  small  in  size.  It  is  the  "slender  column  "  of  Lockhart 
Clarke  (Fig.  34).  It  extends  upwards  as  high  as  the  highest  part  of 
the  glosso-pharyngeal  nucleus,  while  downwards  it  passes  into  the 
deep  part  of  the  lateral  column  of  the  cord ;  its  fibres  have  been 
traced  as  far  as  the  middle  of  the  cervical  enlargement,  and  may 
extend  lower  still.  Some  fibres  of  the  glosso-pharyngeal,  pneumo- 
gastric, and  spinal  accessory  nerves  pass  into  it,  or  rather  arise  from 
it,  and  hence  it  has  been  termed  their  ascending  root,  or  the  ascend- 
ing root  of  the  glosso-pharyngeal.*  It  is  supposed  to  be  connected 
with  the  process  of  respiration,  to  which  the  spinal  accessory  and 
vagus  have  such  important  relations.  Hence  Krause  termed  it  the 
*  "  Common  ascending  root  of  the  lateral  mixed  system  "  by  Meynert. 


STRUCTURE    AND    FUNCTIONS.  47 

*'  respiratory  column."  Division  of  it  on  both  sides  is  said  to  arrest 
all  movements  of  respiration.* 

The  nucleus  of  the  pneumogastric  and  glosso -pharyngeal  nerves  is 
thus  a  tract  of  grey  matter  which  lies  beneath  the  outer  half  of  the 
floor  of  the  fourth  ventricle,  having  the  hypoglossal  nucleus  on  the 
inner  side,  and,  on  the  outer  side,  the  restiform  body  below  (where  the 
pneumogastric  arises,  Fig.  34),  and  the  lower  part  of  the  auditory  nuclei 
above  (where  it  gives  origin  to  the  glosso-pharyngeal,  Fig.  35).  Some 
fibres  arise  from  groups  of  large  nerve-cells  in  the  deeper  part  of  this 
tract,  and  these  are  probably  the  motor  fibres  of  the  nerves  ;  such  cells 
are  especially  conspicuous  in  the  glosso-pharyngeal  portion  (Fig.  35). 
Other  fibres  arise  from  smaller  nerve-cells  in  the  more. superficial  grey 
part  of  the  nucleus.  Some  fibres  seem  to  come  from  the  "  slender 
column,"  as  already  stated,  and  others  have  been  traced  inwards  to  the 
raphe.  According  to  Meynert,  some  fibres  of  the  pneumogastric  pass 
to  the  cerebellum ;  the  gastric  functions  of  the  nerve  are  readily 
deranged  by  disturbance  of  the  equilibration,  as  in  the  vomiting  of 
vertigo.  Lastly,  from  the  neighbourhood  of  this  nucleus,  where  the 
nerve  enters  it,  fibres  pass  forward  towards  the  deep  part  of  the  teg- 
mentum (xx,  Figs.  34  and  35).  These  have  been  thought  to  arise 
from  a  small  collection  of  large  nerve-cells  (X),  but  most  of  them 
certainly  pass  by  this  nucleus  f  to  nerve-cells  near  the  surface. 

The  deep  origin  of  the  auditory  nerve  is  still  involved  in  some 
uncertainty.  Its  attachment  to  the  medulla  (at  the  junction  of  this 
with  the  pons)  is  by  two  roots,  one  of  which  (Fig.  37)  winds  round 
the  restiform  body  (inferior  cerebellar  peduncle),  while  the  other 
(Fig.  36)  passes  into  the  substance  of  the  medulla.  The  former  is 
termed  the  superficial  (or  outer)  root,  and  the  latter  the  deep  (or 
inner)  root.  The  former  is  a  little  posterior  to  the  latter,  so  that  the 
two  are  not  shown  in  the  same  section  ;  the  lowest  superficial  fibres 
are  on  a  level  with  the  glosso-pharyngeal  nucleus  (Fig.  35),  but  the 
nuclei  of  the  auditory  nerve  extend  still  lower  in  the  medulla,  as  far 
as  the  middle  of  the  vagal  nucleus  (Fig.  34).  The  outer  or  super- 
ficial root  contains  fibres,  continuous  with  those  of  the  cochlear  part 
of  the  auditory  nerve,  and,  in  coursing  round  the  medulla,  contains 
some  grey  matter  mingled  with  its  fibres.  Some  of  the  fibres  are 
continuous  with  those  of  the  auditory  striae,  which  seem  to  pass  to  the 

*  Gierke.  At  the  same  time  the  division  of  this  tract  without  injury  to  adjacent 
structures,  on  a  living  animal,  is  manifestly  impossible.  The  connection  with  the 
vagus  has  been  described  by  almost  all  investigators,  but  ha^  been  contested 
by  Spitzka  ('New  York  Med.  Record,'  1884). 

f  The  nucleus  has  been  termed  the  tl  anterior  nucleus  "  of  these  nerves  by  some, 
by  others  the  "  nucleus  ambiguus."  It  is  not  certain  that  the  fibres  that  go  towards 
it  are  root-fibres.  I  believe  they  are  connected  with  scattered  nerve-cells  which  lie 
among  the  arciform  fibres,  between  the  ascending  root  of  the  fifth,  and  the  olivary 
body.  I  have  many  times  traced  the  fibres  to  this  part,  and  observed  that  these  cells 
send  a  process  in  the  direction  of  these  fibres.  The  nucleus  X  is  not,  as  might  be 
imagined  from  its  position,  continuous  with  that  of  the  facial  nerve. 


48 


BRAIN. 


Fig.  36. 


INT.  PVA 


A 


Mi 


middle  line  aud  opposite  side  of  the  medulla.*     Many  of  the  fibres 
end  in  a  thick  tract  of  grey  matter,  which   occupies  the  inner  two 

thirds  of  the  floor  of  the  fourth 
ventricle  at  this  level,  the  "  inner 
auditory  nucleus  "  (Au.  i,  Figs. 
34 — 37),  which  is  commonly 
known  as  the  chief  nucleus  of 
the  nerve.  Outside  this  is  a 
smaller  area  containing  many 
groups  of  longitudinal  fibres, 
which  is  commonly  known  as 
the  "  external  auditory  nucleus  '* 
(Au.  e),  or  Deiter's  nucleus  (see 
foot-note)  ;  to  it  some  fibres  of 
the  superficial  root  seem  to  go, 
but  it  is  probable  that  they 
merely  pass  through  it,  and 
that  its  chief  connection  is  with 
the  inner  or  deep  root.f  As 
the  nerve  courses  round  the 
medulla  many  fibres  curve  in- 
wards into  the  restiform  body  ; 
some  may  change  their  direc- 
tion and  join  the  restiform  fibres, 
but  others  appear  to  pass  trans- 
versely through  the  restiform 
body,  and  to  be  continuous  with 
the  transverse  fibres  of  the  teg- 
mental portion  of  the  pons. 
What  their  destination  is  we 
do  not  know.  Meynert  thinks 
that  they  may  pass  to  the  oppo- 
site restiform  body  aud  the 
cerebellum. 

The  deep  root  (Fig.  36)  is  con- 


wt 


Fig.  37. 

Figs.  36  and  37. — Origin  of  auditory  nerve. 
Fig.  36  shows  the  origin  of  the  deep 
(Au.  d.),  Fig.  37  of  the  superficial  root. 
Au.  a,  i,  aud  e,  anterior,  internal,  and  so- 
called  external  nuclei ;  Ya,  ascending  root 
of  fifth ;  Fa,  nucleus  of  facial  nerve  ; 
A  P,  anterior  pyramid ;  Tr  Pons,  trans- 
verse fihres  of  pons. 


tinuous  with  the  vestibular  part 
of  the  auditory  nerve,  and  passes  inwards  and  upwards,  on  the  inner 
side  of  the  restiform  body,  at  the  level  of  the  lowest  fibres  of  the  pons. 
It  goes  to  the  external  auditory  nucleus  above  described.  But  many 
fibres  curve  outwards  into  the  restiform  body  and  pass  towards  the 
middle  lobe  of  the  cerebellum.     These  are  probably  the  fibres  that 

*  Their  connection  with  the  nerve  is  doubted  by  Bechterew.  See  '  Neur.  Cent.,' 
May,  1S92. 

f  Monakow  found  it  atrophied  after  hemisection  of  the  lower  part  of  the  medulla 
('Arch.  f.  Psych.,'  Bd.  xiv).  See  also,  on  this  subject,  Onafrowicz  (ib.,  Bd.  xvi). 
This  nucleus  has  been  also  termed  "  Deiter's  nucleus,"  as  an  indifferent  designation, 
but  the  name  has  not  come  into  general  use,  and  it  is  marked  Au.  e  in  the  diagrams, 
in  accordance  with  prevailing  usage. 


STRUCTURE    AND    FUNCTIONS.  "49 

come  from  the  semicircular  canals,  and  subserve,  not  auditory  sensa- 
tions, but  impressions  from  the  canals  determined  by  the  position 
and  movement  of  the  body.  A  few  fibres  may  reach  the  "internal 
auditory  nucleus,"  while  others  turn  outwards  before  reaching  the 
restiform  body  to  an  important  collection  of  grey  matter  which  lies 
in  front  of  the  latter,  the  "  anterior  or  accessory  auditory  nucleus  " 
(Au  «,  Fig.  36).  Lower  down,  this  nucleus  lies  in  the  angle  between 
the  two  roots  of  the  nerve,  and  (together  with  the  cells  in  the  outer 
division  of  the  nerve)  seems  to  give  rise  to  a  considerable  number  of 
the  fibres  of  the  nerve.* 

Of  the  auditory  path  to  the  hemisphere  we  know  only  that  it  passes 
by  the  posterior  part  of  the  internal  capsule.  It  probably  passes  in 
the  most  superficial  layer  of  the  tegmentum  of  the  crus.f  Meynert 
thinks  that  it  passes  through  the  cerebellum,  and  not  through  the  pons ; 
and,  improbable  as  this  may  seem,  it  cannot  be  said  that  we  have  any 
facts  at  present  inconsistent  with  the  hypothesis.  The  central  connec- 
tions of  the  accessory  nucleus  are  numerous,  and  include  one  with 
the  cerebellum  ;  their  meaning  is  too  uncertain  to  make  it  worth  while 
to  describe  them. %  The  chief  connection  is  probably  with  the 
tegmental  region,  possibly  with  the  opposite  flocculus.  The  functions 
of  the  auditory  nerve  are  very  closely  connected  with  those  of  other 
cranial  nerves,  more  so  indeed  than  we  can  readily  perceive,  and  the 
connections  are  of  great  physiological  importance. 

Above  the  auditory  stria3  the  most  prominent  part  of  the  eminentia 
teres  marks  the  position  of  the  nucleus  of  the  sixth  nerve  (Fig.  38),  to 
which  the  fibres  pass  through  the  inner  part  of  the  reticular  formation. 
They  enter  the  nucleus  on  its  inner  side.  The  fibres  of  the  facial  nerve 
pass  outside  the  reticular  formation  to  the  neighbourhood  of  the  sixth 
nucleus,  where  they  form  a  loop  and  turn  downwards,  most  of  them 
in  a  compact  bundle  around  the  upper  extremity  of  the  nucleus,  but 
some  through  the  nucleus  itself.  They  then  radiate  downwards, 
forwards,  and  outwards  to  a  column  of  nerve-cells  (Fa,  Figs.  36,  37), 
which  lies  above  the  outer  part  of  the  fillet,  near  the  grey  tract 
known  as  the  "  superior  olivary  body,"  supposed  to  be  related  to  the 
conjugate  rotation  of  the  head  and  eyes,  an  opinion  supported  by  the 
entrance  of  fibres  into  it  from  the  sixth  nucleus.  There  is  also  a 
very  close  physiological  connection  between  the  muscles  of  the  lip  and 
tongue,  and  the  facial  nucleus  extends  down  almost  to  the  level  of 
the  hypoglossal  nucleus,  although  the  two  are  some  distance  apart, 

*  So  that  it  lias  been  regarded  as  the  chief  auditory  nucleus,  although  by  some  it 
is  looked  upon  as  analogous  to  a  spinal  ganglion.  But  Bechterew  traces  many  fibres 
of  this  root  to  the  grey  matter  in  the  lateral  wall  of  the  fourth  ventricle — to  what 
has  been  termed  the  "  angular  nucleus,"  and  has  also  been  named  after  him  ('Neur. 
Cent./  1887). 

f  See  a  case  published  by  me,  'Lancet,'  March  15th,  1879,  in  which  bilateral  deaf- 
ness was  caused  by  a  tumour  of  the  corpora  quadrigemina,  damaging  the  superficial 
layer  of  the  tegmentum  on  each  side. 

%  See  Baginsky,  'Neur.  Cent.,'  1889;  Flechsig,  ib.,  1890. 

VOL.  II.  4 


50  BRAIN. 

and  we  do  not  know  whether  the  connection  between  the  lips  and  tongue 
is  subserved  by  fibres  that  pass  between  the  two  nuclei,  or  whether  (as 
is  possible)  the  nerve-fibres  for  the  lips  actually  arise  from  the  hypo- 

•  \.  FACIAL 

o   ,-i  .     .'>.  £M*    TERES         Dosceno^  Loop  /& 


5  -  •" 


^ 


FlO-.  38. — Transverse  section  of  the  pons  at  the  level  of  the  nuclei  of  the  sixth 
nerves  (VI) ;  bet.  porm.,  reticular  formation ;  Vni,  motor  nucleus  of  fifth 
nerve ;  ~Ta,  its  ascending  root  seen  in  section ;  st/p.  ol.,  superior  olivary  body. 

glossal  nucleus.  Many  of  the  fibres  of  the  facial  nerve,  turning  down- 
wards at  the  loop,  have  a  longitudinal  course  in  the  inner  part  of  the 
reticular  formation,  and  may  readily  reach  the  hypoglossal  nucleus.* 

Similarly  it  has  been  suggested 
fibrls  '      that  the  fibres  in  the  facial  sup- 


:  ■^r_r: ^'J_;7 ."-\'   v"~/2i  plymg    the    orbicularis    palpe- 

^..- ' r  •,.''.  brarum,    frontalis,    and    corru- 

.;,  "  gator  supercilii  are  derived  from 

>m,:1-:  -      •-•:■  the  nucleus  of  the  third  nerve, 

■- "  -  -  and  reach  the  facial  by  way  of 

-      :     :.--  the  posterior  longitudinal  bun- 

%ir-,:--.-       ....            .-.  '/:■  lllt. _:  ;  .■-;■';'.-';  dles.t     But  for  evidence  of  these 

**v"  .  -    ~~  hypotheses    we    have    still    to 

FIFTH'       .-  --  -•:  -■;•  *\ 

NE.RVE       •--  V'        Wait. 

Lt*   TRANSVERSE    FIBRE*  The    origin  Qf   the  j^    nervQ 

Fig.  39.— Origin  of  fifth  nerves.     V  mot.,  (-pm.  39)  is  very  extensive,  its 
motor  nucleus :   V  asc,  ascending  root.        ,  ..  n.         P 

deep  connection  reaching  from 

the  level  of  the  anterior  quadrigeminal  tubercle  to  the  lowest  part  of 
*  The  closeness  of  the  central  relation  between  the  lips  and  tongue  is  shown  both 

by  their  simultaneous  affection  in  disease,  such  as  labio-glossal  paralysis,  and  by  the 

fact  that  the  transverse  fibres  of  the  tongue  and  the  orbicularis  oris  can  only  contract 

together. 

t  See  Mendel,  '  Neur.  Cent.,'  1887,  and  Tooth  and  Turner,  '  Brain,'  1891. 


STRUCTURE    AND    FUNCTIONS.  51 

the  medulla.  This  is  not  surprising  when  Ave  reflect  that  this  nerve 
represents  the  sensory  roots  of  all  the  motor  cranial  nerves,  from  the 
third  to  the  hypoglossal.  The  two  parts  of  the  nerve  pass  backwards 
and  inwards  through  the  outer  part  of  the  pons,  or  rather  through 
the  inner  part  of  the  middle  peduncle  of  the  cerebellum.  The  smaller, 
motor  root  is  a  little  higher  up  than  the  other.  The  sensory  root 
reaches  the  outer  part  of  the  tegmentum,  beneath  the  outer  edge  of 
the  floor  of  the  fourth  ventricle,  and  there  some  of  its  fibres  terminate 
in  small  collections  of  grey  matter,  which  are  collectively  termed  the 
middle  nucleus,  or  "  chief  nucleus."  It  is  certainly  not  the  chief 
origin  of  the  nerve,  for  by  far  the  largest  number  of  the  fibres  turn 
downwards  and  descend  the  pons  and  medulla,  as  a  compact  collection 
of  bundles,  lying  in  the  same  relative  position,  on  the  outer  side  of 
the  tegmentum.  This  is  termed  the  ascending  root,  but,  to  avoid 
ambiguity,  may  be  better  called  the  lower  root.  It  is  a  conspicuous 
object  in  all  sections,  and  is  shown  in  most  of  the  preceding  figures 
{Vase).  It  becomes  smaller  as  it  passes  down  the  medulla,  but  may 
be  traced  to  the  upper  cervical  region,  and  the  source  of  the  lower 
fibres  is  uncertain.  It  may  be  from  nerve-cells  of  the  posterior  horn 
(Bechterew).  Some  fibres  of  the  nerve  course  inwards,  beneath  the 
floor  of  the  fourth  ventricle;  passing  through  the  posterior  hori- 
zontal fibres,  they  reach  the  raphe,  and  probably  go  to  the  opposite 
half  of  the  pons  :  their  precise  origin  is  not  known.  This  is  termed 
the  medial  root.  It  is  easily  mistaken  for  the  loop  of  the  facial  nerve 
which  has  a  similar  position  a  little  lower  down  the  pons.  Fibres 
probably  connect  the  two  motor  nuclei,  and  others  may  brino-  the 
motor  path  from  the  other  side  of  the  pons  (and  other  hemisphere). 
A  few  fibres  are  said  to  turn  outwards  to  the  cerebellum,  but  this 
connection,  probable  as  it  is,  still  needs  confirmation.  The  descending 
root  of  the  nerve  (better  termed  the  upper  root)  consists  of  a  series  of 
bundles  which  pass  upwards*  and  lie  outside  the  aqueduct  of  Sylvius, 
where  they  are  arranged  somewhat  in  the  form  of  a  crescent  (Fiijs. 
40  and  41). f  They  can  be  traced  as  far  as  the  upper  part  of  the 
corpora  quadrigemina,  but  lessening  in  number,  and  they  appai-ently 
rise  from  large  rounded  nerve-cells  that  lie  adjacent  to  the  root.  The 
root  has  commonly  been  regarded  as  one  origin  of  the  sensory  portion 
of  the  nerve,  but  it  has  been  stated  that  most  of  its  fibres  enter  the 
motor  division.  J     Almost  all  the  fibres   of  the  motor  root  end  in  a 

*  The  terms  ascending  and  descending  have  been  adopted  apparently  under  the 
influence  of  the  word  "  root,"  but  the  fibres  conduct  in  the  direction  opposite  to  that 
indicated  by  the  names.     Hence  the  alteration  I  have  suggested. 

f  See  abo  Fig.  24  (p.  30),  in  which  the  crescent  on  each  side  of  the  aqueduct 
represents  the  descending  root. 

J  Henle,  Forel,  Bechterew,  &c.  In  spite  of  the  high  character  of  these  autho- 
rities, the  statement  is  so  opposed  to  the  opinion  of  other  investigators  that  the 
point  must  be  regarded  as  at  present  unsettled.  Both  coarse  and  fine  fibres  are  said 
by  Obersteiner  to  proceed  from  the  same  cells,  the  latter  passing  upwards.  See,  in 
connection  with  this  point,  "  Facial  hemiatrophy,"  at  a  subsequent  page. 


52  BRAIN. 

large  collection  of  nerve-cells  (V mot.),  which  lies  on  the  inner  side  of 
the  sensory  root,  in  the  outer  part  of  the  tegmentum,  and  extends  for 
a  short  distance  down  the  pons.* 

Each  fourth  n'erve,  arising  from  the  valve  of  Vieussens  (superior 
medullary  velum),  decussates  within  the  substance  of  the  valve  with 
its  fellow  (Fig.  41).     It  is  the  only  nerve  that  decussates  between 

Fig.  40. 


i 

i.  . 


of    ccap.    Quad. 
Aq.  Syl 


V1E.USSENS       FOURTH 
--.  NERVtvs*» 


Fig.  41. 

FlGS.  40,  nucleus,  and  41,  origin  of  fourth  nerves.  T.  tjes., 
descending  root  of  the  fifth  nerve  j  IV,  IV,  sections  of 
fasciculi  of  the  fourth  nerves. 

its  surface  origin  and  nucleus,  with  tbe  exception  of  the  optic.  In  its 
course  in  the  velum  the  nerve  divides  into  a  series  of  bundles,  which 
curve  forwards  and  upwards,  ronnd  the  central  grey  matter  lining  the 
aqueduct  of  Sylvius,  to  a  collection  of  nerve-cells  at  the  hinder  and 
outer  part  of  the  posterior  longitudinal  fibres  (Fig.  40).  The  nucleus 
lies  beneath  the  junction  of  the  anterior  and  posterior  quadrigeminaj.' 
bodies  and  beneath  the  latter,  but  it  is  not  sharply  denned  from  the 
third  nucleus,  so  that  many  of  the  fibres  pass  the  whole  length  of  the 
nates  before  reaching  the  nucleus.  Hence,  according  to  the  position 
of  the  section,  the  bundles  of  origin  are  divided  transversely,  obliquely, 
or  longitudinally  (see  Figs.  40  and  41).     Some  fibres  seem  to  pass  to 

*  A  connection  with  the  1.  cceruleus  (s.  ferruginea)  has  been  asserted  and  also 
denied  (Bechterew). 


steuctiJke  and  functions.  53 

the  posterior  longitudinal  bundles ;  some  (Westphal)  to  a  group  of 
round  dark  cells  behind  these,  near  the  raphe.* 

The  fibres  of  the  third  nerve  arise  from  a  column  of  nerve-cells 
that  occupies  the  anterior  part  of  the  central  grey  matter  below  the 
aqueduct  of  Sylvius,  beneath  the  anterior  quadrigeminal  bodies  and 
the  posterior  commissure  (Fig.  24,  p.  30).  The  cells  from  which  the 
fourth  nerve  arises  are  in  the  lowest  part  of  this  column.  The 
fibres  of  origin  of  the  third  nerve  pass  forwards,  curving  outwards 
through  the  red  nucleus,  and  then  inwards,  to  the  side  of  the  crus, 
where  they  emerge.  The  cells  lie  in  a  double  series  :  a  smaller,  towards 
the  dorsal  aspect,  gives  origin  to  fibres  that  cross  the  middle  line  ;  and 
.a  larger  "  ventralwards,"  from  which  the  fibres  pass  through  the 
posterior  horizontal  bundles  which,  as  we  have  seen  (p.  37),  are  con- 
nected with  this  nucleus,  and  seem  to  establish  an  association  between 
it  and  the  sixth  nucleus,  through  which  the  external  and  internal 
recti  act  together. f  The  nucleus  of  the  third  nerve  consists  of  a 
series  of  groups,  almost  fused,  corresponding  to  the  several  functions 
subserved  by  the  nerve,  the  most  anterior  being  related  to  accommo- 
dation, the  next  to  the  reflex  action  of  the  iris,  while  the  remainder 
of  the  nucleus,  comprising  its  chief  part,  subserves  the  external 
ocular  muscles  in  the  following  order,  from  before  backwards : — In- 
ternal rectus,  superior  rectus,  levator  palpebral  superioris,  inferior 
rectus,  inferior  oblique.  It  is  highly  probable  that  the  same  arrange- 
ment obtains  in  man,  and  that  the  serial  disposition  of  the  filaments 
of  origin  of  the  nerve  corresponds  to  the  series  of  functions  and 
of  centres.  But  the  contiguity  of  these  is  lateral  as  well  as 
antero-posterior,  and  the  disposition  thus  complex'  (see  "Motor 
Nerves  of  the  Eyeball").  A  complex  arrangement  also  seems  to 
subserve  the  association  of  the  internal  and  external  recti.  When 
acting  together  both  these  muscles  are  innervated  through  the  nucleus 
of  the  sixth,  disease  of  which  causes  loss  of  at  least  the  associated  action 
of  the  internal  rectus.  The  path  from  the  sixth  nucleus  to  the  origin  of 
the  internal  rectus  is  doubtless  by  the  posterior  longitudinal  fibres ; 
and  there  is  some  reason  to  regard  the  superior  olivary  body  as  con- 
cerned in  the  action.  The  subject  is  considered  more  fully  in  the  account 
of  diseases  of  the  oculo-motor  nerves.  Fibres  pass  to  the  third  nuclei 
from  the  grey  matter  of  the  quadrigeminal  bodies,  and  doubtless  sub- 
serve the  relation  between  visual  impressions  and  ocular  movements. 
The  downward  path  from  the  cortex  in  the  internal  capsule  seems  to  be 
at  or  in  front  of  the  angle  or  just  behind  it,  according  as  a  section  divides 
their  oblique  course.    (See  Beevor  and  Horsley,  'Phil.  Trans.,'  1890.) 

*  J.  Stilling  describes  a  fine  root  from  the  cerebellum  which  runs  through  the 
lingula  and  joins  the  trochlear,  perhaps  without  crossing.  It  is  supposed  that  the 
connections  of  the  trochlear  with  the  cerebrum,  testes,  and  posterior  longitudinal 
"bundle  are  the  same  as  those  of  the  oculo-motor,  to  be  afterwards  described. 

t  The  upper  third  of  the  nucleus  has  an  oval  section,  and  consists  of  large  pale 
«ells  (Perlia,  'A.  f.  O.,'  1890,  who  describes  a  minute  subdivision  of  the  nucleus). 


54  BKAIN. 

The  origin  of  the  optic  nerves  is  complex  and  still  imperfectly  under- 
stood.    At  the  optic  chiasma  a  partial  decussation  takes  place,  the 
fibres  from  the  nasal  half  of  each  retiua  cross,  and  as  the  temporal 
half  of  each  field  of  vision  (subserved  by  the  nasal  half  of  the  retina) 
is  (functionally)  the  larger,*  more  fibres  cross  than  pass  uncrossed. 
Thus  each  optic  tract  contains  the  fibres  from  the  same-named  half 
of  each  retina,  which  conduct  impressions  from  the  other-named  half 
of  each  field.     Fibres  also  pass  from,  one  tract  to  the  other  by  the 
posterior  portion  of  the  chiasma.     The  old  opinion  that  fibres  pass 
from  one  optic  nerve  to  the  other  by  the  anterior  part  of  the  chiasma 
seems  to  be  erroneous,  but  some  go  to  the  central  grey  matter  lining 
the  third  ventricle. f     Tn  thj  nerve,  the  uncrossing  fibres  lie  in  thick 
bundles  in  the  lateral  (outer)  part.     In  the.  tract,  the  fibres  from  the 
opposite  eye  lie  chiefly  on  the  inferior   (basal)  surface ;    the  direct 
fibres  lie  in  the  superior  part  of  the  tract ;  and  the  fibres  from  the 
opposite  tract  are  on  the  inner  side  (v.  G-udden).     The  fibres  from 
the  lower  half  of  each  retina  lie  outside  to  those  from  the  upper  half.  J 
Beneath  the   posterior   extremity  of  the  thalamus  the  optic  tract 
divides  into  two  parts.     The  outer  is  the  larger,  and  goes  to  the  optic 
thalamus,  external  corpus  geniculatum,  and  anterior  quadrigeminal 
body.     All  these  structures  atrophy  after  extirpation  of  the  eye  of 
young  animals  (v.  G-udden).     From  each  of  these  bodies  fibres  pass 
to  the  posterior  (sensory)  portion  of  the  internal  capsule,  and  thence 
to  the  white  substance  of  the  occipital  lobes,  in  the  "  optic  radiation  " 
of  Gratiolet.     Some  fibres  of  the  tract  have  been  said  to  pass  directly 
to  the  hemisphere,  but  it  is  doubtful  whether  any  have  this  direct 
course.     Of  these  intermediate  stations,  the  external  corpus  genicu- 
latum has  been  commonly  regarded  as   that  which  is  of   chief  im- 
portance in  connection  with  the  visual  fibres,  since  its  atrophy  has- 
been    frequently    observed    in    cases    of    long-standing   atrophy   of 
the  tract.      But  many  recent  observations  establish   the   fact   that 
disease   limited    to    the  posterior   extremity    of   the   optic   thalamus 
may  cause  hemianopia,  and  it  seems  doubtful  whether  the  symptom 
is  caused  by  disease  of  the  external  geniculate  body.§     Hence  we  must 
regard  the  pulvinar  as  the  intermediate  visual  centre,  and  the  precise- 
function  of  the  external  corpus  geniculatum  becomes  again  mysterious.  ■ 
The  inner  root  of  the  optic  nerve  goes  to  the  internal  geniculate  body,, 
and  is  said  to  contain  only  those  fibres  which,  at  the  optic  commissure, 

*  See  "  Optic  Nerve." 

f  Obersteiner. 

J  Marchand,  'A.  f.  0./  xxviii,  and  Magnus,  ib.  See,  however,  also  Delbriiek, 
'  A.  f.  Psych.,'  xxi,  746.  • 

§  It  is  commonly  believed  that  the  fibres  are  interrupted  by  nerve-cells  in  these 
o-anglia,  but  Darkschewitsch  ('Arch.  f.  Anat.  u.  Phys.,'  1886)  has  asserted  that  they 
pass  through  without  interruption,  a  fact  that  can  scarcely  be  proved  by  the  method 
of  investigation  employed  by  him.  Secondary  degeneration  from  a  lesion  of  the 
occipital  lobe  causing  hemianopia  has  been  traced  into  the  pulvinar,  but  no  farther 
(Eichter,  '  Arch,  f .  Psych.,'  xvi,  638). 


STRUCTURE    AND    FUNCTIONS. 


00 


turn  back  to  the  opposite  optic  tract  (v.  GTudden).     Through  this  body 
the  nerve  also  appears   to  be  connected  with  the  posterior  corpus 


PlG.  42. — Diagram  of  the  relation  of  the  fields  of  vision,  retina,  and  optic 
tracts.  R  F,  L  F,  right  and  left  fields— the  asterisk  is  at  the  fixation- 
point;  &  R,  L  K,  right  and  left  retina— the  asterisk  is  at  the  macula  lutea; 
ITi,  r'h,  left  and  right  half  of  each  retina,  receiving  rays  from  the  opposite 
halves  of  the  fields  ;EK,L  X,  right  and  left  optic  nerves ;  Ch,  chiasma ; 
R  T,  L  T,  right  and  left  optic  tracts ;  helow  are  the  superimposed  halves  of 
the  fields  from. which  impressions  pass  by  each  optic  tract. 

quadrigeniinuni,  but  some  fibres  seem  also  to  reach  the  anterior  body.* 
The  connection  of  the  optic  nerves  with  these  bodies  probably  sub- 
serves  the  relation  between  visual  impressions  and  ocular  movements. 
The  relation  of  the  parts  concerned  in  vision  is  illustrated  and  also' 
confirmed  by  an  instructive  case  of  congenital  atrophy  of  one  occipital 
lobe,  extending  as  far  as  the  middle  of  the  posterior  limb  of  the 
fissure  of  Sylvius.  There  was  also  atrophy  of  the  pulvinar,  the  optic 
tract,  the  external  geniculate  body,  the  superficial  layer  of  the  ante- 

*  Stilling,  Obersteiner. 


56  BE A IN. 

rior  quadrigeminal  body,  and  its  anterior  brachium.*  Tbe  relation 
of  the  cortex  to  vision  has  been  already  mentioned,  and  some  otber 
points  in  connection  witb  the  function  of  the  nerves  will  be  described 
in  tbe  account  of  their  diseases. 

The  central  connections  of  the  olfactory  nerve  are  still  but  little 
known.  The  external  root,  crossing  the  fissure  of  Sylvius,  passes  to 
the  temporal  lobe,  towards  the  anterior  part  of  the  uncinate  convolu- 
tion. There  is  some  evidence,  as  we  bave  seen,  tbat  an  olfactory 
centre  exists  in  this  locality.  Some  fibres  (according  to  Obersteiner) 
pass  to  the  optic  tbalamus  on  the  same  side.  Tbe  fibres  of  tbe  inner 
root  go  to  the  anterior  commissure,  one  part  of  which,  in  animals,  is 
large  in  proportion  to  tbe  size  of  the  olfactory  nerves,  and  is  regarded 
as  commissural  between  the  two 'olfactory  bulbs.  But  there  is  evi- 
dence that  tbe  path  from  one  olfactory  nerve  reaches  the  cortex  of  tbe 
opposite  hemisphere,  since  the  sense  of  smell  bas  been  affected,  together 
with  the  other  special  senses  on  the  same  side,  by  disease  of  the  posterior 
part  of  the  opposite  internal  capsule,  and  also  by  disease  of  the  cortex 
(see  p.  20).  It  is  possible,  as  Cbarcot  suggests,  that  the  path  dam- 
aged by  disease  involving  the  internal  capsule  is  that  which  crosses  by 
tbe  anterior  commissure. f 


Cerebellum:. 

The  division  of  the  cerebellum  into  two  hemispheres  and  a  middle 
lobe,  founded  on  external  conformation,  is  borne  out  by  the  little  we 
know  of  its  function.  Nevertheless  all  parts  consist  of  similar  struc- 
tural elements.  Branching  folia  everywhere  constitute  the  superficial 
layer ;  the  grey  substance  which  envelops  these  folia,  and,  following 
all  the  involutions  of  their  surface,  is  of  enormous  superficial  extent,  has 
an  identical  three-layered  structure  in  all  parts.  Below  a  superficial 
"  gelatinous  stratum  "  is  a  layer  that  contains  nuclei  and  branching 
fibres,  which  are  the  processes  of  the  large  "  cells  of  Purkinje." 
These  cells  lie  at  the  junction  of  this  and  the  deepest  layer-of  the  cor- 
tex ;  the  latter  is  composed  of  nuclear  bodies  similar  in  aspect  to  those 
that  constitute  the  granule  layers  of  the  retina.     The  grey  matter  is 

*  Kreusner, '  Allg.  Zeitschr.  f.  Psych.,'  Bd.  xlviii. 

f  The  subject  is  involved  in  great  obscurity.  The  other  fibres  of  the  anterior 
commissure  pass  into  the  temporal  lobe,  but  they  have  not  been  traced  to  the  uncinate 
gyrus.  Meynert  says  that  fibres  pass  back  from  the  anterior  commissure,  and  thus 
the  olfactory  path  (whether  from  the  nerve  by  the  one  part  of  the  commissure,  or 
from  the  opposite  uncinate  centre  by  the  other  part  of  the  commissure)  may  react, 
as  it  certainly  does,  the  internal  capsule,  but  Ganser  denies  that  fibres  pass  back- 
wards from  the  anterior  commissure.  As  a  further  instance  of  the  uncertainty  as  to 
the  precise  relations  of  the  anterior  commissure,  most  of  its  fibres  have  been  found 
secondarily  degenerated  in  a  case  of  bilateral  softening  of  the  region  of  the  lingual 
gyrus  by  Popow,  who  regards  it  as  a  commissure  between  these  convolutions 
('  Wratsch,'  1886,  and  'Cent.  f.  Nervenh.,'  18S6,  p.  684). 


STRUCTURE    AND    FUNCTIONS. 


57 


not  confined  to  the  cortex.  It  exists  also  in  the  white  substance  as 
a  series  of  masses  or  "  nuclei."  Of  these  the  corpus  dentatum  lies  in 
the  inner  part  of  the  hemisphere,  and  closely  resembles  the  olivary- 
body  of  the  medulla.  In  the  white  substance  of  the  middle  lobe  is 
the  "  roof  nucleus  "  (KN,  Pig.  43),  so  called  by  Stilling  because  it  lies 


Fig.  43. —  Nuclei  of  the  cerebellum.  C  d,  corpus  dentatum;  E,  emboliform 
nucleus ;  S  s,  parts  of  the  spherical  nucleus ;  A  C,  anterior  commissure ; 
Sem.,  semilunar  tract. 


just  above  the  roof  of  the  fourth  ventricle.  At  the  junction  of  the 
hemisphere  and  middle  lobe  are  two  other  grey  bodies,  the  "  spherical " 
and  "emboliform"  nuclei  (Stilling).  The  latter  is  the  nearer  to  the 
dentate  body. 

The  course  of  the  fibres  in  the  white  substance  is  still  imperfectly 
known.  The  difficulty  of  tracing  them  is  extreme,  unaided  as  it  is  by 
secondary  degeneration,  and  the  conclusions  reached  by  different 
investigators  do  not  altogether  correspond.  Although  much  has  been 
written  on  the  subject,  the  facts  are  so  meagre,  and  their  application 
is  so  uncertain,  that  a  lengthy  discussion  of  the  subject  is  unprofitable. 
There  are  few  well-marted  tracts  of  fibres,  and  of  those  that  can  be 
distinguished,  such  as  the  semilunar  tract  (Sem.,  Fig.  43)  in  the  outer 
part  of  the  hemisphere,  the  connections  are  doubtful.  Some  fibres  of 
the  hemisphere  appear  to  pass  in  various  directions  between  the 
different  folia  of  the  cortex;  others  pass  inwards,  or  towards  the 
middle  line.  Of  the  latter,  some  go  to  the  dentate  nucleus,  and  inter- 
lace around  it  in  a  felty  capsule,  the  "  fleece  "  of  Stilling ;  others 
pass  to  the  middle  peduncle,  and  end  in  the  grey  matter  of  the  pons, 
and  through  this  are  connected  with  the  cortex  of  the  cerebral' 
hemispheres  and  with  the  corpus  striatum,  as  we  have  already  seen 
(p.  32).  Other  fibres  pass  to  the  middle  lobe,  part  of  which  may 
have  a  commissural  function.  Flechsig  states  that  many  fibres 
connect  the  cortex  of  the  superior  vermiform  process  with  that  of  the 
cerebellar  hemispheres. 


58  BRAIN. 

Of  the  fibres  of  the  inferior  peduncle  many  course  to  the  neighbour- 
hood of  the  dentate  nucleus  ;  some  enter  this  nucleus,  and  apparently 
connect  it  with  the  olivary  body.  The  destination  of  those  that  pass 
by  the  dentate  nucleus  is  very  uncertain.  Stilling  thinks  that  most 
go  to  the  cortex  of  the  hemisphere,  and  a  few  directly  to  the  superior 
peduncle.  Another  and  very  important  series  of  fibres  of  the  inferior 
peduncle  pass  to  the  middle  lobe.  Among  these  are  the  fibres  of  the 
direct  cerebellar  tract,  and  probably  fibres  from  the  posterior  pyramids 
and  from  the  auditory  neiwes  and  nuclei.*  Most  of  these  fibres  are 
believed  to  cross  the  middle  line,  and  end  in  the  grey  matter  of  the 
opposite  side  of  the  middle  lobe ;  some  in  the  roof  nucleus,  others 
probably  in  the  grey  cortex  of  the  superior  vermiform  pi*ocess.  The 
fibres  of  the  middle  peduncle  connect  the  grey  matter  of  the  pons  with 
the  cortex  of  the  cerebellar  hemisphere,  and  also,  it  is  said,  the  fillet 
with  the  middle  lobe.  Most  of  the  fibres  of  the  superior  peduncle  go 
to  the  neighbourhood  of  the  dentate  nucleus,  but  some  are  said  by 
Stilling  to  radiate  to  the  cortex  of  the  anterior  and  outer  part  of  the 
hemisphere,  others  to  pass  to  the  inferior  peduncle,  and  others  again 
to  the  middle  lobe.  The  fibres  of  the  superior  peduncle  cross  the 
middle  line  beneath  the  corpora  quadrigemina,  and  pass  through  the 
opposite  red  nucleus,  but  one  group  is  said  to  ascend  to  the  optic 
thalamus  of  the  same  side  (March!) . 

The  precise  functions  subserved  by  the  cerebellum  have  been 
long  a  mystery.  There  is,  however,  abundant  evidence,  experimental 
and  pathological,  to  "show  that  this  part  of  the  brain  is  in  some 
way  connected  with  the  co-ordination  of  movement,  and  especially 
with  those  muscular  actions  which  maintain  the  equilibrium  of  the 
body.  It  appears,  however,  that  this  function  is  confined  to  the 
middle  lobe.  As  Nothnagel  first  showed,  the  function  is  not  impaired 
by  disease  of  the  hemispheres  unless  such  disease  compresses  the 
middle  lobe.  We  do  not  know  to  what  extent  this  function  is 
subserved  by  the  roof  nucleus,  or  by  the  grey  matter  of  the  middle 
cortex.  We  may  reasonably  assume  that  the  fibres  which  go  to  the 
middle  lobe  from  the  cord,  those  of  the  direct  cerebellar  tract  and 
(probably)  those  from  the  post-pyramidal  nuclei,  are  connected  with 
this  function,  since  we  have  seen  reason  (in  the  account  of  the  spinal 
cord)  to  believe  that  these  fibres  constitute  the  path  of  centripetal 
impressions  from  the  muscles,  interruption  of  which  causes  inco- 
ordination. All  the  tracts  certainly  or  probably  connecting  the  spinal 
cord  with  the  cerebellum  in  man  conduct  upwards.  The  existence  of 
connections  between  the  cerebellum  and  other  structures  is  no  proof 
of  downward  conduction  of  impulses  from  it. 

With  this  function,  and  with  the  relation  of  the  upbearing  paths 
from  the  muscles,  we  must  associate  the  fibres  which  pass  from  the 

*  In  some  of  the  lower  animals  some  of  the  fibres  of  the  direct  cerebellar  tract  are- 
said  to  degenerate  downwards  after  extirpation  of  the  cerebellum,  but  the  existence 
of  such  fibres  in  man  has  not  been  ascertained  (Marchi,  '  Riv.  sper.  di  fr.,'  xvii). 


STEUCTUKE    AND    FUNCTIONS.  59 

auditory  nerves  or  nuclei  to  the  middle  lobe,  since  that  part  of  the 
auditory  nerve  which  conies  from  the  semicircular  canals  conducts 
impressions  determined  by  the  position  and  movement  of  the  body 
(acting  on  the  endolymph),  and  disturbance  of  these  fibres  deranges 
the  maintenance  of  equilibrium.  The  only  effect  of  electrical  stimu- 
lation of  the  middle  lobe  obtained  by  Eerrier  was  a  movement  of  the 
eyes.  It  is  not  pi-obable  that  there  are  centres  for  the  ocular  move- 
ments in  the  cerebellum,  but  a  connection  between  the  centres  for 
these  movements  and  the  middle  lobe  is  highly  probable,  since  the 
relation  of  seen  objects  to  the  body  is  estimated  unconsciously  from  the 
position  of  the  eyes,  and  thus  the  degree  of  innervation  of  the  ocular 
muscles  must  influence  the  mechanism  for  maintaining  equilibrium. 
It  is  to  be  noted  that  most  of  these  impressions,  e.g.  from  the  muscles 
of  the  legs  and  from  the  semicircular  canals,  do  not  influence  con- 
sciousness directly,  and  so  cannot,  strictly  speaking,  be  called  "  sen- 
sory." It  may  be  that  in  the  middle  lobe  of  the  cerebellum  we  have 
a  mechanism  by  which  the  various  centripetal  impulses  are  combined 
and  harmonised,  and  that  an  influence  is  thence  exerted  on  the  motor 
centres  in  the  cerebral  hemispheres,  from  which  the  muscles  are  excited 
to  the  necessary  contraction.  There  is  no  actual  evidence  that  the 
cerebellum  aids  co-ordination  by  direct  downward  influence  on  the 
spinal  cord.  On  the  contrary,  such  a  connection  is  opposed  to  what 
we  know  of  the  voluntary  motor  process.  Movements  are  arranged 
by  the  establishment  of  a  certain  relation  between  the  activity  of  the 
motor  cells  of  the  cerebral  cortex,  and  the  influences  which  determine 
this  relation  must  be  exerted  on  those  cells.  Besides  the  true  sensory 
impulses,  we  can  conceive  that  an  iufluence  proceeds  from  the  cere- 
bellum, arising  in  it  from  the  combined  effect  of  the  impressions  from 
the  muscles,  from  the  semicircular  canals,  and  from  the  centres  which 
determine  the  position  of  the  head  and  eyes  (possibly  the  superior 
olivary  body),  and  that  this  influence  induces  such  a  corresjDonding 
related  activity  of  the  motor  cells  of  the  cortex.  We  can  also  under- 
stand that  the  state  of  these  cells  thus  induced  acts  upon  con- 
sciousness, and  thus  gives  rise  to  the  perceptions  of  posture  which 
are  not  true  sensations. 

The  function  of  the  hemispheres  of  the  cerebellum  is  still  mysterious. 
They  lessen  in  size  as  we  descend  the  scale  of  animals,  until  they 
disappear  in  birds,  in  which  the  whole  cerebellum  coi'responds  to  the 
middle  lobe  of  man.  They  are  connected  chiefly  with  those  parts  of 
the  cortex  of  the  cerebrum  which  chiefly  subserve  psychical  pro- 
cesses. With  these  parts,  moreover,  the  cerebellar  heinisjmeres  have 
this  in  common,  that  simple  loss  of  substance  causes  no  definite  and 
recognisable  loss  of  any  function  of  the  brain.  The  loss  can  apparently 
be  compensated  by  other  parts.  Hence  it  seems  possible  that  the  old 
theory  may  be  correct  which  assumes  that  the  cerebellar  hemispheres 
are  in  some  way  connected  with  psychical  processes.* 

*  Extirpation  of  tlie  whole  cerebellum  in  an  animal  renders  it  dependent  on  vision 


60  BRAIN. 


Blood-vessels  of  the  Brain. 

The  blood-supply  to  the  brain  is  a  subject  of  great  importance,  because  many 
■diseases  are  due  to  the  rupture  or  obstruction  of  vessels,  and  the  distribution  of 
the  vessels  (especially  that  of  the  arteries)  explains  the  incidence  of  a  large 
number  of  cerebral  lesions. 

Distribution  of  the  Ceeebral  Arteries.* — The  blood-supply  to  the  brain 
comes  from  the  carotid  and  vertebral  arteries.  The  mode  of  origin  of  the  two 
carotids  presents  an  important  difference,  which  explains  why  embolism  is  more 
frequent  on  the  left  side  than  on  the  right.  The  left  carotid  arises  directly  from 
the  highest  part  of  the  ai'ch  of  the  aorta,  and  its  course  is  thus  almost  a  direct 
continuation  of  the  direction  of  the  current  of  blood  in  the  aorta,  whereas  the 
right  carotid  comes  from  the  innominate,  which  arises  from  the  aorta  at  a*i  angle 
with  the  course  of  the  aortic  blood.  Hence  clots,  washed  from  the  cardiac 
valves,  pass  into  the  left  carotid  more  readily  than  into  the  right. 

There  is  a  similar  difference  in  the  mode  of  origin  of  the  two  vertebrals.  The 
left,  usually  the  larger,  arises  from  the  left  subclavian  in  the  ascending  part  of 
its  coarse,  while  the  right  subclavian  gives  origin  to  its  vertebral  when  horizontal. 
Hence  a  plug  can  enter  the  left  vertebral  more  readily  than  the  right,  because 
the  direction  of  this  vessel  is  that  of  the  blood-current,  and  this  is  probably 
also  the  reason  why  the  left  vertebral  is  usually  larger  than  the  right.  But  this 
does  not  determine  any  difference  in  the  frequency  of  embolic  obstruction  in  the 
two  posterior  cerebral  arteries,  because,  to  reach  these,  the  plug  has  to  pass 
through  the  common  basilar. 

The  "circle  of  Willis,"  it  will  be  remembered,  is  formed  by  the  two  posterior 
communicating  arteries,  which  pass,  one  on  each  side,  from  the  internal  carotids 
to  the  posterior  cerebrals  into  which  the  basilar  divides,  and  by  the  anterior 
communicating  artery,  between  the  two  anterior  cerebrals  of  the  internal 
carotid.  The  usual  arrangement  is  subject  to  occasional  variations,  which  are 
important  because  they  explain  some  of  the  anomalous  facts  of  disease.  The 
vertebrals  often  present  abnormalities  which  will  be  described  further  on.  One 
posterior  communicating  artery  is  sometimes  very  small,  and  occasionally 
one,  usually  the  right,  is  abnormally  large,  and  through  such  a  vessel  the  pos- 
terior cerebral  may  even  arise  from  the  carotid,  a  minute  branch  from  the  basilar 
representing  the  usual  origin  of  the  vessel.  Duret  has  even  seen  the  chief 
blood-supply  to  the  basilar  come  from  the  carotid  by  a  large  artery  which 
entered  the  basilar  in  the  middle  of  its  course,  the  vertebrals  and  the  lower 
part  of  the  basilar  being  very  small.  Occasionally  one  anterior  cerebral,  almost 
always  the  right  (Duret),  is  very  small  at  its  origin,  and  the  anterior  commu- 
nicating artery  is  abnormally  large,  so  that  the  right  anterior  cerebral  virtually 
arises  from  the  left.  It  is  to  be  noted  further  that  there  are  usually  coL.-muni- 
cating  branches  between  the  posterior  cerebrals  and  the  anterior  cerebellar  arteries, 
which,  with  the  posterior  communicating  arteries,  constitute  an  important  con- 
nection between  the  carotid  and  the  basilar  systems. 

The  internal  carotid,  on  each  side,  divides  into  the  anterior  and  middle  cere- 

for  the  imperfect  co-ordination  which  remains,  and  if  the  eyes  are  covered  with  a 
bandage  all  voluntary  movement  is  at  once  abolished,  and  the  creature  seems  to  pass 
into  a  state  of  stupor  (Borgherini,  'Neurolog.  Centralbl.,'  1891,  p.  649). 

*  Our  knowledge  of  the  distribution  of  the  vessels  within  the  substance  of  the 
brain  is  largely  due  to  the  researches  of  Duret,  'Arch,  de  Physiologie,  1873  and 
1S74;  and  Heubner,  '  Centralblutt  f.  m.  Wissensch./  1872. 


STRUCTURE    AND    FUNCTIONS.  61 

bral  arteries,  and  from  these,  and  the  posterior  cerebral,  the  blood-supply  of  each 
hemisphere  is  derived.  From  the  circle  of  Willis,  and  the  commencement  of 
the  three  cerebral  arteries,  small  branches  arise  which  supply  the  central 
ganglia  of  the  hemisphere  and  the  adjacent  white  substance,  while  the  three 
arteries  ramify  over  the  surface  of  the  brain,  and  supply  the  grey  cortex  and 
the  greater  part  of  the  white  substance  of  the  hemisphere.  Between  these  cen- 
tral and  cortical  systems  there  are  no  anastomoses,  nor  do  the  central  branches 
communicate  with  each  other.  The  anastomoses  between  the  several  cortical 
branches  seem  to  vary  in  different  persons.  In  many  the  communications  are 
too  slight  to  permit  of  the  establishment  of  a  collateral  circulation.  In  other* 
they  appear  to  be  sufficient  to  maintain  nutrition.  Moreover,  similar  differences 
seem  to  exist  among  the  cortical  branches  in  the  same  individual,  and  even 
among  those  of  the  same  vessel ;  hence  the  effect  of  obstruction  of  these  vessel* 
varies  much.* 

The  central  arteries  may  be  divided  into  six  groups,  two  medial  and  four 
lateral,  two  on  each  side. 

The  anterior  medial  group  consists  of  a  few  twigs,  inconstant,  which  are 
given  off  from  the  anterior  cerebrals  and  anterior  communicating  artery.  They 
supply  the  anterior  extremity  of  each  caudate  nucleus.  The  posterior  medial 
group  consists  of  twigs  given  off  by  the  posterior  cerebral  arteries  near  their 
origin  from  the  basilar  ;  these  twigs  pass  into  the  posterior  perforated  spot,  and 
supply  the  inner  parts  of  the  optic  thalami  and  the  walls  of  the  third  ventricle* 
The  supply  by  these  groups  is  insignificant  as  regards  extent,  but  important  in 
regard  to  position,  on  account  of  its  proximity  to  the  ventricles,  into  which 
blood,  escaping  from  one  of  these  vessels,  may  readily  pass. 

The  lateral  groups  supply  the  chief  part  of  the  central  ganglia.  The  antero- 
lateral group  arises  from  the  middle  cerebral  near  its  origin  (in  the  first  inch  of 
its  course),  and  consists  of  a  number  of  small  arteries  which,  coming  off  at  a 
right  angle,  pass  into  the  "  anterior  perforated  space,"  and  supply  the  caudate 
nucleus  (except  its  head),  the  lenticular  nucleus,  the  internal  capsule,  and  part 
of  the  optic  thalamus.  These  arteries  are  of  great  importance,  and  may  be 
divided  into  two  sets  (Fig.  44)  :  an  internal  set,  the  vessels  of  which  pass- 
directly  through  the  internal  segment  of  the  lenticular  nucleus  to  the  internal 
capsule  ;  and  an  external,  consisting  of  vessels  that  course  upwards  for  a  short 
distance  outside  the  lenticular  nucleus,  and  then  pass  into  its  third  segment,  and 
through  this  to  the  internal  capsule.  The  vessels  extend  through  the  internal 
capsule,  the  anterior  to  the  caudate  nucleus  (except  its  head),  the  posterior  to 
the  optic  thalamus  (except  its  inner  and  hinder  part).  Hence  the  anterior  have 
been  called  the  lenticulo- striate,  and  the  posterior  the  lenticulo -optic  arteries. 
These  vessels  are  prone  to  rupture,  and  one  of  the  former  group,  which  runs  at 
the  outer  side  of  the  lenticular  nucleus  (Fig.  44),  from  its  size  and  tendencv  to 
give  way,  has  been  called  by  Charcot  "the  artery  of  cerebral  haemorrhage." 
The  vessels  burst  chiefly  outside  the  lenticular  nucleus,  and  the  ha3inorrha°-e 
separates  the  nucleus  from  the  external  capsule. 

The  postero-lateral  group  arises  from  the  posterior  cerebral,  after  it  has. 
passed  round  the  cms,  and  supplies  the  hinder  part  of  the  optic  thalamus. 
Haemorrhage  from  the  rupture  of  these  vessels  is  apt  to  invade  the  crus  on  the 

*  The  conclusions  of  Heubner  and  Duret  differ  regarding  the  anastomoses  of  the 
cortical  vessels;  the  latter  could  not  find  the  anastomoses  described  by  the  former. 
The  facts  of  pathology  are  strongly  in  favour  of  the  view  that  anastomoses  between 
the  cortical  branches  occur  often,  but  not  invariably.  An  injection  often  passes 
beyond  the  limit  of  the  distribution  of  the  artery  injected. 


62 


BRAIN. 


one  side  and  the  hinder  part  of  the  internal  capsule  on  the  other.  The 
posterior  cerebral  gives  branches  also  to  the  cms  and  to  the  corpora  quadri- 
gernina. 

V    ^c v — -— • i 


WMM< 


TE1MP.     LOBE 


FlG.  44. — Diagram  of  the  blood-supply  to  the  central  ganglia  by  the  lenticulo- 
striate  arteries,  external  (E)  and  internal  (2").  Ill  V,  third  ventricle; 
P  P,  pillars  of  the  fornix ;  Mid.  C,  middle  cerebral  artery.     (After  Duret.) 

Of  the  supply  to  the  cortex  from  the  three  vessels,  that  from  the  middle 
cerebral  is  the  most  extensive  and  the  most  important,  embracing  as  it  does 

Fig.  45. 


o  /v. 


Fig.  46. 

Figs.  45  and  46. — Area  of  the  cortex  on  the  outer  and  medial  aspects, 
supplied  by  the  anterior  cerebral  artery.  The  supply  of  the  several  branches 
is  indicated  by  the  dotted  lines. 

the  central    (motor)  convolutions.     The  general  plan  of  distribution  of  each 
artery  is  the  same.     Each  divides  into  certain  branches,  and  these  again  divide 


STRUCTURE    AND    FUNCTIONS. 


63 


and  ramify  ;  from  the  branches  and  the  ultimate  ramifications  (in  the  pia  mater) 
twigs  are  given  off  to  the  cerebral  substance.  These  are  of  two  kinds,  long  and 
short.  The  short  are  cortical,  supplying  only  the  grey  cortex,  in  which  they 
form  a  capillary  network,  most  abundant  in  the  middle  layers  which  contain  the 
large  nerve-cells.  The  long  are  medullary,  and,  passing  through  the  cortex, 
penetrate  the  white  substance  to  various  depths.  The  distribution  of  the  longest 
reaches  the  neighbourhood  of  that  of  the  central  vessels,  but  the  two  do  not 
blend,  and  at  the  confines  of  the  two  areas  small  cavities  often  form  in  old  a°-e. 
The  cortical,  moreover,  do  not  communicate  with  each  other,  and  although  there 
is  a  scanty  communication  between  the  areas  supplied  by  the  larger  trunks, 
it  is  often  insufficient  to  establish  a  collateral  circulation  if  one  is  obstructed. 
Hence  the  obliteration  of  branches  usually  (though  not  invariably)  causes 
softening  limited  to  the  area  supplied.  This  is  most  extensive  on  the  surface, 
and  lessens  in  extent  towards  the  centre  of  the  brain. 

The  anterior  cerebral  curves  round  the  corpus  callosum  and  supplies  part  of 
the  orbital  lobule,  the  inner  surface  as  far  as  the  quadrate  lobule,  and  the 
frontal  lobe,  with  the  exception  of  the  inferior  and  ascending  frontal  convolu- 
tions. Its  chief  branches  are  three,  and  supply  the  following  parts  : — (1)  the 
supra-orbital  lobule  (as  far  as  the  orbital  sulcus)  and  the  inner  aspect  of  the 
anterior  extremity  of  the  hemisphere  ;  (2)  the  anterior  half  of  the  inner  surface 
in  front  of  the  quadrate  lobule,  also  the  first  and  second  frontal,  and  the  highest 
part  of  the  ascending  frontal  convolution  ;  (3)  the  quadrate  lobule  (precuneus). 

The  middle  cerebral  divides,  opposite  the  island  of  Eeil,  into  four  branches, 
marked  I,  II,  III,  IV,  in  Fig.  47-     These  lie  in  the  sulci  of  the  insula,  and  then, 


FlG.  47. — Course  of  the  branches  of  the  middle  cerebral  artery. 


passing  on  to  the  surface  of  the  hemisphere,  have  the  following  distribution 
(Figs.  47  and  48) : — (1)  to  the  third  (inferior)  frontal  convolution  ;  (2)  to  the 
lower  two  thirds  of  the  ascending  frontal  and  the  root  of  the  middle  frontal 

(3)  to  the  whole  ascending  parietal,  superior  parietal  lobe,  and  adjacent  part  of 
the  inferior  parietal  lobule,  often  also  to  a  small  part  of  the  ascending  frontal ; 

(4)  to  the  convolutions  about  the  posterior  limb  of  the  fissure  of  Sylvius,  viz. 
part  of  the  inferior  parietal  lobule  (supra-marginal  and  angular  gyrus),  posterior 
extremity  of  the  superior  parietal  lobule,  and  the  hinder  part  of  the  first  two 
temporal  convolutions.  From  this,  near  its  origin,  one  or  two  large  branches 
arise  (V)  which  supply  the  anterior  part  of  the  first  and  the  greater  part  of  the 


64 


BRAIN. 


second  temporal  convolutions.     There  are  individual  variations  in  the  precise 
area  supplied  by  the  branches,  and  also  in  the  posterior  limit  of  the  distribution 


FlG.  48. — Area  of  distribution  of  the  branches  of  the  middle  cerebral  artery. 

of  the  middle  cerebral.  This  is  of  considerable  importance,  because  the  poste- 
rior part  of  the  angular  gyrus  often  escapes  the  softening  caused  by  obstruction 
of  the  middle  cerebral. 

The  posterior  cerebral  supplies  the  greater  part  of  the  inferior  aspect  of  the 
brain,  and  also  the  occipital  lobe,  inner  and  outer  surfaces,  by  three  branches. 


Fig.  49. 


Fig.  50. 

FIGS.  49  and  50. — Area  of  the  cortex  supplied  by  the  branches  I,  II,  III, 
of  the  posterior  cerebral  artery. 

The  vessel  divides  into  these  branches  after  winding  over  the  crus,  and  giving 
off  its  central  branches  and  twigs  to  the  tegmentum  of  the  crus,  and  to  the  cor- 


STKUCTUliE    AND    FUNCTIONS.  G5 

pora  quadrigemina.  Its  branches  supply  (1)  the  lower  part  of  the  uncinate 
convolution  ;  (2)  the  inferior  part  of  the  temporal  lobe  ;  (3)  the  cuneus,  lingual 
convolution  (i.  e.  the  posterior  part  of  the  uncinate  gyrus  beueath  the  calcarine 
fissure),  and  also  the  outer  surface  of  the  occipital  lobe. 

Thus  the  middle  cerebral  supplies  the  chief  part  of  the  motor  convolutions 
and  the  motor  central  structures,  as  well  as  the  cortical  auditory  centre,  and  the 
greater  part  of  the  angular  region.  The  posterior  cerebral  supplies  the  optic 
ganglia  (optic  thalamus  and  corpora  quadrigemina  and  geniculata),  and  in  the 
cortex  the  visual  region  in  the  occipital  lobe. 

The  blood -supply  to  the  pons,  medulla  oblongata,  and  cerebellum  is  derived 
from  the  vertebrals  and  basilar.  The  arrangement  of  the  supply  to  the  medulla 
and  pons  is  very  important  on  account  of  the  centres  whioh  are  here  so  closely 
grouped  together. 

It  will  be  remembered  that  each  vertebral,  before  it  joins  its  fellow  to  form 
the  basilar,  gives  off  an  inferior  cerebellar  artery  and  an  anterior  spinal  artery. 
From  all  these  vessels  small  branches  enter  the  pons  and  medulla.  The  cere- 
bellum is  nourished,  not  only  by  the  inferior  cerebellar  from  the  vertebral,  and 
superior  cerebellar  from  the  anterior  extremity  of  the  basilar,  but  also  by  a  large 
branch,  the  middle  cerebellar  artery,  which  comes  off  from  the  basilar  about  the 
middle  of  its  course,  and  passes  outwards  over  the  pons  and  middle  cerebellar 
peduncle. 

The  arterioles  for  the  pons  and  medulla  consist  of  two  sets.  (1)  A  series  of 
medial  vessels  enter  near  the  middle  line  in  front,  and  pass  directly  back,  close 
to  the  raphe,  to  the  nerve-nuclei,  which  receive  from  these  arteries  the  chief 
part  of  their  blood-supply  ;  (2)  lateral  or  radicular  vessels  pass  to  the  nerve- 
roots,  and  on  each  root  an  artery  divides  into  a  descending  branch,  which  extends 
along  the  nerve,  and  an  ascending  branch,  which  enters  the  medulla  with  the 
nerve-fibres,  and  accompanies  them  as  far  as  their  nucleus,  giving  off  branches 
as  it  proceeds.  But  the  blood-supply  to  the  nucleus  derived  from  the  radicular 
branch  is  far  less  than  that  from  the  median.  The  vertebral  supplies  the 
radicular  branches  to  all  the  bulbar  nerves,  except  a  branch  to  the  spinal  acces- 
sory nerves  which  comes  from  the  inferior  cerebellar,  and  to  the  hypoglossal, 
from  the  anterior  spinal  artery.  The  branches  to  the  facial  and  auditory  nerves 
may  come  from  the  vertebral  or  basilar,  or  both.  All  the  other  radicular  branches 
are  derived  from  the  basilar,  but  the  middle  cerebellar  artery  sometimes  gives 
branches  to  the  auditory  and  fifth  nerves. 

The  median  branches  form  a  continuous  series,  but  are  divided  by  Duvet  into 
four  sets,  termed,  from  their  position,  bulbar,  subpontine  (at  the  lower  edge  of 
the  pons),  medio -pontine  (along  the  pons),  and  supra-pontine  (at  the  upper  edge 
of  the  pons).  The  lower  bulbar  branches  come  from  the  anterior  spinal,  and 
supply  the  nuclei  below  the  calamus  scriptorius — the  hypoglossal  and  accessory. 
The  subpontine,  from  the  basilar,  supply  the  pneumogastric,  glosso-pharyngeal, 
and  auditory  nuclei,  while  the  medio-pontine  and  supra-pontine  branches  supply 
the  nuclei  in  the  upper  half  of  the  floor  of  the  fourth  ventricle,  as  well  as  the 
sixth.     The  anastomoses  of  these  vessels  are  unimportant. 

It  is  necessary  to  remember  that  the  larger  trunks  about  the  medulla  present 
frequent  variations,  which  entail  corresponding  variations  in  the  origin  of  the 
nutrient  arteries.  The  left  vertebral  is  usually  larger  than  the  right,  and  the 
latter  may  be  very  small,  so  that  the  basilar  is  practically  a  continuation  of  the 
left  vertebral  only.  There  is  usually  only  one  anterior  spinal  artery,  arising 
from  both  vertebrals,  or  arising  from  the  left  only.  If  there  are  two,  they 
usually  communicate,  but  the  left  occupies  the  medial  furrow  and  furnishes  the 

VOL.  II.  5 


66  BR  A IX. 

median  nutrient  arteries.  These  variations  explain  why  obstruction  of  one 
vertebral  sometimes  affects  the  nuclei  on  one  side,  sometimes  on  both,  and  some- 
times on  neither. 

Branches  to  the  olivary  body  and  anterior  pyramids  come  from  the  vertebral 
or  anterior  spinal ;  those  to  the  restiform  body  arise  from  the  inferior  cerebellar, 
and  this  also  gives  off  the  posterior  spinal  arteries,  from  which  branches  pass  to 
the  posterior  pyramids  and  to  the  upper  part  of  the  central  canal,  chiefly  at  the 
level  of  the  decussation  of  the  pyramids. 

The  chief  cerebellar  arteries  are  (1)  the  posterior  from  the  vertebral  (some- 
times  from  the  basilar),  -which  winds  round  the  medulla  between  the  hypoglossal 
and  pneumogastric  nerves,  and,  after  giving  origin  to  the  posterior  spinal  and 
branches  to  the  choroid  plexus  of  the  fourth  ventricle,  supplies  the  inferior 
vermiform  process  and  the  posterior  region  of  the  hemisphere ;  (2)  the  median 
(Duret),  which  leaves  the  basilar  at  the  middle  of  the  pons  and  passes  outwards 
over  the  middle  peduncle  of  the  cerebellum  to  ramify  on  the  under  surface  ;  (3) 
the  superior  cerebellar,  arising  from  the  basilar  close  to  its  bifurcation,  curves 
round  the  pons,  and  supplies  the  anterior  and  upper  parts  of  the  hemisphere. 
These  cerebellar  arteries  communicate  with  each  other,  and  the  superior  is  often 
connected  by  one  or  more  twigs  with  the  posterior  cerebral. 

Yexotts  Cihctjxation. — The  veins  of  the  convexity  of  the  hemisphere,  and  of 
its  inner  surface,  ascend  and  open  in  a  forward  direction  into  the  superior  longitu- 
dinal sinus.  One  of  the  veins  of  the  convexity  courses  at  first  along  the  fissure 
of  Sylvius,  and  afterwards  ascends  across  the  hemisphere  :  it  has  been  termed  the 
'•  Sylvian  vein  "  by  Duret.  The  course  of  the  surface  veins  is  important  because 
it  helps  to  explain  the  frequency  with  which  clots  form  within  them.  Elsewhere 
the  blood  from  ascending  arteries  passes  into  descending  veins,  so  that  the  feeble 
pressure  through  the  capillaries  is  supplemented  by  the  influence  of  gravitation. 
Elsewhere  ascending  veins  convey  blood  that  has  been  brought  by  descending 
arteries,  and  the  venous  pressure  is  aided  by  the  "  hydrostatic  pressure,"  which 
tends  to  make  the  blood  rise  in  the  veins  to  the  level  of  the  heart.  But  on  the 
brain,  blood  from  ascending  arteries  passes  into  ascending  veins.  The  openings 
of  these  veins  into  the  longitudinal  sinus  being  directed  forwards,  the  entering 
blood  is  opposed  in  direction  to  the  current  in  the  sinus,  and  the  effect  must  be 
to  retard  the  flow  in  both  veins  and  sinus.  Moreover,  in  the  erect  posture,  the 
anterior  part  of  the  longitudinal  sinus  has  also  an  ascending  course,  while  the 
trabecule  that  occupy  the  lumen  of  the  sinus  must  offer  some  hindrance  to  the 
movement  of  the  blood.  These  circumstances  help  us  to  understand  the  readi- 
ness with  which  clots  form  in  the  cortical  veins  and  longitudinal  sinus,  when 
other  circumstances  favour  the  coagulation  of  the  blood.  Indeed,  the  marvel  is 
that  thrombosis  is  not  more  common  than  it  is. 

The  veins  of  the  inferior  surface  of  the  brain  enter — the  anterior  the  cavern- 
ous sinus,  the  middle  the  petrosal  sinuses,  the  posterior  the  lateral  sinus.  The 
veins  of  Galen,  from  the  ventricles,  receive  not  only  the  blood  from  the  ventri- 
cular walls  and  choroid  plexuses,  but  also  from  the  corpus  callosum.  The  veins 
of  the  upper  surface  of  the  cerebellum  open  into  the  veins  of  Galen  or  the 
straight  sinus  in  which  the  veins  of  Galen  end.  Those  of  the  inferior  surface 
0pen — the  posterior  into  the  lateral  sinus,  and  the  anterior  into  the  occipital 
sinuses.  The  individual  veins  have  not,  as  a  rule,  free  communications  with 
those  adjacent,  although  differences  exist  in  this  respect.  But  the  system  of 
the  convexity  (superior  longitudinal  sinus)  has  three  important  communications. 
A  large  vein  always  passes  from  the  Sylvian  vein  to  the  superior  petrosal  siuus 


SECONDARY    DEGENERATIONS.  67 

(Trolard),  and  another,  at  the  base,  connects  the  commencement  of  the  Sylvian 
vein  with  the  basilar  vein,  and  thus  with  the  straight  sinus.  The  vein  of  the 
corpus  callosum  (going  to  the  veins  of  Galen)  often  communicates  freely  with 
the  veins  on  the  inner  surface  of  the  hemisphere,  which  go  to  the  superior 
longitudinal  sinus.  The  communication  between  the  various  sinuses,  with 
the  exception  of  the  superior  longitudinal,  are  free.  Thus  the  two  cavernous 
sinuses  are  connected  by  the  circular  sinus  around  the  pituitary  body,  and  each 
cavernous  sinus  has  a  double  communication  (by  the  two  petrosal  sinuses)  with 
the  lateral  sinus  and  jugular  vein,  while  the  two  inferior  petrosal  sinuses  are 
connected  by  the  "  transverse  sinus  "  across  the  basilar  process  of  the  occipital 
bone.  The  cavernous  sinus  receives  the  ophthalmic  vein,  the  superior  petrosal 
sinus  receives  veins  from  the  internal  ear,  and  into  the  lateral  sinus  some  mas- 
toid veins  open.  The  occipital  sinus  receives  the  spinal  veins,  and  many  sinuses 
receive  veins  from  the  diploe  of  the  skull. 

There  exist  certain  communications  between  the  cerebral  sinuses  and  veins 
outside  the  skull.  The  following  are  the  chief.  Veins  from  the  nose  enter  the 
anterior  extremity  of  the  superior  longitudinal  sinus.  The  ophthalmic  vein 
(cavernous  sinus)  communicates  freely  with  the  facial  vein.  By  the  veins  of 
the  mastoid  cells  the  occipital  vein  communicates  with  the  lateral  sinus.  More- 
over, small  "  emissary  "  veins  pass  through  minute  foramina  in  the  cranium  and 
connect  certain  sinuses  with  external  veins.  The  most  important  of  these  are 
between  the  superior  longitudinal  sinus  and  the  veins  of  the  scalp,  between  the 
cavernous  sinus  and  the  pterygoid  plexus  of  the  internal  maxillary  vein,  between 
the  inferior  petrosal  sinus  and  the  deep  veins  of  the  neck.  A  further  communi- 
cation, very  variable  in  degree,  is  established  by  the  veins  of  the  diploe.  Lastly, 
the  spinal  system,  which  has  free  external  communication,  is  connected  by  six 
veins  with  the  sinus  system  of  the  brain.  The  cerebral  veins  and  sinuses  have 
no  valves.  These  facts  are  important  in  regard  to  the  external  signs  of  throrn 
bosis  in  the  sinuses  within  the  skull. 


Secondary  Degeneration  in  the  Brain. 

We  have  already  seen  that  some  tracts  of  fibres  in  the  brain 
undergo  degeneration  after  a  lesion  in  their  course  or  in  the  grey 
matter  from  which  they  spring.  Ip  the  latter  case  the  whole  length 
of  the  fibre  degenerates,  in  the  former  only  that  portion  which  lies 
on  the  distal  side  of  the  lesion,  i.  e.  on  the  side  farthest  from  the 
nerve-cell  which  gives  origin  to  the  fibre.  This  secondary  degene- 
ration proceeds  until  the  fibres  are  again  interrupted  by  grey  matter, 
and  there  it  ceases.  The  nature  of  secondary  degeneration  was  con- 
sidered in  vol.  i,  where  we  saw  that  the  axis-cylinder  of  each  nerve- 
fibre  must  be  regarded  as  the  prolonged  process  of  a  nerve-cell, 
depending  on  that  nerve-cell  for  its  nutritional  integrity,  and  that  the 
nerve-fibre  therefore  undergoes  degeneration  when  the  cell  is  destroyed 
or  the  fibre  is  cut  off  from  the  cell.  As  a  general  rule  the  direction 
in  which  a  fibre  degenerates  is  that  in  which  it  conducts;  that  is,  the 
cell  on  which  the  nutrition  of  the  fibre  depends,  the  cell  of  which  it 
is  the  prolonged  process,  is  the  cell  from  which  the  nerve  impulses 
originate  that  traverse  the  fibre,  or,  in  other  words,  it  is  this  cell  only 


63 


BRAIN. 


which  excites  the  functional  activity  of  the  fibre.  But  this  rule  of 
the  identity  of  the  direction  of  conduction  and  degeneration  does  not 
seem  to  be  true  of  all  nerve-fibres.  As  far  as  is  yet  known,  it  is  true 
of  all  motor  fibres,  but  there  is  a  conspicuous  exception  to  it  in  the 
case  of  the  fibres  of  the  peripheral  sensory  nerves.  These  conduct 
centripetally,  but  degenerate  centrifugally  from  the  ganglion  on  the 
posterior  root.  Above  the  ganglion  they  conform  to  the  general  law. 
In  the  central  nervous  system  we  may  take  the  direction  of  degeneration 
as  presumptive  but  not  as  absolute  proof  of  the  direction  of  conduction. 
It  is  doubtful  whether  all  nerve-fibres  undergo  secondary  degeneration. 
The  fibres  of  the  corpus  callosum  apparently  do  not.  Possibly  some 
fibres  pass  between  two  nerve-cells,  and  are  so  related  to  both  (con- 
necting, for  instance,  undivided  processes)  that  either  cell  is  able  to 
maintain  the  nutrition  of  the  fibre. 

The  most  important  and  extensive  secondary  degeneration  is  that 
of  the  fibres  of  the  pyramidal  tracts,  proceeding  from  the  central 
convolutions.  The  course  of  these  fibres  has  been  already  fuily 
described  (p.  28).  The  lesion  causing  their  degeneration  may  be  in 
the  cortex,  or  anywhere  in  the  course  of  the  fibres.  If  it  is  above  the 
cms,  the  degeneration  appears  at  the  under  surface  of  the  eras,  in  ita 


Fig.  51. 


Fig.  52. 


Fig.  51. — Lesion  of  the  upper  part  of  the  central  convolutions,  causing 
descending  degeneration  of  the  pyramidal  tract  in  the  crus  and  the  anterior 
pyramid  of  the  medulla.     (After  Erissaud.) 

Fig.  52. — Partial  disease  of  the  central  convolutions,  causing  partial 
degeneration  of  the  pyramidal  fibres  in  the  crus  and  medulla.  More 
degenerated  fibres  come  to  the  surface  near  the  pons  than  near  the  tract. 

middle  two  fifths  (Fig.  51),  and  is  -wider  above,  near  the  optic  tracts 
than  below,  near  the  pons,  where  the  pyramidal  fibres  are  overlapped 
by  those  on  each  side.  The  pons  is  reduced  in  size  on  the  side  of  the 
degeneration,  and  the  anterior  pyramid  of  the  medulla  is  small  and 
grey.     To  cause  extensive  degeneration  of  these  tracts,  a  lesion  of  the 


SECONDARY    DEGENERATIONS. 


69 


z.F. 


J?.F. 


Soft 


LTy. 


•-    /DeegTr. 


cortex  must  be  also  exten- 
sive, such  as  that  shown  in 
Fig.  51.  A  slighter  lesion 
(Fig.  52)  causes  partial  de- 
generation ;  some  fibres  are 
involved  and  others  escape. 
A  lesion  of  the  marginal  con- 
volution in  the  monkey  is 
followed  by  scattered  de- 
generation in  the  internal 
capsule  behind  its  bend,  but 
not  in  front  of  this,  and  in 
the  pons  and  cord,  where  it 
is  more  compact.  Lesions  of 
the  gyrus  fornicatus  are  fol- 
lowed by  similar  degenera- 
tion in  the  pons  and  medulla, 
but,  in  the  cord,  this  is  spread 
out  over  the  whole  trans- 
verse sectional  area  of  the 
crossed  pyramidal  tract  of 
the  opposite  side  alone,  and 
gradually  diminishes  in 
amount  from  above  down- 
wards. (France,  '  Phil.  Tr.,' 
1889.) 

A  lesion  within  the  pons 
causes  degeneration  only  of 


Fig.  53. — Softening  in  the  left 
side  of  the  pons  in  the  crustal  por- 
tion (A),  and  near  the  nucleus  of 
the  filth  nerve  (B  x).  The  other 
figures  represent  sections  through 
various  parts  of  the  medulla  and 
decussation  of  the  pyramids;  the 
last  is  of  the  spinal  cord.  L  Py, 
R  Py,  left  and  right  pyramidal 
tract;  L  F,  R  F,  left  and  right 
fillet ;  Deep  Tr,  Sup  Tr,  deep  and 
superficial  transverse  fibres  of  the 
pons;  V mo,  Vase,  motor  nucleus 
and  ascending  root  of  the  fifth, 
nerve;  Au  d,  Au  s,  deep  and  super- 
ficial roots  of  the  auditory  nerve; 
Au,  e,  i,  a,  its  external,  internal, 
and  anterior  nuclei;  Rest,  restiform 
body ;  LAP,  RAP,  left  and  right 
anterior  pyramid;  Dd,  degenerated 
(left),  N  d,  not  degenerated  (right) 
pyramidal  fibres  at  the  decussation 
of  the  pyramids ;  L  A  P  T,  left  ant. 
pyr.  tract ;  R  L  P  T,  right  lateral  pyr.  tract ;  a  c,  anterior  cornu ;  y,  slight  degene- 
ration in  the  anterior  part  of  the  lateral  column. 


70 


BRAIN. 


the  fibres  below  the  lesion,  as  in  the  case  shown  in  Pig.  59.  The 
effects  of  the  area  of  softening  in  the  crustal  half  of  the  pons,  shown 
in  Fig.  53,  present  a  good  illustration  of  the  downward  course  of  the 

Fig.  54.  Fig.  55. 


Fig.  56. 

Fig.  54. — Degeneration  of  the  right  anterior  and  left  lateral  pyramidal 
tracts  in  the  spinal  cord,  consequent  on  a  lesion  in  the  right  hemisphere  of 
the  brain,  causing  left  hemiplegia. 

Fig.  55.  —  Bilateral  degeneration  of  the  pyramidal  tracts  secondary  to  a. 
lesion  in  the  right  hemisphere.     (Prom  secti  >ns  by  Prof.  Pitres.) 

Fig.  56. — Area  of  disease  of  the  right  pre-frontal  lobe,  causing  partial 
degeneration  of  the  inner  fibres  of  the  crusta. 


SECONDARY   DEGENERATIONS..  71 

degeneration  through  the  medulla  and  the  decussation  of  the  pyra- 
mids. In  Fig.  B  the  degenerated  bundles  of  the  pyramidal  tract  are 
separate,  but  in  C  and  D  they  are  united  in  the  anterior  pyramid, 
which  is  completely  degenerated.  The  passage  of  the  degenerated 
fibres  through  the  decussation  of  the  pyramids  is  shown  in  F  and  G- ; 
in  the  latter  most  of  them  have  reached  the  opposite  lateral  column 
of  the  cord,  and  occupy  the  position  of  the  lateral  pyramidal  tract, 
while  the  degeneration  in  the  anterior  column  is  reduced  almost  to 
the  small  dimensions  which  it  presents  in  the  lowest  figure  (of  the 
cord).  The  descending  changes  in  the  spinal  cord  have  been  described 
in  the  first  volume,  and  are  shown  in  Fig.  54. 

In  some  cases  of  disease  of  the  motor  path  in  one  hemisphere  there 
is  a  double  degeneration  in  the  cord,  a  slight  degeneration  in  the 
lateral  pyramidal  fibres  on  the  side  of  the  cerebral  lesion,  as  well  as 
considerable  degeneration  in  the  lateral  tract  of  the  opposite  side. 
Attention  has  been  called  to  the  frequency  of  this  double  degeneration 
by  Pitres.*  An  example  of  it  is  shown  in  Fig.  55.  It  is,  perhaps, 
related  to  the  double  representation  of  the  leg  in  both  hemispheres  of 
the  brain,  which  will  be  mentioned  in  the  account  of  the  symptoms 
of  brain  disease.     It  is  not  present,  however,  in  all  cases. 

Another  frequent  secondary  degeneration  is  that  of  the  fibres  which 
course  from  the  pre-frontal  lobe  of  the  brain  (in  front  of  the  central 
convolutions)  through  the  anterior  limb  of  the  internal  capsule,  and 
the  inner  part  of  the  crusta  of  the  cerebral  peduncle  to  the  grey 
matter  of  the  pons.  In  the  pons  their  degeneration  ceases,  but  the 
evidence  that  they  are  connected,  through  its  grey  matter,  with  the 
cerebellum  is  very  strong  (see  p.  32).  Hence  they  are  termed  the 
fron to- cerebellar  fibres  (F  C,  Fig.  56).  Their  degeneration  is  visible 
in  the  most  internal  portion  of  the  crus,  and  may  be  produced  by 
disease  either  of  the  frontal  lobe  in  front  of  the  ascending  frontal 
convolution  (see  Fig.  56)  or  of  the  anterior  limb  of  the  internal  capsule 
(Fig.  57). 

Degeneration  of  the  most  external  fibres  of  the  crusta,  those  that 
pass  between  the  grey  matter  of  the  pons  and  the  temporal  and 
occipital  lobes,  has  been  met  with  in  rare  cases.  In  an  instructive 
case  of  congenital  atrophy  of  one  occipital  lobe,  extending  as  far  as 
the  middle  of  the  posterior  limb  of  the  fissure  of  Sylvius,  there  was  also 
atrophy  of  the  pulvinar,  the  optic  tract,  the  external  geniculate  body, 
the  superficial  layer  of  the  anterior  quadrigemmal  body,  and  its 
anterior  brachium.f  Degeneration  of  those  fibres  has  been  caused 
by  extensive  damage  to  the  cortex  (Bechterew),  or  by  a  lesion  in  the 
vicinity  of  the  hindmost  fibres  of  the  internal  capsule,  as  in  the  case 
shown  in  Fig.  58.  It  is  not  the  disease  of  the  capsule  itself  which 
causes  the  degeneration,  for  the  fibres  that  run  in  this  part  of  the 
capsule  proceed  from  the  tegmentum  (p.  32),  and  probably  degenerate, 

*  See  also  Hadden  and  Sherrington,  '  Brain,'  18S6. 
t  Kreusner,  'Allg.  Zeitschr.  f.  Psych.,'  Bil.  xlviii. 


72  BKAIN. 

as  they  certainly  conduct,  upwards.  The  degeneration  is  due  to  the 
damage  to  the  adjacent  fibres,  which,  as  tbey  leave  the  cms,  do  not 
enter  the  capsule,  but  pass  close  by  it,  to  radiate  to  the  temporal  and 
occipital  cortex. 

Fig.  57.  Fig.  58.  Fio.  59. 


FlO.  57. — Lesion  of  the  lenticular  nucleus  and  of  both  limbs  of  the  cap- 
sule, causing  partial  degeneration  of  the  inner  and  pyramidal  fibres  of  the 
crusta. 

Fig-.  58. — Disease  of  the  posterior  part  of  the  capsule,  damaging  also  the 
adjacent  fibres  from  the  outer  part  of  the  crusta,  which  have  undergone 
secondary  degeneration.     (After  Brissaud.) 

FiG.  59. — A  lesion  (S)  of  the  pons,  causing  secondary  degeneration  of 
the  transverse  fibres  (D  D)  and  of  the  anterior  pyramid  of  the  medulla. 

The  transverse  fibres  of  the  pons  are  said  to  degenerate  when  intei-- 
rnpted  by  a  leaion  in  their  course.  Of  adjacent  fibres,  some  seem  to 
degenerate  in  one  direction,  and  other  fibres  in  the  opposite  direction, 
so  that  the  degeneration  extends  on  each  side  of  the  lesion,  as  in 
Fig.  59.  In  the  case  shown  in  Fig.  53  such  degeneration  could  not  be 
distinctly  traced. 

The  above  are  the  chief  secondary  degenerations  that  are  of  medical 
significance.  Some  other  degenerations  have  been  met  with,  such, 
for  instance,  as  that  of  the  fillet,  but  they  are  not  yet  of  sufficient 
de finite ness  to  warrant  their  detailed  description. 


THE   SYMPTOMS    OF   BRAIN   DISEASE. 


The  symptoms  produced  by  diseases  of  the  brain  are,  for  the  most 
part,  the  same  in  character,  whatever  be  the  morbid  process  that  causes 
them.  They  depend  on  the  seat  of  the  disease,  and  on  the  nature  of 
the  change  that  the  nerve-elements  undergo,  rather  than  on  the  patho- 
logical character  of  the  primary  lesion.  In  most  diseases  that  we 
term  "organic"  the  primary  morbid  process  is  outside  the  nerve- 
elements  themselves ;  the  changes  these  elements  undergo  are 
secondary,  and  are  few  in  kind,  while  the  diseases  by  which  they  are 
produced  are  numerous.  In  the  maladies  that  we  term  "  functional  " 
(which  are  better  conceived  as  "nutritional,"  see  vol.  i,  p.  2)  there  is 


SOLl'TOHS.  73 

no  lesion  outside  the  nerve-elements  ;  the  change  which  these  undergo, 
and  on  which  the  symptoms  immediately  depend,  is  primary.  This  is 
probably  the  case  also  in  the  degenerations  of  the  brain,  although  the 
changes  in  the  nerve-elements,  and  those  in  the  interstitial  tissue, 
often  seem  to  occur  almost  at  the  same  time. 

The  symptoms  of  disease  show  that  there  is  disorder  of  function, 
either  "  objective  "  and  recognisable  by  another  person,  or  "  subjec- 
tive" and  perceived  only  by  the  sufferer  himself.  The  disturbance  of 
function  is  of  two  kinds  :  (1)  a  diminution  of  action,  which  may  present 
every  degree  down  to  abolition  ;  and  (2)  an  increase  of  action.  These 
two  effects  are  often  combined.  Disease  may  lessen  the  possible 
amount  of  functional  action,  and  yet  render  that  which  remains  too 
readily  excited.  This  is  the  "irritable  weakness"  of  old  writers. 
The  increase  of  action  caused  by  disease  is  commonly  called  "  irri- 
tation." But  irritation  sometimes  lessens  function  by  the  process 
that  physiologists  term  "inhibition."  Thus  loss  of  function  may 
be  due  to  structural  damage  or  to  irritation ;  from  the  latter  the  loss 
is  transient,  from  the  former  it  is  permanent.  Lastly,  function  may 
be  gravely  deranged  and  even  arrested  by  a  change  in  the  blood, 
especially  by  the  presence  in  it  of  new  elements,  constituting  what  is 
termed  a  "  toxseinic  "  state.  The  facts  at  present  available  suggest 
that  these  agents  may  be  either  organisms  or  the  products  of  their 
growth — perhaps  merely  the  chemical  products. 

Structural  damage  to  the  nerve-elements  is  produced  in  various 
ways  by  organic  disease  of  the  brain.  The  following  are  the  most 
important  mechanisms : — (1)  Mechanical  interruption  or  destruction, 
as  when  nerve-fibres  are  torn  across,  or  nerve-cells  are  separated 
by  an  extravasation  of  blood.  This  involves,  of  necessity,  entire 
abolition  of  function.  (2)  Mechanical  compression,  which  may  be 
sudden  or  slow  in  its  production,  and  varies  in  its  influence  on  func- 
tion according  to  its  rapidity.  Very  slight  compression,  if  suddenly 
or  rapidly  induced,  arrests  function ;  on  the  other  hand,  a  consider- 
able amount  of  pressure  produces  little  or  no  effect  if  it  be  very 
slowly  induced.  We  do  not  know  whether  pressure  acts  on  function 
by  a  mechanical  influence  on  the  nerve-elements,  or  by  an  arrest  of 
the  blood-supply  due  to  compression  of  the  capillaries.  The  differ- 
•ence  between  the  effect  of  slow  and  sudden  pressure  suggests  that 
its  influence  on  the  nerve-elements  is  direct,  since  the  effect  on  the 
capillaries  must  be  the  same  in  each  case.  Pressure  does  more  than 
arrest  function  ;  it  causes  structural  disintegration  of  nerve-elements, 
and  this  also  is  greater  when  the  pressure  is  rapidly  produced.  (3) 
Arrest  of  the  blood-supply  causes  arrest  of  fuction,  and  diminution  of 
the  blood-supply  causes  impairment  of  function.  Here  also  we  may 
trace  a  relation  to  rapidity  of  production,  although  slighter  than  in 
the  case  of  pressure,  and  perhaps  due  to  the  fact  that  slow  obstruc- 
tion gives  time  for  the  establishment  of  a  collateral  circulation.  The 
immediate  arrest  of  function  that  follows  a  sudden  arrest  of  blood- 


74  BKAIN. 

supply  is  very  remarkable.  If  the  heart  fails,  for  instance,  conscious- 
ness is  instantly  lost.  It  is  probable  that  the  influence  is  in  part 
mechanical,  due  to  the  sudden  diminution  in  the  pressure  to  which 
the  nerve-elements  are  normally  exposed.  It  is  probable,  therefore, 
that  a  decrease,  as  well  as  an  increase,  of  pressure  interferes  with 
function.  (4)  Inflammation — which,  in  the  brain  as  in  other  tissues, 
involves  the  interstitial  tissue  and  the  proper  elements  of  the  part,  as 
well  as  the  blood-vessels.  (5)  Molecular  disintegration  or  wasting  of 
the  nerve-elements.  This  constitutes  the  primary  and  chief  element 
in  many  degenerative  processes,  in  which  it  is  associated  with  changes 
in  the  interstitial  tissue.  It  occurs  also,  in  rapid  form,  in  consequence 
of  many  of  the  other  morbid  processes  above  described. 

Some  symptoms,  such  as  local  paralysis,  are  due  to  and  indicate 
interference  with  the  function  of  a  definite  part  of  the  brain.  They 
are  often  termed  focal  symptoms.  Other  symptoms,  such  as  loss  of 
consciousness  or  delirium,  indicate  a  wide-spread  interference  with  func- 
tion, and  are  called  diffuse.  The  distinction,  although  useful,  must  not 
be  conceived  as  absolute.  Some  symptoms  may  be  at  one  time  diffuse, 
at  another  focal.  The  same  terms  are  also  applied  to  the  morbid 
processes,  but  the  two  applications  do  not  altogether  correspond. 
Diffuse  processes  may  cause  focal  symptoms,  as  when  hemiplegia 
results  from  an  inflammation  extending  over  the  whole  of  one 
hemisphei'e.  On  the  other  hand,  a  focal  lesion  may  cause  a 
diffuse  symptom,  as  when  a  small  haemorrhage  produces  loss  of 
consciousness. 

It  is  necessary,  in  the  first  place,  to  describe  the  characters  of  the 
several  symptoms  of  organic  disease  of  the  brain.  Some  of  these 
symptoms  consist  of  disturbance  of  the  functions  of  the  cranial 
nerves,  and  it  will  be  convenient  to  describe  them  in  connection  with 
the  diseases  of  those  nerves,  before  we  consider  the  general  rules  of 
diagnosis  and  the  special  diseases  of  the  brain. 

Motor  Symptoms. — Motor  Paralysis — Hemiplegia.-^  Loss  of 
voluntary  power  over  the  muscles  is  one  of  the  most  frequent  and 
important  effects  of  brain  disease.  A  distinction  is  often  drawn 
between  complete  and  partial  loss  of  power,  and  the  former  is  termed 
"  paralysis,"  the  latter  "  paresis."  The  two  differ  only  in  degree,  and 
the  term  "  paralysis  "  is  also  applied  to  all  grades  of  deficiency.  The 
loss  is  due  to  interference  with  the  motor  centres  or  the  motor  path, 
which,  as  we  have  seen,  passes  from  the  central  convolutions  down 
through  the  centrum  ovale,  the  internal  capsule,  the  crusta  of  the 
cerebral  peduncle,  and  the  corresponding  region  of  the  pons,  to  the 
anterior  pyramid  of  the  medulla.  The  disease  that  causes  paralysis 
may  be  situated  in  any  one  of  these  regions.  Disease  elsewhere  does 
not  cause  loss  of  motor  power  unless  it  exerts  pressure  on  the  motor 
tracts.     The  paths  from  the  two  sides  are  near  together  in  the  pons, 


STAIfTOilS.  75 

and  still  nearer  in  the  medulla  ;  hence  a  lesion  in  either  of  these 
situations  may  paralyse  both  sides  of  the  body.  Even  in  the  pons, 
however,  a  single  lesion  often  affects  one  side  only,  while  in  the  crura 
the  paths  diverge,  and  both  suffer  only  when  they  are  damaged  by  a 
large  tumour.  In  the  cerebral  hemispheres  a  single  lesion  always 
affects  only  one  motor  path.  The  unilateral  paralysis  that  results 
from  disease  of  the  tract  on  one  side  is  termed  "  hemiplegia."  The 
paths  decussate  in  the  medulla,  and  therefore  the  limbs  are  paralysed 
on  the  side  opposite  to  the  lesion  in  the  brain.  In  the  pons  the 
motor  paths,  before  crossing  the  middle  Hue  to  the  hypoglossal  and 
facial  nuclei,  are  associated  with  the  path  from  the  limbs,  and  hence 
a  lesion  anywhere  above  the  middle  of  the  pons  usually  causes  also 
paralysis  of  the  face  and  tongue,  which  is  on  the  same  side  as  the 
palsy  of  the  limbs.  The  motor  fibres  diverge  in  the  internal  capsule, 
and  still  more  as  they  pass  through  the  white  substance  to  the  cortex, 
where,  as  we  have  seen,  are  centres,  to  some  extent  separate,  for  the 
leg,  arm,  face,  and  tongue.  Hence  lesions  of  the*  cortex,  or  of  the 
white  substance  just  beneath  it,  may  paralyse  one  of  these  parts 
without  the  others ;  but  such  partial  palsy  seldom  results  from  a 
lesion  in  the  internal  capsule,  because,  to  have  so  limited  an  action, 
a  lesion  there  must  be  minute. 

To  the  rule  that  the  paralysis  is  on  the  side  opposite  to  the  cerebral 
lesion,  apparent  exceptions  have  been  met  with,  in  which  hemiplegia 
was  on  the  same  side  as  the  lesion.  Morgagni  suggested  that  in  these 
cases  the  ordinary  decussation  of  the  motor  tracts  does  not  occur  ;  and 
the  discovery  by  Flechsig  that  there  are  great  variations  in  the  decus- 
sation of  the  pyramids  in  the  medulla  has  been  regarded  as  confirming 
the  hypothesis  of  Morgagni.  But  there  is  strong  reason  to  believe 
that  when  the  paths  do  not  decussate  in  the  medulla  they  cross  lower 
down  the  spinal  cord,  and  if  so  this  explanation  falls  to  the  ground. 
Much  more  frequent  than  hemiplegia  on  the  same  side  as  the  lesion 
is  hemiplegia  without  any  discoverable  lesion  to  account  for  it.  The 
nature  of  these  cases  is  mysterious,  but  most  pathologists  have  met 
with  instances.  They  are  probably  due  to  a  morbid  blood-state,  as 
already  explained. 

In  a  case  of  severe  "complete"  hemiplegia  the  arm  and  leg  are 
powerless ;  the  face  is  paralysed,  chiefly  in  the  lower  part,  and  moves 
almost  as  well  in  the  upper  part  as  on  the  unparalysed  side ;  the  tongue, 
when  protruded,  deviates  towards  the  paralysed  side,  being  pushed 
over  by  the  genio-hyo-glossus  of  the  sound  side.  But  the  muscles  of 
mastication  contract  equally  in  ordinary  action,  and  the  two  sides  of 
the  thorax  move  equally  in  ordinary  respiration.  Some  of  the  trunk 
muscles  may  be  weakened ;  the  patient  cannot  sit  up.  If  he  takes 
a  deep  breath,  and  brings  into  action  the  extraordinary  muscles 
of  respiration,  the  half  of  the  thorax  on  the  paralysed  side  often 
expands  less  than  the  other.  Thus  some  muscles  are  completely 
paralysed,   others  are   merely   weakened,   others  are  apparently  un- 


76  BRAIN. 

•affected.  This  difference  in  the  condition  of  the  muscles  becomes 
greater  after  the  lapse  of  a  few  months.  Even  when  the  motor  path 
in  one  hemisphere  is  completely  interrupted  by  the  disease,  and  the 
interruption  is  permanent,  the  muscles  that  were  merely  weakened  im- 
prove in  strength,  and  in  some  others,  that  were  at  first  totally  para- 
lysed, a  certain  amount  of  voluntary  power  returns.  Some  movement 
•of  the  leg  is  regained,  especially  at  the  hip-  and  knee-joints ;  in  the 
arm  the  shoulder- joint  can  be  moved  a  little,  and  often  also  the  elbow, 
although  the  hand  may  remain  motionless.  Such  recovery,  the  lesion 
persisting,  occurs  to  some  extent  at  all  ages,  but  much  more  readily 
in  the  young  than  in  the  old.  In  children  the  recovery  of  the  leg  is 
so  great  that  in  time  there  is  ability  to  walk  long  distances,  in  spite 
of  the  destruction  of  the  motor  path.  In  adults,  the  palsy  of  the 
hand  may  remain  almost  absolute  ;  often,  however,  slight  power  of 
flexing  the  fingers  returns,  and  in  children  some  recovery  of  movement 
in  the  hand  is  invariable,  and  it  may  ultimately  be  considerable, 
although  disordered.-* 

This  difference  in  the  initial  palsy,  and  the  return  of  power  in  certain 
muscles,  manifestly  suggest  a  complex  relation  of  the  muscles  to  the 
centres  of  each  hemisphere,  and  this  relation  is  often  stated  by  an. 
hypothesis  called  "  Broadbent:s ;"  but,  as  stated  by  Broadbent,  it  was 
in  a  form  somewhat  different  from  that  which  seems  best  to  meet  the 
exigencies  of  present  knowledge.  Its  form  has  indeed  changed  more 
than  once,  but  the  credit  belongs  to  him  of  having  first  definitely 
stated  it.  Some  muscles  of  the  body,  as  the  intercostals  and 
masseters,  are  used  only  with  their  fellows  of  the  opposite  side ; 
others  are  often  used  with  their  fellows,  but  often  also  alone,  as  the 
zygomatici,  the  trapezii,  and  many  leg  muscles  ;  others  are  chiefly 
used  alone,  as  the  muscles  of  the  hand.  Movements  are  represented 
exclusively  in  the  opposite  hemisphere  in  proportion  as  they  are  uni- 
lateral, in  both  hemispheres  in  proportion  as  they  are  bilateral  in 
execution.  In  other  words,  either  hemisphere  can  excite  the  bilateral 
movements,  but  only  the  opposite  hemisphere  can  excite  the  unilateral 
movements.  The  muscles  that  are  sometimes  used  with  their  fellows 
of  the  opposite  side  and  sometimes  alone,  which  recover  partially  with 
.a  persistent  lesion,  are  connected  with  both  hemispheres,  but  are 
habitually  excited  from  the  opposite  hemisphere ;  they  recover  some 
power  because  the  hemisphere  on  the  same  side  gains  the  influence 
over  them  for  which  structural  arrangements  previously  existed,  but 
had  not  been  used. 

We  do  not  yet  know  the  nature  of  the  connection  between  the 
hemisphere  and  the  muscles  on  the  same  side.  Broadbent  thought  it 
was  by  a  connection  between  the  lower  (spinal  and  bulbar-)  centres  on 

*  Thus,  in  one  case  of  severe  hemiplegia  in  early  life,  the  patient  became  able  to 
-walk  long  distances,  and  had  some  power  of  (disordered)  movement  in  the  hand. 
After  death  in  adult  life  the  opposite  internal  capsule  was  lound  destroyed.  A  large 
cavity  occupied  the  whole  of  the  central  ganglia. 


SYMPTOMS.  77 

the  two  sides,  which  enabled  the  bilateral  muscles  to  be  excited 
together  from  one  hemisphere.  It  is  highly  probable  that  such  a 
connection  does  exist,  aud  it  may  be  actually  effective  in  the  case  of 
the  bilateral  use  of  muscles;  but  such  a  connection  cannot  subserve 
the  unilateral  use  of  such  muscles,  as,  for  instance,  the  isolated  move- 
ment of  the  leg.  This  implies  a  separate  path  to  the  lower  centre ; 
a  mere  connection  of  the  lower  centres  would  not  suffice.  We  do  nob 
know  whether  this  separate  path  is  by  pyramidal  fibres  that  do  not 
decussate  (as  by  the  anterior  pyramidal  tract,  or  by  the  passage  of 
some  fibres  into  the  lateral  column  of  the  same  side),  or  whether  it  is 
by  a  recrossing  in  the  cord.  We  must,  however,  associate  this 
relation  with  the  fact  that  degeneration  may  be  found  in  both  lateral 
columns  when  the  disease  is  on  one  side  of  the  brain  (see  p.  70)  ;  but 
there  is  a  difference  of  opinion  as  to  the  way  in  which  this  degenera- 
tion arises,  whether  the  fibres  that  degenerate  come  down  from  the 
medulla,  as  is  suggested  by  Pitres'  observations  on  man,  or  whether 
they  are  due  to  a  recrossing  in  the  cord,  as  Sherrington  concludes 
from  his  experiments  on  animals.* 

But  the  retention  of  some  movements  and  the  return  of  others 
suggests  another  correlated  fact.  If  bilateral  movements  are  excited 
from  both  hemispheres,  disease  of  one  hemisphere  should  lessen  the 
power  on  both  sides.  In  proportion  as  muscles  escape  or  recover  on 
the  side  opposite  to  the  lesion  they  should  be  weakened  on  the  side  of 
the  lesion.  As  a  matter  of  fact  this  is  so.  Most  of  the  bilateral 
muscles  are,  however,  so  placed  that  their  strength  cannot  be 
measured,  but  many  muscles  of  partly  bilateral  use  can  be  tested,  and 
these  are  always  found  to  be  weakened  on  the  side  of  the  lesion.  The 
weakening  of  this  side  was  pointed  out  long  ago  by  Brown- Sequard, 
and  has  been  also  investigated  by  Pitresf  and  Friedlander.J  It  is- 
greater  when  the  lesion  is  in  the  left  hemisphere  than  when  the  right 
is  diseased.  In  the  leg  the  loss  is  always  considerable,  and  is  indeed 
conspicuous,  even  on  a  cursory  examination.  It  exists  also  in  the 
trunk  muscles,  where  it  is  less  readily  detected,  and  it  exists  also  in 
the  arm  in  a  degree  for  which  theory  scarcely  prepares  us.  The 
power  of  the  hand  is  often  reduced  to  not  mi*ch  more  than  one  half 
of  the  normal.  Such  a  loss  is  not  adequately  explained  by  the 
hypothesis  above  stated,  and  seems  to  show  that  this  hypothesis, 
however  true  and  important,  does  not  express  the  whole  truth,  part 
of  which  may  be  lost  sight  of,  obscured  by  developmental  processes 
in  which  it  arose..  This  is  especially  true  of  the  complementary 
weakening  that  should  correspond  to  the  preservation  of  strength, 
and  which  can  scarcely  be  otherwise  explained. 

Some  other  features  of  hemiplegia  remain  to  be  described.     Certain 
movements  towards  one  side  are  produced  by  the  action  of  muscles 

*  '  Journ  of  Pliys.,'  vi,  Nos.  4  and  5. 

t  'Arch,  de  Neurologie,'  1882. 

J  '  Neur.  Centralbl.,'  1883,  p.  241. 


78  BBAIN. 

situated  on  both  sides.  Such,  for  instance,  is  the  lateral  movement 
of  the  eyes,  by  the  external  rectus  of  one  side  and  the  internal  rectus 
of  the  other.  Such  also  is  tbe  rotation  of  the  head;  the  face  is 
turned  towards  one  side  by  the  opposite  sterno-mastoid,  acting  with 
other  less  important  muscles  of  tbe  side  towards  which  the  bead  is 
turned.  In  hemiplegia  these  movements  towards  the  paralysed  side 
may  be  impaired.  The  head  and  eyes  cannot  then  be  turned  towards 
the  affected  side;  and  the  unopposed  antagonistic  muscles  may 
even  turn  the  head  and  eyes  towards  the  unparalysed  side.  This  is 
termed  "  conjugate  deviation  of  the  eyes."  The  symptom  usually 
passes  away  in  the  course  of  a  few  days,  but  occasionally  continues 
for  weeks,  and  is  perhaps  occasionally  represented  by  nystagmus 
on  movement  in  the  direction  concerned.  From  this  we  learn 
two  facts.  First,  that  movements,  rather  than  muscles,  are 
represented  in  the  cerebral  hemispheres,  and  are  lost  in  disease. 
Secondly,  that  these  lateral  movements  by  muscles  of  both  sides  are 
represented  in  both  hemispheres,  but  that  in  a  normal  state  they  are 
chiefly  effected  by  the  opposite  hemisphere.  When  this  is  diseased 
they  are  impaired,  until  the  hemisphere  on  the  same  side  has  acquired 
functional  power  over  them  through  mechanisms  before  existing  but 
unused. 

A  sudden  cerebral  lesion,  such  as  causes  hemiplegia,  is  often 
attended  by  loss  of  consciousness.  We  are  then  deprived  of  the 
direct  evidence  of  loss  of  voluntary  power,  and  a  slight  degree  of 
weakness  cannot  be  detected.  But  the  existence  of  considerable  ]:>ara- 
lysis  can  generally  be  ascertained.  There  may  even  be  greater  flaccidity 
of  the  paralysed  limbs,  which,  if  raised,  fall  like  a  weight  influenced 
only  by  gravitation,  while  the  opposite  limbs,  although  they  also  fall, 
do  so  less  suddenly.  We  are  also  helped  in  this  condition  by  the 
state  of  reflex  action,  which  is  often  though  not  always  diminished 
or  abolished.  This  is  best  seen  in  the  abdominal,  cremasteric,  and 
plantar  reflexes,  when  these  are  compared  with  the  corresponding 
actions  on  the  opposite  side.  Moreover,  during  the  period  of  un- 
consciousness, the  conjugate  deviation  of  the  head  and  eyes  is  often 
distinct ;  if  the  head  be  placed  in  the  mid-position,  the  deviation 
slowly  returns.  A  slight  degree  of  ptosis  may  also  sometimes  be 
noticed  on  the  paralysed  side. 

If  the  patient  is  conscious,  the  power  of  voluntary  movement  can 
be  directly  tested,  and  if  the  paralysis  is  not  absolute  the  several 
movements  of  each  joint  should  be  separately  examined,  and  the 
force  with  which  passive  movement  can  be  resisted  should  be  ascer- 
tained. The  patient  is  almost  always  able  to  close  the  eye,  but 
often  a  strong  contraction  of  the  orbicularis  is  less  on  the  para- 
lysed side  than  on  the  other.  When  there  is  no  difference  in  the 
strength  of  contraction  of  the  orbiculares  palpebrarum,  the  patient, 
if  previously  able  to  shut  the  eye  on  the  hemiplegia  side  without 
the  other,  is  usually  no  longer  able  to  do  so.     In  the  early  stage 


SYMPTOMS. 


79 


the  patient  may  be  unable  even  to  close  tbe  eye  on  the  hemiplegia 
side.  Sometimes  there  is  even  slight  weakness  of  the  frontalis,  and 
the  forehead  may  be  smoother  on  the  paralysed  side  than  on 
the  other.  In  the  lower  part  of  the  face  there  may  be  a  marked 
difference  in  the  degree  of  affection  of  the  voluntary,  emotional,  and 
associated   movements    (Figs.    60 — 62).      The    former   is   tested  by 


Fig.  60. 


Fig.  61. 


Fig.  62. 


Figs.  60 — 62. — Different  affoction  of  voluntary  and  emotional  move- 
ments of  the  face  in  a  case  of  right  hemiplegia.  The  appearance  of  the 
face  at  rest  is  shown  in  Fig.  60 ;  an  attempt  to  raise  the  upper  lip  on  both 
sides  in  Fig.  61 ;  a  smile  in  Fig.  62.  The  last  was  much  more  nearly  equal 
on  the  two  sides  than  the  figure  suggests.     (From  photographs.) 


making  the  patient  raise  the  upper  lip,  and  move  the  mouth  from  side 
to  side ;  emotional  movement  is  seen  in  a  smile,  and  the  associated 
movement  is  obtained  by  causing  the  patient  to  grasp  strongly  with 
the  sound  hand.  This  difference  is  occasionally  of  considerable  dia- 
gnostic importance.  In  some  cases,  in  the  early  stage,  the  eye  cannot 
be  closed,  and  there  may  be  a  doubt  whether  the  paralysis  is  due  to 
disease  of  the  nerve  or  of  the«motor  tract  in  the  hemisphere.  In  the 
former  case  all  emotional  movement  is  lost,  as  well  as  that  which  is 
voluntary.  In  the  latter  the  smile  may  be  equal  on  the  two  sides 
although  voluntary  movement  is  lost  on  one.  The  movement  of  the 
tongue  within  the  mouth  should  be  observed,  as  well  as  its  deviation 
on  protrusion.  The  base  of  the  tongue  is  usually  higher  on  the 
paralysed  side  than  on  the  other. 

If  hemiplegia  is  complete  in  extent  but  imperfect  in  degree,  the 
condition  is  similar  to  that  of  perfect  hemiplegia  which  is  in  process 
of  recovery.  The  loss  of  power  is  greater  in  the  arm  than  in  the  leg, 
and  greater  towards  the  extremity  of  each  limb  than  in  the  part' 
nearest  the  trunk.  The  muscles  moving  the  hand  are  weaker  than 
those  of  the  shoulder,  and  in  the  leg  the  most  affected  movements  are 
those  of  the  foot,  especially  flexion  of  the  ankle.  Hence,  in  walking, 
the  foot  is  swung  round  (or,  less  commonly,  the  knee  is  unduly  flexed) 
in  order  to  prevent  the  contact  of  the  toes  with  the  ground  when  the 


80  BRAIN. 

foot  is  brought  forwards.  There  is  often  more  power  of  using  the  leg 
with  the  other,  as  in  walking  or  standing,  than  there  is  in  the  separate 
movements  of  the  limb. 

To  the  rule  that  the  leg  recovers  before  the  arm,  and  the  proximal 
parts  of  the  limbs  before  the  distal,  apparent  exceptions  are  some- 
times met  with.  The  arm  may  recover  earlier  and  more  than  the  leg, 
and  sometimes  the  distal  recover  before  the  proximal  parts  of  the 
limbs.  We  should  remember  that,  in  comparing  the  two  modes  of 
recovery,  we  are  (or  may  be)  comparing  things  in  their  nature  unlike 
— the  return  of  power  due  to  compensation  by  the  other  hemisphere, 
with  that  due  to  the  recovery  of  the  damaged  hemisphere. 

Varieties  of  hemiplegia  depend,  for  the  most  part,  on  differences 
in  the  seat  of  the  lesion.  These  differences  may  be  spoken  of  as 
transverse  and  vertical.  The  transverse  variations  determine  differ- 
ences in  the  distribution  of  the  palsy  on  the  affected  side,  and  are 
greater  the  higher  the  lesion  is  in  the  motor  path,  reaching  their 
maximum  at  the  cortex.  The  vertical  differences  determine  chiefly 
the  associations  of  the  hemiplegia,  although,  as  we  have  just  seen,, 
they  are  not  without  influence  on  its  distribution,  on  account  of  the 
different  compactness  of  the  path,  and  consequent  differences  in  the 
scope  for  transverse  variations  in  the  lesion.  Where  the  path  occu- 
pies a  small  transverse  area,  a  single  lesion  can  hardly  fail  to  influence 
the  whole  of  it. 

The  varieties  determined  by  the  relative  amount  of  damage  to  the- 
several  parts  of  the  motor  path  or  centres  depend  on  the  distribution 
of  the  palsy,  whether  this  is  "  complete  "  from  a  total  lesion,  or  "  in- 
complete "  from  a  partial  lesion.  The  latter  occurs  chiefly  when  the 
disease  is  in  the  white  substance  of  the  hemisphere  or  in  the  cortex. 
Such  limited  palsy  is  termed  "monoplegia,"*  or  " dissociated  hemi- 
plegia." The  arm  only,  the  leg  only,  or  the  face  and  tongue  may  be 
affected.  The  two  last  named  are  usually  involved  together  in  conse- 
quence of  the  proximity  of  their  centres  and  path.  These  varieties  have 
been  termed  brachial,  crural,  andfacio-lingiial  monoplegia.  The  face  and 
arm  may  also  suffer  together  (bra chio-facial monoplegia).  The  para- 
lysis is  never  absolute  in  these  cases  of  limited  range,  and  the  condition 
of  the  limb,  as  regards  loss  of  power,  usually  resembles  that  of  hemi- 
plegia which  is  in  process  of  recovery.  The  coarse  movements  of  the 
upper  part  of  the  limb  are  preserved,  while  the  movements  of  the  hand 
may  be  lost. 

The  second  class  of  varieties  depend  on  the  vertical  position  of  the 
lesion.  If  this  is  in  the  medulla  the  face  escapes  altogether,  or  only 
the  lips  are  involved.  Disease  at  the  level  of  the  hypoglossal  may,  by 
damaging  the  fibres  of  this  nerve,  cause  its  paralysis  on  the  same  side 

*  Strictly,  "  monoplegia  "  ought  to  be  used  to  designate  double  hemiplegia,  but 
this  is  commonly  called  diplegia.  We  have  thus  the  anomalous  nomenclature  (too 
firmly  rooted  to  be  disturbed)  that  two  half-palsies  make  a  double  palsy,  and  that 
a  one-palsy  is  part  of  a  half-palsy  ! 


SYMPTOMS.  81 

as  the  lesion,  and  a  deviation  of  the  tongue  towards  the  tmparalysod 
side.  Theoretically,  hemiplegia  without  paralysis  of  face  or  tongue 
may  result  from  a  lesion  of  one  pyramid  below  the  hypoglossal  nuclei, 
but  such  cases  are  extremely  rare.  In  the  lower  part  of  the  pons 
the  facial  nerve  is  damaged  on  the  side  of  the  lesion,  and  therefore 
on  the  side  opposite  to  the  palsy  of  the  limbs.  In  the  upper  part 
of  the  pons  the  fibres  from  the  opposite  facial  nucleus  have  joined 
the  motor  tract,  and  the  hemiplegia  does  not  differ  from  that  pro- 
duced by  disease  of  the  internal  capsule,  unless  the  fifth  nerve  is 
involved  on  the  side  opposite  to  the  limbs.  If  the  lesion  is  in  the 
crus,  the  fibres  of  the  third  nerve  may  be  damaged  on  the  side  of  the 
lesion,  and  there  is,  in  addition  to  the  hemiplegia,  palsy  of  the  third 
nerve  opposite  to  the  hemiplegia,  usually  complete,  sometimes  incom- 
plete, and  affecting  especially  the  levator.  The  impairment  of  sensa- 
tion that  often  accompanies  hemiplegia  will  be  described  in  a  separate 
section. 

Associated  movements  sometimes  occur  in  the  parts  paralysed. 
An  effort  to  grasp  with  the  unaffected  hand  will  sometimes  cause 
a  similar  movement  in  the  paralysed  hand.  More  common  still  is  a 
movement  of  the  paralysed  arm  during  the  act  of  yawning  or  stretch- 
ing, or  even  during  coughing.  When  partial  recovery  of  power  has 
taken  place,  voluntary  movements  of  the  affected  limb  may  cause  an 
associated  movement  of  the  unaffected  limb.  The  explanation  of 
these  associated  movements  is  doubtless  to  be  found  in  the  connections 
of  the  subsidiary  centres  through  which  they  are  produced. 

The  diminution  in  the  superficial  reflex  action  already  mentioned 
is  almost  invariable  at  first.  Sometimes  it  passes  away  in  the  course 
of  weeks  or  months  ;  in  other  cases  it  persists.  In  rare  cases  an 
increase  in  the  superficial  reflex  action  has  been  met  with:  This 
difference  bears  no  relation  to  the  change  in  sensibility.  We  do  not 
yet  know  the  significance  of  the  difference.  Some  physiological 
researches  suggest  that  there  is  a  cerebral  centre  which  normally 
restrains  the  activity  of  the  spinal  reflex  centres,  and  that  this  is,  in 
its  tm*n,  controlled  by  a  higher  centre,  the  influence  of  which  may  be 
cut  off  by  the  lesion.  In  consequence,  the  reflex  inhibitory  centre  is 
unrestrained,  and  lowers  reflex  action  on  the  paralysed  side.  This  loss 
of  reflex  action  is  of  diagnostic  importance,  because  it  often  occurs  when 
the  motor  paralysis  is  slight. 

In  rare  cases,  considerable  movements  of  the  limbs,  even  of  the  arm, 
similar  to  the  associated  movements,  may  be  produced  by  cutaneous 
stimulation.  The  effect  may  not  be  confined  to  the  paralysed  side. 
Thus,  Nothnagel  mentions  a  case  in  which  a  moderate  pinch  of  the 
hemiplegic  arm  caused  muscular  contractions  in  the  other  arm  ;  on  a 
stronger  pinch  the  contractions  extended  to  the  other  leg,  and  on  a 
still  stronger  pinch,  to  the  leg  also  on  the  same  (the  hemiplegic) 
side,  whilst  the  arm  that  was  pinched  always  remained  still.* 
*  •  v.  Ziemsseu's  Handbuch,'  Bd.  xi,  1,  ii  Auflage,  p.  110. 
VOL.  II.  6- 


82  BRA  IX. 

Muscular  Bigidity. — At  some  period  the  paralysed  linibs  usually 
preseut  rigidity  of  the  muscles,  which  stiffens  the  limbs  in  a  certain 
posture,  and  opposes  passive  movement.  The  attempt  to  overcome 
the  rigidity  by  forced  extension  of  the  muscles  causes  pain.  Todd 
first  drew  a  distinction  between  two  forms,  "  early  "  and  "  late  " 
rigidity,  and  to  these  we  must  add  two  others.  (1)  Initial  rigidity 
comes  on  immediately  after  the  onset,  and  often  lasts  for  a  few 
hours  only.  It  is  due  to  the  irritation  of  the  fibi-es  by  the  process 
that  interrupts  their  continuity,  and  is  often  absent.  The  (2)  early 
rigidity  comes  on  within  a  few  days  of  the  onset,  and  lasts  for  a 
few  weeks.  The  posture  which  the  limbs  assume  is  that  of  rest.  It  is 
apparently  due  to  the  irritation  of  the  fibres  of  the  motor  tract  by  the 
inflammation  that  the  lesion  sets  up.  It  is  usually  slight  in  degree, 
but  sometimes  considerable,  when  there  is  an  unusual  amount  of 
irritation.  If  the  initial  rigidity  is  prolon  ged  it  may  pass  into  the  early 
rigidity.  The  (3)  late  rigidity  comes  on  in  the  course  of  a  few  weeks, 
and  lasts  for  months  or  years  ;  in  cases  of  enduring  paralvsis  it  may 
be  permanent.  This  rigidity  occurs  when  there  is  descending  degene- 
ration in  the  motor  (pyramidal)  tracts,  and  seems  to  be  influenced  in 
its  degree  by  the  irritative  nature  of  this  degeneration  (Charcot).  In 
the  upper  limb  the  position  is  that  of  adduction  of  the  shoulder, 
flexion  of  the  elbow,  flexion  and  pronation  of  the  wrist,  and  still  greater 
flexion  of  the  fingers,  especially  of  the  distal  phalanges,  by  the  con- 
traction of  the  long  flexor  (fig.  63),  the  interossei,  which  flex  the 
metacarpo-phalangeal  joints,  being  little  affected  in  this  form  of  con- 
tracture. When  the  wrist  is  passively  flexed  the  fingers  can  be  ex- 
tended freely,  but  if  the  wrist  is  extended  they  return  to  the  state  of 
flexion,  because  extension  of  the  wrist  lengthens,  and  flexion  shortens 
the  course  of  the  flexor  tendons  (fig.  64).  Although  the  contracture 
preponderates  in  the  flexor  muscles,  the  extensors  present  also  some 
rigiditv,  as  passive  movement  readily  demonstrates.  Very  rarely  the 
fingers  are  extended  at  all  joints  (including  the  metacarpo-phalangeal), 
but  in  these  cases  there  is  never  complete  paralysis,  and  the  rigidity 
also  is  slight.  Iu  the  leg  the  rigidity  is  more  nearly  equal  in  the  two 
groups  of  muscles,  and  produces  extensor  contracture,  so  that  the  leg 
is  straight,  and  the  foot  tends  to  assume  the  position  of  talipes  equino- 
varus.     The  face  does  not  participate  in  this  form  of  rigidity. 

The  late  rigidity  depends  on  an  active  muscular  contracture.  It 
lessens  very  much  during  sleep,  and  when  the  limb  is  placed  in  warm 
water.  It  can  also  be  overcome  by  passive  extensiou,  most  readily 
when  this  is  gentle  and  long  continued.  The  relaxation  is  facilitated 
by  rubbing  the  muscle.  Faradisation  of  the  opponents  of  the  most 
contracted  muscles  also  lessens  the  rigidity.  "When  late  rigidity  has 
continued  for  a  considerable  time,  tissue  changes  sometimes  take  place 
in  the  shortened  muscles,  in  consequence  of  which  their  passive 
elongation  is  no  longer  possible.  Thus  we  must  distinguish  from  the 
active  late  rigidity  an  ultimate  (4)  structural  contracture. 


SYMPTOMS. 


83 


Fig.  63. — Late  rigidity  inhemi- 
piegia  five  months  after  the 

onset. 


The  rigidity,  early  and  late,  evidently  depends  on  the  over -action  of 
the  spinal  centres.  The  centres  which  thus  overact  are  probably  those 
on  -which  normal  muscular  "tone"  de- 
pends, and  the  rigidity  is  an  excessive 
degree  of  this  "tone."  With  it  is  asso- 
ciated an  excess  of  the  peculiar  muscular 
irritability  on  which  the  so-called  "ten- 
don reflexes  "  depend,  due  probably  to  a 
muscle-reflex  action  (see  vol.  i,  p.  15). 
The  excess  is  not  usually  evident  until  a 
week  or  ten  days  after  the  onset  of  the 
hemiplegia.  In  consequence  of  this  in- 
creased irritability  there  is,  in  most  cases 
of  hemiplegia  with  persistent  weakness, 
au  excessive  knee-jerk,  and  a  foot-clonus 
can  generally  be  obtained.  Sometimes  a 
rectus-clouus  can  be  elicited.  The  same 
condition  may  be  observed  in  the  arm. 
A  tap  on  the  front  of  the  wrist  causes  a 
contraction  in  the  flexors  of  the  fingers ; 
one  of  the  radius  produces  a  contraction 
in  the  biceps,  one  on  the  ulna  a  contrac- 
tion in  the  triceps,  and  this  can  be  still 
better  obtained  by  a  tap  on  the  tendon 
of  the  triceps  just  above  the  olecranon. 
A  clonus  can  sometimes  be  obtained  in  the 
flexors  of  the  fingers  by  putting  sudden 
tension  on  them.  I  have  even  obtained 
a  similar  clonus  in  the  trapezius  by 
sudden  depression  of  the  shoulder. 

The  increase  of  myotatic  irritability, 
which  depends  on  degenerative  changes 
in  the  pyramidal  tracts,  comes  on,  as  has 
been  said,  about  ten  days  after  the  onset 

of  the  hemiplegia.  But  the  myotatic  irritability  sometimes  presents 
variations  before  the  degenerative  increase  is  established,  and  these 
are  probably  due  to  the  cerebral  irritation,  which  may  increase  or 
inhibit  the  action  of  the  spinal  centres  on  which  the  phenomena  depend. 

Indeed,  immediately  after  the  onset  of  hemiplegia,  the  knee-jerk 
may  be  absent,  and  it  may  return  in  a  few  hours.  When  it  is  thus 
lost  there  is  perfect  relaxation.  More  frequent  than  this  loss  is  an 
initial  increase  ;  soon  after  the  onset  the  knee-jerk  is  increased,  and  a 
foot-clonus  can  be  obtained.  This  early  increase  may  or  may  not  pass 
away  before  the  degenerative  excess  is  developed. 

Muscular  Irritability  and  Nutrition.— In  cerebral  disease  there  is 
rarely  any  considerable  change  in  the  irritability  of  the  muscles.     It 


Fig.  R4  — Lnte  rigidity  in  hemi- 
plegia, showing  tlie  flexion  of 
the  middle  and  distal  pha- 
langes when  the  wrist  is  ex- 
tended, and  their  extension 
when  flexion  of  the  wrist 
shortens  the  course  of  the 
tendons. 


84  BRAIN. 

may  be  tire  same  as  that  on  the  unparalysed  side,  or  it  may  present  a 
slight  change,  increase  or  diminution.  The  change  is  never  consider- 
able, and  is  the  same  to  both  faradism  and  voltaism.  The  increase  is 
the  earlier  change  ;  a  decrease  is  not  usually  present  until  some  months 
after  the  onset.  In  the  cases  in  which  there  is  an  alteration  of  mus- 
cular irritability,  there  is  genei'ally  wasting  of  the  muscles,  sometimes 
considerable,  but  never  reaching  the  degree  seen  in  progressive  mus- 
cular atrophy.  Both  the  wasting  and  the  alteration  in  irritability  are 
probably  due  to  the  irritative  character  of  the  descending  degeneration 
in  the  pyramidal  tracts.  Although  the  degeneration  does  not  spread 
to  the  motor  nerve-cells  as  a  destructive  process,  it  seems,  when  irri- 
tative in  character,  to  influence  their  nutrition  and  the  nutrition,  of 
the  motor  nerve-fibres  proceeding  from  them,  and,  through  these,  that 
of  the  muscles. 

Vaso-motor  and  Trophic  Chatiges. — The  paralysed  limbs  (1)  may 
present  no  vascular  changes ;  (2)  they  may  be  warmer  by  half  a  degree 
or  so  than  those  of  the  opposite  side  ;  (3)  they  may  be  colder,  pale  or 
livid.  Eulenberg  and  Landois  have  ascertained  that  the  cortex  contains, 
near  the  motor  centres  for  the  limbs,  other  centres  that  influence  the 
vascular  state  of  the  limbs.  Irritation  of  these  centres  causes  pallor 
and  coldness,  while  hyperemia  and  increased  warmth  are  probably  the 
result  of  a  loss  of  the  central  influence,  and  may  be  due  to  disease  of 
the  cortex  or  of  the  path  from  it,  which  seems  to  pass  in  the  posterior 
limb  of  the  internal  capsule.  The  elevation  of  temperature  may  be 
from  '2°  to  15°  F.  above  that  of  the  unparalysed  side.  It  is  often 
uniformly  raised  for  ten  days  or  a  fortnight,  and  then  presents  varia- 
tions, sometimes  an  elevation,  sometimes  a  depression.  The  elevation 
of  temperature  may  be  accompanied  by  redness  of  the  skin  ;  when  the 
temperature  falls  the  vessels  may  contract,  causing  pallor,  or  may 
remain  distended,  and  the  limb  then  has  a  bluish-red  aspect.  Occa- 
sionally there  is  increased  sweating.  There  may  be  some  subcu- 
taneous oedema,  most  marked  towards  the  extremity  of  the  limb. 
This,  in  slight  degree,  is  very  common,  and  may  come  on  at  the 
end  of  one  or  two  days  and  persist  for  many  weeks.  It  is  especially 
great  when  there  is  kidney  disease,  and  may  be  very  marked  in  the 
paralysed  limb  and  absent  elsewhere.  In  some  cases  there  is  a 
tendency  to  acute  trophic  changes.  Slight  pressure,  continued  for 
a  few  hours,  may  raise  a  blister,  and  even  cause  the  skin  to 
slough;  sometimes,  indeed,  the  vesication  and  sloughing  seem  spon- 
taneous. Bedsores  thus  readily  occur.  Their  most  common  seat  in 
hemiplegia  is  the  gluteal  region,  while  in  paraplegia  it  is  usually 
over  the  sacrum.  The  skin  over  the  trochanter,  malleolus,  and  heel 
is  also  apt  to  slough,  manifestly  because  these  points  are  the  most 
exposed  to  pressure.  A  marked  tendency  to  such  sloughing  is  of  bad 
prognostic  significance. 

More  chronic  trophic  changes  are  sometimes  observed.     Dissemi- 


SYMPTOMS.  85 

nated  neuritis,  with  considerable  thickening  of  the  nerves  at  certain 
spots,  has  been  met  with  (Leubuscher),  and  is  said  to  be  independent 
of  degeneration  in  the  pyramidal  tracts  (Charcot).  Inflammation  of 
the  larger  joints,  attended  with  redness  and  swelling,  has  been  occa- 
sionally observed  during  the  latter  part  of  the  period  of  inflammatory 
reaction,  three  or  four  weeks  after  the  onset.  It  is  limited  to  the 
hemiplegic  side,  and  is  evidently  analogous  to  the  similar  inflammation 
that  is  secondary  to  acute  myelitis.  This  condition  is  met  with  more 
frequently  in  cases  of  cerebral  softening  than  of  cerebral  haemor- 
rhage. 

In  some  cases  there  are  symptoms  that  suggest  paralysis  of  the 
cervical  sympathetic  (Nothnagel).  These  are  contraction  of  the  pupil, 
slight  drooping  of  the  eyelid  (not  due  to  paralysis  of  the  levator, 
because  the  eyelid  can  be  raised  as  high  as  on  the  paralysed  side), 
narrowing  of  the  palpebral  fissure,  retraction  of  the  eyeball,  and  an 
increased  secretion  of  tears  and  of  nasal  mucus.  The  pulse  on  the 
paralysed  side  is  often  smaller  than  on  the  other,  and  sphygmographic 
tracings  are  said  to  show  a  lessened  contractility  of  the  wall  of  the 
vessel  (Wolff  and  Eulenberg). 

Occasionally  the  nutrition  of  the  nails  is  changed,  and  they  become 
more  curved  and  brittle.  Rarely  there  is  an  inci'ease  in  the  growth  of 
hair  and  a  thickening  of  the  skin.  When  hemiplegia  comes  on  in 
childhood  the  growth  of  the  limbs  is  usually  retarded,  and  they  never 
attain  the  normal  size.  The  difference  is  more  marked  in  the  upper 
than  in  the  lower  limbs,  and  affects  all  parts,  including  the  bones  ;  in 
the  scapula  it  is  often  very  conspicuous. 

Disorders  of  Movement  after  Hemiplegia. — Besides  the  rigidity 
already  mentioned  the  affected  limbs  sometimes  present  other  forms 
of  spasm, — tremor,  rhythmical  movements,  and  esj>ecially  irregular 
movements,  occasionally  quick,  more  often  slow.  These  occur  only 
when  there  is  some  return  of  voluntary  power,  not  when  the  paralysis 
remains  absolute.  The  spasm  is  especially  conspicuous  on  voluntary 
movement,  although  it  may  also  occur,  in  slighter  degree,  when  the 
limbs  are  at  rest.  All  forms  are  more  frequent  and  more  considerable 
in  the  arm  than  in  the  leg.  The  spasm  does  not  manifest  itself  until 
some  months  after  the  onset  of  the  hemiplegia,  coming  on  with  the 
return  of  voluntary  power;  once  established,  it  usually  persists, 
although  it  may  lessen  somewhat  in  the  course  of  years. 

Simple  tremor  is  not  common.  It  is  usually  fine,  and  occurs  chiefly 
during  movement,  rarely  when  the  limb  is  at  rest.  It  is  confined  to 
the  arm.  Rhythmical  movements  are  also  rare,  and  likewise  occui 
only  in  the  upper  limb.  There  may  be  alternate  flexion  or  exten- 
sion of  the  fingers  or  wrist,  or  pronation  and  supination  of  the  hand, 
continuous  or  only  on  movement. 

The  most  common  form  is  that  in  which  there  is  tonic  spasm,  slowly 
varying  in  relative  degree  in  different  muscles,  and  thus  causing  slow 


8Q 


BRAIN. 


irregular  movements,  chiefly  conspicuous  in  the  hand,  and  slow  irre- 
gular inco-ordination.  From  this  feature  it  mav  conveniently  be 
termed  "  mobile  spasm."  It  is  commonly  conjoined  with  more  or  less 
permanent  rigidity,  which  tends  to  fix  the  limb  in  a  certain  posture. 
This  fixed  rigidity  is  generally  proportioned  to  the  amount  of  paralysis. 
If  the  loss  of  power  is  slight,  and  there  is  no  fixed  rigidity,  tbe 
movements  may  extend  in  range.  In  some  cases  the  movements  are 
quiet  instead  of  slow.  In  rare  cases,  these  movements  come  on 
without  preceding  hemiplegia;  such  a  condition  was  called  by 
Hammond  "athetosis"  (=  without  fixed  position).  Such  primary 
spasm  is  similar  in  characters  to  that  which  may  succeed  hemiplegia, 
and  every  gradation  is  met  with  between  such  cases  of  extensive 
movement  without  rigidity  and  the  more  frequent  cases  in  which  the 
movements  are  slighter,  and  are  combined  with  fixed  contracture. 
The  condition  has  also  been  termed  "  spastic  hemiplegia  "  and  "  post- 
hemiplegic chorea."  This  latter  term  is  objectionable,  because  the 
condition  has  nothing  to  do  with  chorea,  and,  except  in  very  rare 
cases  of  quick  movement,  the  resemblance  to  true  chorea  is  remote. 
In  this  condition  the  upper  arm  is  usually  adducted ;  the  elbow- 


Fig.  65. 


Fig.  66. 


Fig.  65. — Continuous  mobile  spasm  (athetosis)  after  slight  hemip'egia. 
(Patient  aged  24;  onset  of  hemiplegia  at  23;  of  spasm  lour  months  later. 
Previous  syphilis.)  The  hand  was  in  continuous  movement  between  the 
two  positions  shown.  The  foot  was  habitually  inverted,  and  the  great  toe 
often  over-extended. 

Fig.  66.— Post-hemiplegic  mobile  spasm.  (The  hemiplegia  came  on  at 
23,  probably  from  embolism,  and  was  severe.  Spasm  commenced  a  year 
after  the  onset,  at  the  same  time  as  slight  return  of  voluntary  power.  The 
figures  show  some  of  the  postures  of  the  hand  six  years  after  the  onset, 
especially  the  predominant  spasm  of  the  iuterossei.) 

joint  is  commonly  flexed,  sometimes  extended,  and  occasionally  the 
extended  arm  is  carried  backwards  by  the  spasm  and  rotated  inwards, 
so  that  the  hand  is  held  against  the  lumbar  region  with  the  palm 


SYMPTOMS. 


87 


turned  outwards.     In  the  same  patient,  the  arm  may  be  sometimes 
extended  and  sometimes  flexed.     If  there  is  fixed  rigidity,  this  usually 
affects  chiefly  the  flexors  of  the  wrist,  so  that  this  joint  is  bent  at  a 
right  angle.     If  there  is  no  fixed  rigidity,  the  wrist  is  sometimes 
flexed,  sometimes  over-extended.     In  the  hand  (Figs.  65  and  66)  the 
spasm  has  almost  always  a  peculiar  distribution.     It  affects  especially 
the  interossei  and  lumbricales,  which  flex  the  metacarpo-phalangeal 
and  extend  the  phalangeal  joints  ;  sometimes  it  affects  also  the  long 
extensor,  but  never  the  long  flexors  of  the  fingers,  which  are  the  espe- 
cial seat  of  the, ordinary  "  late  rigidity."     Hence,  the  hand  is  usually 
in  the  "  interosseal  position"  (such  as  the  interossei  produce),  with 
flexion  of  the  proximal  and  extension  of  the  middle  and  distal  phalan- 
ges, but  the  amount  of  spasm  varies  from  time  to  time  in  the  muscles 
of  the  different  digits ;  now  one  is  slowly  extended,  then  another  ;  and 
the  thumb  is  sometimes  pressed  against  the  forefinger,  sometimes  over- 
extended.    At  one  time  all   the  fingers 
may  be   extended   and   separated,  then 
one   or  another  is   adducted   or  flexed, 
the   wrist    being  sometimes   flexed   and 
sometimes  extended,  and  the  slow  irre- 
gular changes   in   position   suggest   the 
movements  of  the  tentacles  of  a  cuttle- 
fish.    The  constant  spasm  of  the  inter- 
ossei may,   after  a  time,   so   affect  the 
middle  and    distal  phalangeal    articula- 
tions  that   they   become   over-extended 
and  undergo  a  subluxation,  so  that  the 
head  of  the  nearer  phalanx  is  prominent 
on  the  palmar  aspect  of  the  finger.*     The 
exercise  of   the  muscles  by  the  contin- 
uous   activity  may    lead  to    their   over- 
growth, so  that  the  affected   arm   may 
be   larger  in    circumference    than    the 
other,  and  this  even  in  cases  in  which 
growth  has  been  arrested  and  the  limb 
is  shorter   than  the  other.     When  the 
hand  is  at  perfect  rest,  the  movements 
become    slighter   and    often   cease,   but 
they   are   renewed   by   any   attempt   at 
voluntary  action,  and  even  by  attention. 
In  more  severe  cases,  such  as  those  to  which  the  term  "athetosis" 
is  strictly  applicable,  the  movements  continue  during  rest,  and  may 
even  persist  during  sleep.     On  the  other  hand,  in  many  cases  the 
spontaneous  movements  are  trifling,  and  close  observation  may  be 
*  This  occurs  chiefly  when  the  spasm  comes  on  early  in  life.     In  children  over- 
extension of  the  phalangeal  joints  can  readily  be  produced,  and  it  is  kept  up  and 
increased  by  the  spasm. 


Fig.  67.— Mobile  and  fixed  spasm 
in  hand  alter  hemiplegia  in 
early  life.  In  the  upper  figure 
the  thumb  is  held  so  as  to  show 
the  over-extension  of  the  midd  le 
phalanges  of  the  fingers.  As 
soon  as  the  thumb  was  released, 
the  hand  assumed  the  positiou 
shown  in  the  lower  figure. 


88  BKALY. 

necessary  to  detect  them.  In  all  cases  voluntary  movement  is 
irregular  and  difficult,  the  spasm  excited  by  the  attempt  producing  a 
peculiar  slow  inco-ordination. 

The  leg  is  always  affected  in  much  slighter  degree  than  the  arm. 
The  spasm  is  extensor,  and  in  the  foot  tends  to  cause  elevation  of 
the  heel  and  inversion  of  the  foot — talipes  equino-varus.  Some  fixed 
rigidity  in  these  muscles  usually  coexists.  There  is  often  also  a 
marked  over-extension  of  the  great  toe.  The  mobile  spasm  in  the 
leg  is  rarely  spontaneous,  but  is  usually  at  once  excited  by  movement, 
especially  by  attempts  to  walk. 

The  face,  in  these  cases,  presents  as  a  rule  no  spontaneous  spasm  ;* 
the  same  spasmodic  tendency  is  nevertheless  seen  also  here,  causing 
a  slight  movement  to  be  greater  in  degree  on  the  affected  side  than 
on  the  other,  and  the  result  may  be  of  great  diagnostic  importance. 
In  a  slight  smile,  for  instance,  the  angle  of  the  mouth  is  drawn  out- 
wards more,  and  ofteu  sooner,  on  this  side  than  on  the  other,  although 
there  may  be  a  manifest  deficiency  of  power  on  a  stronger  movement. 
The  slight  over-action  in  the  face  is  often  a  most  valuable  diagnostic 
indication  in  cases  of  old  infantile  hemiplegia,  of  which  little  trace 
may  remain  elsewhere. 

In  about  half  the  cases  in  which  this  condition  follows  hemiplegia 
in  the  adult,  there  is  impaired  sensation  on  the  affected  side — hemi- 
anesthesia. But  in  the  cases  which  date  from  childhood,  sensation 
is  always  normal.  (A  lesion  of  the  brain  in  childhood  seldom,  if  ever, 
causes  persistent  loss  of  sensibility.) 

It  has  been  mentioned  that  movement  intensifies  the  spasm  and 
is  disordered  by  it,  being,  in  consequence,  rendered  ataxic  or  inco- 
ordinate. In  some  cases  there  is  no  spontaneous  spasm,  but  simply 
inco-ordination  of  voluntary  movement,  varying  in  degree  from  mere 
awkwardness  or  unsteadiness  to  wild  disorder,  and  there  may  be 
jerking  inco-ordination  resembling  that  seen  in  disseminated  sclerosis. 

Regarding  the  nature  and  position  of  the  disease  which  causes 
these  disorders  of  movement  "we  have  as  yet  but  little  pathological 
evidence.  The  symptom  is  observed  after  recovery  from  the  para- 
lysis, and  hence  in  patients  who,  for  the  most  part,  live  on  and  pass 
out  of  observation.  But  two  etiological  facts  are  of  great  signifi- 
cance. The  first  is  that  these  disorders  of  movement  are  far  more 
frequent  after  cerebral  softening  from  vascular  occlusion  than  after 
cerebral  haemorrhage. f  The  second  is  that  they  follow  hemiplegia 
far  more  frequently  when  this  comes  on  in  infancy  or  childhood  than 
when  it  comes  on  in  adult  life.  The  probable  significance  of  the  first 
fact  is  that  in  softening,  slight  damage  to  the  cerebral  tissue  is  more 
extensive  than  the  actual  destruction,   and  the  spontaneous  spasm 

*  But  cf.  a  case  by  Beevor  and  Horsley,  'Brit.  Med.  Journ.,'  1890,  ii,  12S6. 
Many  other  anomalous  cases  have  been  recorded,  chiefly  solitary  (see  Remak,  'Neur. 
Cent.,5  1888,  392;  Blocq  and  Blum,  'Rev.  de  Med.,'  1888,  p.  79;  Kraft  Eb!ng, 
'Wien  Kl.  Woch.,'  1889.  &c). 

t  See  "  Athetosis,"  &c,  '  Med.-Chir.  Trans.,'  1876. 


SYMPTOMS.  89 

must  be  referred  to  the  overaction  of  grey  matter,  which  is  in  a  state 
of  altered  nutrition  and  function.  Hence  we  can  understand  the 
occurrence  of  this  symptom  from  a  lesion  which  involves  extensive 
slight  damage.  The  significance  of  the  second  fact — the  frequency 
with  which  the  condition  follows  infantile  hemiplegia — is  probably 
the  greater  facility  with  which  the  growing  and  developing  nerve- 
cells  recover,  and  their  greater  susceptibility  to  disorder  of  function 
when  their  development  is  perverted. 

Begarding  the  seat  of  the  disease  which  gives  rise  to  these  sym- 
ptoms, the  facts  at  present  recorded  are  too  few  to  permit  any  accurate 
generalisation.  It  is,  however,  probable  that  a  distinction  must  be 
drawn  between  the  cases  in  which  the  lesion  occurs  in  childhood  and 
in  adult  life.  In  the  latter,  the  condition  is  rare,  and  in  most  of  the 
recorded  cases  the  disease  has  been  situated  either  in  or  outside  the 
optic  thalamus ;  in  several,  it  involved  the  posterior  part  of  the 
internal  capsule,  a  fact  which  explains  the  occasional  association  of 
hemiansesthesia.  The  disease  of  the  internal  capsule  has  usually 
been  incomplete,  not  involving  the  whole  thickness  of  the  capsule,  and 
the  lesion  has  always  involved  the  grey  matter  of  the  lenticular  nucleus 
or  the  caudate  nucleus.  Since  the  optic  thalamus  is  not  in  the  motor 
path,  disease  limited  to  this  must  produce  the  synrptom  indirectly 
by  disturbing  the  function  of  some  motor  structures.  It  is  certain, 
moreover,  that  the  symptom  may  result  from  disease  which  is  limited 
to  the  cottex.*  Eegarding  the  cases  that  date  from  childhood  we  have 
very  few  facts.  In  those  that  have  been  examined,  the  disease  has 
varied  much  in  position  and  extent.  This,  and  the  frequency  of  its 
occurrence,  suggest  that,  as  mentioned  above,  the  symptom  is  due  to 
the  quality  of  the  lesion  (impairment  of  the  nutrition  of  growing 
motor  nerve-cells)  rather  than  to  its  site. 

The  relation  between  these  various  forms  of  post-hemiplegic  diseases 
of  movement  is  shown  in  the  following  table. 

Post-hemiplegic  disorders  of  movement. ,f 

,  rp  f  Fine. 

(  1  remor  <  p 

f  Regular  (continuous,  or  J  *■ 

|       on  movement)  .         .  |  Certain  regular  movements, due 

Quick,   clonic   spasm,   of  J  [     to  interossei,  pronators,  &c. 

intermitting  type  .   j  .,  f  Continuous  spasm, 

I    Irregular    (continuous,  f  Choreoid  I  •       ..    ,.      ,• 

I  °  v  ,,       '  <  .     T  .         <      or  incoordination 

I       or  on  movement)       .  I  lerkinar    I       e 
\.  '  u  6     I     ot  movement. 

_,,  ...  „         f  Continuous  =  "  Athetosis." 

Slow  mobile  spasm,  of  re-  I  0,i  movement  =  Slow,  cramp-  ,  _       ,.         .       ,      „    „ 
nutting  type         .        .  \      like  inco6rdinafcioil'  F  S  'Spastic contracture   of 

"■  ;  hemiplegic  children. 

Tonic  spasm,  varying        .  "1    /  O  fin  terossei  conspicuous 
Fixed  rigidity,  unvarying  J    \  Of  flexor  longus  digitorum  conspicuous  =  late  rig:dity. 

*  A  conclusive  case  has  been  published  by  Den  ange,  '  Revue  de  Medecine,'  May, 
1883,  Case  ii,  p.  375.  See  also  Beevor  aud  Horsley,  'Brit.  Med.  Journ.,'  1890,  ii, 
1286. 

t  From  "Athetosis  and  Post-hemiplegic  Disorders  of  Movement,"  'Med.-Chir. 
Trans.,'  1876,  p.  271. 


90  BRA.1N. 

Convulsions. — Convulsions  are  frequent  in  organic  brain  disease. 
They  are  produced  in  two  ways :  (1)  By  active  irritation,  as  in 
meningitis,  growing  tumours,  encephalitis,  and  in  acute  cerebral 
lesions,  haemorrhage  or  softening.  (2)  By  altered  nutrition  of  grey 
matter  around  a  stationary  lesion ;  in  consequence  of  the  alteration 
the  grey  matter  possesses  deficient  stability,  and  "discbarges."  By 
each  meebanism  convulsions  are  produced  most  readily  and  most 
frequently  when  the  disease  is  at  the  cortex,  andtbe  second  mechanism 
is  practically  confined  to  cortical  lesions.  Stationary  lesions  scarcely 
ever  cause  convulsions,  unless  they  are  situated  in  or  near  the  motor 
convolutions.  On  the  other  hand,  irritating  disease  often  causes  con- 
vulsions when  it  is  at  a  distance  from  the  motor  region,  both  when  it 
is  in  the  cortex  itself  and  in  the  deeper  parts  of  the  brain,  even  in  the 
pons.  Convulsions  also  result  from  general  increase  of  intracranial 
pressure. 

The  convulsions  that  result  from  organic  brain  disease  may  be 
general,  and  similar  to  those  of  idiopathic  epilepsy,  consisting  first  of 
tonic  and  then  of  clonic  spasm,  with  sudden  loss  of  consciousness.  A 
full  description  of  their  character  is  unnecessary  here,  since  they  are 
described  in  the  chapter  on  Epilepsy.  The  fits  are  usually  of  this 
type  when  they  are  due  to  a  diffuse  morbid  process,  as  meningitis,  or 
to  disease  away  from  the  motor  region,  and  also  whenever  the  dis- 
charge is  intense.  But  in  most  cases  in  which  the  convulsions  are 
due  to  focal  disease,  especially  when  this  is  in  or  near  the  motor 
region  of  the  cortex,  the  convulsion  is  of  a  different  type,  distinct  in 
at  least  some  of  the  attacks.  The  discharge  commences  at  the  seat 
of  irritation,  and  spreads  thence  in  the  motor  region.  Hence  the 
onset  of  the  convulsion  is  deliberate  aud  local ;  often  consciousness  is 
not  lost  until  the  cerebral  discharge  has  progressed  beyond  its  point 
of  commencement.  The  local  commencement  may  be  seen  by  an 
observer,  and  often  the  patient  is  aware  of  the  commencing  fit,  and 
of  the  manner  in  which  it  commences.  The  local  commencement  of 
the  convulsion  is  usually  in  the  side  of  the  face,  in  the  arm,  or  in  the 
leg.  If  slight,  the  convulsion  may  be  limited  to  the  part  in  which  it 
commences  (partial  convulsion),  and  consciousness  may  not  be  lost 
at  all.  If  more  severe,  the  convulsion  extends  to  all  parts  of  the  side 
on  which  it  commences,  and  consciousness  may  or  may  not  be  lost. 
If  still  more  severe  it  may  extend  to  the  opposite  side,  and  then 
consciousness  is  almost  always  lost.  But  there  is  a  further  distinction 
to  be  made  in  the  mode  of  affection  of  the  muscles  of  the  two  sides. 
These  are  involved  in  different  degree  and  order,  according  to  their 
unilateral  or  bilateral  use  (Broadbent,  Hughlings  Jackson)  and 
corresponding  innervation  from  one  or  both  hemispheres  (see  p.  76). 
We  have  seen  that,  in  proportion  as  movements  are  bilateral,  those 
on  the  paralysed  side  escape  in  hemiplegia.  In  the  same  proportion 
those  on  the  sound  side  are  involved  in  convulsion.  The  bilateral 
representation  which  permits  their  escape  in  one  case  ensures  their 


SYHPTUMS.  91 

involvement  in  the  other.  Hence  we  may  have  three  degrees  of 
extension  :  (1)  In  a  slight  unilateral  fit  the  unilateral  muscles  of  one 
side  are  alone  involved;  the  fit  affects  only  the  arm  and  leg.  (2)  In 
a  more  severe  fit,  in  addition  to  the  unilateral  muscles,  the  bilateral 
muscles  of  both  sides  are  involved,  e.  g.  both  sides  of  the  thorax,  and 
sometimes  the  opposite  leg,  the  arm  remaining  free.  (3)  In  a  still 
more  severe  fit  the  opposite  arm  is  also  involved,  or  the  whole  of 
the  second  side.  An  intense  discharge,  of  local  origin,  may  spread  so 
rapidly  as  to  appear  general  from  the  first.  On  the  other  hand,  it  is 
important  to  remember  the  frequency  with  which  fits  due  to  local 
disease  begin  with  a  sensation,  in  the  limbs  or  special  senses,  to  which 
the  motor  spasm  is  added.  The  slightest  fits,  however,  may  consist  of 
the  sensation  only,  and  this  when  the  discharge  occurs  in  the  "  motor  " 
region.  When  there  is  also  spasm,  the  place  at  which  the  sensation 
begins  (not  the  spasm)  points  to  the  seat  of  instability  in  the  brain. 

Yet  another  distinction  is  necessary.  There  are  muscles  on  the  two 
sides,  which,  together,  have  a  unilateral  action.  These  muscles,  as 
we  have  seen  (p.  78),  are  innervated  from  the  cerebral  hemisphere 
according  to  their  action,  e.  g.  the  muscles  which  move  the  head  and 
eyes  to  the  right  are  innervated  from  the  left  hemisphere.  We  have 
also  seen  that  in  unilateral  paralysis  the  movement  is  lost  by  an 
impairment  of  the  muscles  on  both  sides.  In  a  unilateral  convulsion 
the  spasm  has  a  corresponding  distribution ;  the  head  and  eyes  are 
usually  turned  towards  the  side  convulsed,  by  these  contra-lateral 
muscles,  as  they  may  be  termed.  In  a  fit  which  is  from  the  first 
general,  it  is  common  to  have  the  convulsion  greater  on  one  side  than 
on  the  other,  with  a  corresponding  deviation  of  the  head  and  eyes. 
In  a  fit  in  which  one  side  only  is  at  first  affected,  the  other  side  is 
often  affected  later,  while  the  convulsion  on  the  first  side  is  lessening. 
The  passage  to  the  second  arm  (probably  due  to  the  extension  of  the 
discharge  to  the  opposite  hemisphere)  is  attended  by  a  corresponding 
movement  of  the  head  and  eyes,  which,  turned  at  the  onset  towards 
the  side  first  affected,  are  afterwards  directed  towards  the  second 
side,  when  this  becomes  involved  in  spasm. 

Convulsions  begin  locally  when  the  disease  irritates  a  part  of  the 
brain  in  which  the  centres  for  the  different  parts  are  sufficiently 
separate,  and  chiefly  when  the  disease  is  in  or  near  the  cerebral  cortex, 
in  the  central  (motor)  convolutions  or  paracentral  lobule.  If  the  centre 
is  destroyed,  convulsions  rarely  begin  in  the  part,  which  is  then 
permanently  paralysed.  Hence  convulsions  occur  chiefly  from  disease 
which  partially  damages  the  centres,  or  which  is  in  their  neighbour- 
hood, and  irritates  them.  When  the  irritation  is  in  the  highest  part  of 
these  convolutions  the  convulsion  usually  begins  at  the  foot ;  when  in 
the  middle,  at  the  hand;  when  in  the  lower  part,  at  the  face,  and  then, 
if  the  disease  is  on  the  left  side,  is  often  associated  with  temporary 
loss  of  speech.  It  is  probable  that  a  similar  differentiation  of  spasm 
may  occur  in  limited  disease  of  the  white  substance  or  internal  capsule, 


92  BRAIS. 

but  it  is  very  uncommon  for  convulsions  to  result  from  disease  away 
from  motor  nerve-cells.  "When  the  convulsion  begins  in  one  limb,  it 
may  commence  by  a  motion  or  a  sensation,  according  as  the  motor  or 
sensory  elements  lead  in  the  discbarge.  We  do  not  yet  know  whether 
this  difference  has  a  localising  value.  Probably  it  has  not.  Disease 
of  the  central  convolutions  may  cause  convulsions  commencing  by  a 
sensory  aura.  We  have  seen  that  these  convolutions  have  sensory  as 
well  as  motor  functions.  We  must  at  present  regard  the  commence- 
ment of  the  fit  by  a  sensation  in  the  arm,  leg,  or  face,  as  of  the  same 
diagnostic  value  as  the  commencement  by  motor  spasm. 

In  idiopathic  epilepsy  special  sense  aura?  are  not  infrequent,  but  in 
organic  brain  disease  they  are  rare,  but  most  important.  They  signify 
that  the  disease  is  adjacent  to  the  special  sense  centres  in  the  cortex. 
Thus  I  have  mentioned  elsewhere*  a  case  in  which  a  tumour  of  the 
occipital  lobe  caused  a  visual  aura,  and  another  case  in  which  an 
auditory  aura  preceded  convulsions  due  to  a  tumour  which  commenced 
beneath  the  first  temporal  convolution.f  In  a  third  case  a  tumour 
in  the  middle  of  the  posterior  limb  of  the  fissure  of  Sylvius,  invading 
the  first  temporal  convolution,  caused  convulsions  on  the  opposite  side, 
which  also  began  with  an  auditory  aura  (see  the  chapter  on  Intra- 
cranial Tumours).  The  higher  the  body- heat,  the  more  readily  are 
convulsions  produced. J 

The  convulsions  that  attend  the  onset  of  a  vascular  lesion  are 
usually  general,  but  commence  on  the  side  which  is  subsequently 
paralysed,  and  they  may  be  confined  to  this  side,  especially  in  the  case 
of  surface  lesions,  and  they  may  continue  after  hemiplegia  has 
become  established;  in  deeper  lesions  they  usually  cease  after  the 
onset  of  the  paralysis,  and  if  they  continue  they  usually  affect  only 
the  unparalysed  side.  The  late  post-hemiplegic  convulsions  usually 
affect  only  or  chiefly  the  paralysed  side. 

Unilateral  or  local  convulsion  often  leaves  behind  it  transient 
weakness  in  the  part  convulsed,  lasting  for  a  few  hours  and  then 
passing  away  (post-convulsive  paralysis).  A  severe  fit  probably  pro- 
duces this  weakness  by  exhausting  the  nerve-elements  (Robertson, 
Hughlings  Jackson).  But  similar  weakness  often  follows  or  accom- 
panies very  slight  fits,  especially  those  in  which  the  first  (and  some- 
times the  sole)  discharge  is  sensory,  and  it  is  then  probably  of 
inhibitory  nature.  §  If  fits  succeed  each  other  with  great  frequency 
for  many  days,  this  paralysis  may  persist  during  the  brief  intervals, 
and  be  very  considerable  in  degree,  but  pass  away  rapidly  after  the 
attacks  have  ceased. 

The  great  characteristic,  therefore,  of  the  convulsions  of  organic 
brain  disease  is  their  local  commencement.  ||     A  local  fit,  e.  g.  limited 

*  '  Epilepsy/  1881,  p.  68.  t  lb.,  p.  70. 

J  See  'Arch,  de  Phys.,'  1889.  §  'Epilepsy,'  p.  98. 

||  Ou  account  of  their  careful  study  by  Hughlings  Jackson  they  are  often  called 
"  Jacksonian." 


SYMPTOMS.  93 

to  one  limb,  and  local  commencement  of  a  unilateral  or  general  fit, 
have  the  same  significance.  The  difference  is  of  degree  only.  Each 
shows  that  the  discharge  in  the  brain  begins  locally,  and  indicates  a 
local  change  causing  a  persistent  instability  at  the  spot.  But  local 
commencement,  while  it  proves  local  changes  of  nutrition,  does  not 
pi-ove  that  the  disease  is  what  is  called  "organic,"  i.  e.  such  as  can  be 
detected  by  the  naked  eye,  or  even  by  the  microscope.  Such  local 
commencement  is  sometimes  met  with  in  idiopathic  epilepsy,  but  it  is 
very  rare  in  this  form,  in  which  the  common  onset  is  by  a  general 
or  a  visceral  aura,  or  by  initial  loss  of  consciousness.  The  local  com- 
mencement, therefore,  suggests  orgauic  disease,  just  as  the  visceral 
aura  (as  a  sensation  at  the  epigastrium),  or  general  convulsion  without 
any  warning,  suggests  idiopathic  epilepsy.  If  the  local  fits  are  very 
slight  and  frequent,  the  probability  that  there  is  organic  disease  is 
very  great,  because  there  must  be  an  excessive  degree  of  local  insta- 
bility, unlikely  to  exist  in  idiopathic  epilepsy,  in  which  the  morbid 
state  is  generally  widely  distributed  through  the  brain,  and  the  insta- 
bility is  seldom  confined  to  one  part.  In  all  cases,  therefore,  in  which 
fits  begin1  locally,  a  careful  search  must  be  made  for  any  other  indica- 
tion of  organic  disease.  But  repeated  convulsions  from  stationary 
organic  disease  (in  which  the  discharges  spread  through  the  brain) 
may  induce  a  state  like  that  of  idiopathic  epilepsy.  This  has  a  two- 
fold importance.  (1)  In  diagnosis :  minor  attacks  may  occur,  espe- 
cially when  the  disease  is  in  a  developing  brain,  quite  like  those  of 
the  idiopathic  malady.  (2)  In  treatment :  the  removal  of  the  source 
of  the  discharges  may  not  stop  them  ;  they  may  go  on,  proceeding 
from  the  cells  secondarily  affected.  Hence  the  fits,  after  infantile 
hemiplegia,  may  not  be  arrested  by  removal  of  that  part  of  the 
cortex  that  is  diseased. 

Tetanic  attacks  have  occasionally,  although  rarely,  been  produced  by 
disease  of  the  cerebellum,  or  by  disease  that  exerts  pressure  under  the 
tentorium.  They  may  last  for  hours,  and,  in  the  rigidity  of  the  ex- 
tensors of  the  spine,  bending  backwarks  of  the  head,  and  closure  of 
the  jaws,  may  closely  resemble  paroxysms  of  traumatic  tetanus.  It 
is  not  at  present  known  whether  they  originate  from  the  cerebellum 
or  from  the  pons.  Forced  movements  of  the  trunk,  as  a  tendency  to 
rotation,  are  extremely  rare,  and  their  significance  is  mentioned  in  the 
section  on  Localisation. 

Hysteroid  convulsions  may  occur  in  various  organic  diseases  of  the 
brain,  the  result  of  the  general  disturbance  of  the  cerebral  function. 
Thus  I  have  known  them  to  occur  in  many  cases  of  tumour  of  the 
brain,  in  meningitis,  in  hemiplegia  (which  also  caused  true  epilepti-. 
form  "convulsions),  and  even  at  the  onset  of  embolic  hemiplegia. 
Their  chief  importance  is  due  to  the  readiness  with  which  they  may 
mislead  in  diagnosis.  The  symptoius  of  hysteria  should  never  pre- 
vent a  careful  search  for  any  indications  of  organic  disease,  and  do 
not  in  any  degree  lessen  the  significance  of  the  latter. 


94  BRAIN. 

Sensort  Si'iVptohis, — Loss  of  Sensation  —  Hemianesthesia.  — 
Disease  of  the  brain  may  impair  or  destroy  sensation,  both  in  the 
slun,  muscles,  &c  ,  and  also  in  the  organs  of  special  sense.  The  affec- 
tion, like  that  of  motion,  is  commonly  unilateral,  the  side  affected 
being  that  opposite  to  the  cerebral  lesion.  It  usually  depends  on 
damage  to  the  fibres  which  conduct  sensation,  and  which  probably 
pass  through  the  tegmentum  of  the  pons,  and  certainly  in  that  of  the 
crus,  and  in  the  posterior  third  of  the  hinder  limb  of  the  internal 
capsule  between  the  extremities  of  the  optic  thalamus  and  lenticular 
nucleus,  and  thence  radiate  to  the  central  and  parietal  cortex.  Loss 
of  sensation  is  sometimes  due  to  disease  of  the  cortex  itself,  but  com- 
plete hemiansestbesia  is  rare  from  such  disease,  because  to  produce  it 
a  lesion  must  be  very  extensive.  Some  of  the  sensory  fibres  are  pro- 
bably connected  with  the  optic  thalamus,  perhaps  also  with  the  len- 
ticular nucleus,  but  the  nature  and  functional  significance  of  this 
connection  is  not  yet  understood  ;  and  it  is  not  probable  that  the 
activity  of  these  ganglia  influences  consciousness,  or  that  their  dis- 
ease causes  any  loss  of  sensation.  Moreover,  outside  the  posterior 
portion  of  the  optic  thalamus,  the  visual  fibres  pass  near  the 
posterior  extremity  of  this  sensory  tract,  and  then  leave  it  to 
radiate  to  the  occipital  lobes.  Near  this  sensory  portion  of  the 
capsule  also  pass  fibres  from  the  other  nerves  of  special  sense.  These 
special  sense  tracts  have  likewise  undergone  decussation,  although 
that  of  the  optic  nerves  is  incomplete.  Hence  disease  here  may  cause 
loss  of  the  special  senses,  as  well  as  of  common  sensibility  on  the 
opposite  side,  the  affection  of  vision  being  hemianopia.  To  this 
region,  as  we  have  seen  (p.  40),  the  name  "sensory  cross-way  "  has 
been  given  by  Charcot. 

Thus  in  the  internal  capsule,  a  common  seat  of  disease,  the  paths 
for  motion  and  sensation  are  separate,  but  contiguous.  It  is  common 
for  a  lesion  to  damage  one  much,  and  the  other  but  little  or  not  at  all, 
and  to  produce,  on  the  one  hand,  hemiplegia  without,  or  with  only 
slight,  impairment  of  sensation;  and,  on  the  other  hand,  hemianses- 
tbesia  with  but  little  motor  weakness,  but  sometimes  with  hemianopia. 
But  an  extensive  lesion  may  damage  both.  Sensory  fibres  seem  to 
reach  the  motor  cortex,  and  it  is  common  for  disease  there  to  cause 
some  impairment  of  sensation,  always  most  marked  in  the  extremity 
of  the  limbs,  and  in  monoplegia  confined  to  the  extremity  of  the  limb 
that  is  weakened.*  Hemiausesthesia  may  be  of  purely  functional 
origin,  but  such  cases  have  the  associations  described  in  the 
chapter  on  "  Hysteria,"  and  are  especially  characterised  by  the 
co-existence  of  "  crossed  amblyopia "  (q.  v.)  and  the  absence  of 
hemianopia. 

In  ascertaining  the  condition  of  sensation  it  is  necessary  to  examine 
separately  the  various  forms  of  sensibility.     The  method  of  making 

*  See  the  references  on  p.  20;  also  Pctrina,  *  Prager  Zeitschr.  f.  Heilk.,'  1881, 
ii,  No.  5, 


SYMPTOMS.  95 

this  examination  aud  the  precautions  to  be  taken  have  been  already 
described  (vol.  i,  p.  8). 

Besides  the  ordinary  forms  of  sensory  loss  there  is  one  to  which 
nmch  attention  has  been  directed.  The  patient  may  be  unconscious 
of  the  position  of  a  limb,  on  active  or  passive  movement.  In  brain 
disease  that  causes  this  defect,  the  power  of  active  movement  is  usuallv 
lost;  but  if  an  extremity,  e.g.  the  hand,  is  placed  in  a  given  posture, 
and  the  patient  is  told  to  imitate  this  posture  with  the  other  hand,  he 
may  be  so  far  wrong  as  to  show  that  he  has  a  very  imperfect  percep- 
tion of  the  posture,  and  this  even  when  there  is  no  demonstrable 
impairment  of  cutaneous  sensibility.  The  hand  and  fingers  should 
be  grasped  firmly  by  the  observer,  so  that  the  direction  of  pressure 
may  not  suggest  the  posture.  The  loss  is  regarded  by  Munk  as  a  loss 
of  the  processes  on  which  "conception  of  posture  "  depend,  processes 
that  are,  in  effect,  the  result  of  sensory  (cutaneous  and  muscular) 
impressions.  The  loss  is  commonly  supposed  to  be  due  to  cortical 
disease,  but  it  may,  as  I  have  seen,  be  very  distinct  when  the  disease 
is  in  the  central  ganglia.  Its  actual  significance  has  yet  to  be 
established  by  clinical  and  pathological  observation.  This  may  be 
said  also  of  the  loss  of  other  sensory  "  conceptions  "  as  distinguished 
from  mere  sensations.  Thus  when  tactile  sensibility,  tested  in  the 
ordinary  way,  seems  to  be  normal,  the  patient  may  be  unable  to 
recognise  the  nature  of  objects  in  contact  with  the  skin,  although  they 
are  at  once  recoguised  when  placed  on  the  unaffected  side. 

It  will  be  seen,  from  what  has  been  already  said,  that  loss  of  cuta- 
neous sensibility  may  be  chiefly  on  the  limbs,  and  especially  on  the 
extremities  of  the  limbs,  or  it  may  involve  the  whole  of  one  side 
including  the  trunk  and  the  head.  It  is  to  the  latter  that  the  term 
"  hemiansesthesia  "  is  generally  applied.  The  loss  often  extends  up  to 
the  middle  line,  and  exists  on  the  mucous  membranes  as  well  as  on  the 
skin.  But  it  is  not  always  thus  complete ;  it  may  be  more  considerable 
in  some  parts  than  in  others,  and  may  even  be  unequally  distributed 
over  different  regions  of  the  trunk.  Nor  does  it  involve  equally  all 
forms  of  sensibility  ;  either  touch  or  pain  may  be  chiefly  affected.  It 
is  often  associated  with  impairment  of  the  special  senses,  because,  as 
we  have  seen,  the  paths  of  special  and  cutaneous  sensibility  are  con- 
tiguous, and  their  cortical  centres  probably  occupy  adjacent  regions  in 
the  outer  surface  of  the  cerebral  hemisphere.  In  these  cases  vision 
may  be  impaired  either  as  "  hemianopia  "  or  "  crossed  amblyopia,"  the 
significance  of  which  has  been  mentioned  above,  and  also  in  the  account 
of  the  structure  and  functions  of  the  brain ;  their  characters  will  be 
given  in  the  description  of  affections  of  sight. 

Crossed  anaesthesia  of  limbs  and  face  occurs  only  in  disease  of  the 
upper  part  of  the  pons,  affecting  the  fibres  of  the  fifth  nerve  on  one 
side  and  the  path  from  the  limbs  on  the  other.  Bilateral  anaesthesia, 
affecting  the  limbs  on  both  sides,  may  occur  from  disease  of  the  pons, 
but  is  seldom  complete. 


96  •  BRAIN. 

Sensory  irritation,  pain  in  the  limbs,  is  sometimes  considerable 
•when  the  disease  involves  the  sensory  tract  and  imperfectly  destroys  it. 
In  some  cases  of  slight  or  transient  hemiplegia,  pains  in  the  limbs  are 
very  severe  during  several  years,  and  there  may  be  complete  hemianopia 
and  some  loss  of  cutaneous  sensibility.  The  lesion  has  probablv 
destroyed  the  optic  path  at  the  posterior  extremity  of  the  internal 
capsule,  and  has  damaged  the  latter  so  as  to  irritate  the  fibres,  but  not 
to  interrupt  conduction.  Numbness,  tingling,  formication,  &c,  are 
met  with  in  such  cases,  and  they  are  also  common  at  the  onset  of 
acute  lesions  in  this  situation,  as  well  as  in  irritating  disease  of  the 
cortex.  Tingling  may  attend  the  onset  of  local  convulsions  from 
disease  in  or  near  the  motor  convolutions,  and  in  cases  of  tumour  of 
this  region,  the  paralysis  is  sometimes  accompanied  by  much  pain  in 
the  limbs,  increased  by  passive  movements,  and  these  may  excite  con- 
vulsive attacks.  Such  pain  must  be  distinguished  from  that  due  to 
acute  forms  of  inflammation,  sometimes  met  with  in  the  same  cases. 
Pain  in  the  region  of  the  fifth  nerve  is  frequent  when  there  is  disease 
of  its  fibres  or  nucleus,  and  is  often  the  first  symptom  of  such  a  lesion. 
An  instance  is  afforded  by  the  case  illustrated  in  Fig.  53.  The  spot 
of  softening  near  the  nucleus  of  the  fifth  caused  sevei'e  neuralgic  pain 
in  the  region  of  the  distribution  of  the  nerve.  Similar  symptoms 
of  irritation  of  the  special  senses  are  met  with  in  disease  of  their 
paths  or  centres,  especially  in  association  with  convulsive  seizures 
(p.  92),  and  are  further  considered  in  the  special  account  of  the  nerves 
concerned. 

Headache. — Pain  in  the  head  is  a  frequent  symptom  of  organic 
brain  disease.  At  the  same  time  it  is  far  more  common  apart  from 
such  disease,  as  a  result  of  what  we  call  "functional"  disturbance, 
of  morbid  blood-states,  or  of  gastric  derangement,  &c.  Moreover,  the 
pain  of  neuralgia  in  the  wall  of  the  cranium  often  resembles  the  pain 
of  organic  disease.  Hence  the  mere  occurrence  of  headache  is  of  little 
significance.  Its  character  is  sometimes  suggestive,  and  still  more 
frequently  its  severity;  but  the  chief  significance  of  pain  in  the  head 
is  derived  from  its  associations.  For  instance,  that  which  is  excited 
only  by  use  of  the  eyes  is  often  due  to  some  error  of  ocular  refraction. 

The  pain  of  organic  disease  varies  much  in  degree.  It  is  sometimes 
intensely  severe,  and  is  usually  constant.  Paroxysmal  exacerbations 
occur,  but  the  pain  does  not  cease  during  the  intervals,  and  it  often 
prevents  sleep.  The  latter  is  an  important  characteristic,  because 
other  forms  of  headache  rarely  keep  the  patient  awake.  The  precise 
character  of  the  pain  varies  much  ;  it  may  be  dull  or  acute,  but  it  is 
almost  always  an  actual  pain.  Cephalic  sensations  other  than  pain, 
such  sensations  as  those  of  "  pressure,"  "  weight,"  "  creeping,"  &c, 
seldom  result  from  organic  disease,  while  they  are  common  in  func- 
tional disorders.  It  may  be  said,  as  a  general  rule,  that  deviation 
from  pain  in  character,  involves  also  deviation  in  significance  ;  the  less 


SYMPTOMS.  97 

truly  painful  a  sensation  is,  the  less  important  is  it.  Recollection  of 
this  rule  may  save  from  many  a  practical  error.  The  pain  of  organic 
disease  is  almost  always  increased  by  whatever  augments  the  blood- 
pressure  in  the  skull,  such  as  effort,  cough,  stooping.  In  situa- 
tion, it  may  be  general,  or  in  the  frontal  or  occipital  region,  or  in  auy 
part  of  one  side.  The  disease  causing  the  pain  is  sometimes  in  the 
part  of  the  head  to  which  the  pain  is  referred,  but  there  is  a  close 
correspondence  between  the  two  only  in  some  cases  of  disease  at  or  near 
the  surface  of  the  brain.  The  pain  from  disease  beneath  the  tentorium 
is  generally  felt  in  the  occiput  and  back  of  the  neck,  But  frontal 
pain  may  be  due  to  disease  anywhere  in  the  cerebral  hemispheres,  and 
has  been  known  to  result  even  from  cerebellar  disease. 

The  iutra-cranial  maladies  that  cause  headache  are  for  the  most  part 
active,  irritating  diseases,  such  as  inflammation,  tumour,  abscess,  and 
the  like.  If  active  growth  and  irritation  cease,  the  pain  usually 
lessens,  and  may  even  be  no  longer  felt,  in  spite  of  the  persistence  of 
the  disease  in  a  stationary  condition.  Diseases  that  increase  intra- 
cranial pressure  without  causing  tissue  irritation,  such  as  internal 
hydrocephalus,  may  also  cause  pain,  but  often  run  an  almost  painless 
course.  These  facts,  together  with  the  readiness  with  which  headache 
occurs  apart  from  organic  disease,  make  it  difficult  to  give  a  satis- 
factory explanation  of  the  mechanism  by  which  the  pain  is  caused. 
We  do  not  even  know  in  what  structure  the  pain  is  really  produced. 
The  dura  mater  receives  sensory  fibres,  and  when  inflamed  may  unques- 
tionably be  the  seat  of  pain.  Only  sympathetic  fibres  have  been 
traced  into  the  pia  mater,  but  other  organs  which  receive  only  sym- 
pathetic fibres  may  be  painful  wheu  inflamed,  and  acute  pain  attends 
meningitis  when  the  dura  mater  is  but  little  affected.  The  cerebral 
substance  seems,  under  normal  conditions,  to  be  destitute  of  sensi- 
bility ;  but  from  this  fact  the  assumption  has  perhaps  been  too  hastily 
made  that  it  cannot  be  the  seat  of  pain  when  diseased.  It  should  be 
remembered  that  the  normal  sensibility  of  the  peritoneum  would  not 
prepare  us  for  the  intense  pain  of  peritonitis.  In  the  brain,  intense 
pain  may  be  caused  by  small  lesions  which  do  not  come  near  tbe 
surface. 

Of  the  associations  of  headache  in  organic  disease  (besides  local 
derangement  of  function)  vomiting  and  optic  neuritis  are  especially 
important.  The  vomiting  often  occurs  during  the  severer  paroxysms 
of  pain,  and  patients  sometimes  say  that  the  pain  "  seems  to  make 
them  vomit."  The  association  with  optic  neuritis  is  also  of  great  im- 
portance,  but  is  not  pathognomonic,  since  the  two  occur  together  in 
some  cases  of  ansemia  and  of  kidney  disease.  Iudeed,  pain  is  sometimes 
absent  in  diseases  in  which  it  is  usually  severe  and  almost  characteristic. 

Vertigo. — The  word  means,  literally,  a  turning,  and  is  used  to 
designate  either  an  actual  rotation  of  the  patient,  or  a  sensation  of 
rotation,  or  a  sensation  of  movement  in  some  direction   (which  mav 

VOL.   u,  7 


98  BRAIN. 

not  actually  amount  to  a  sense  of  turning),  or  a  correlated  impression 
that  other  objects  are  moving.  This  involves  a  lessened  perception  of 
the  relation  of  the  individual  to  external  objects,  i.  e.  a  slight  obscu- 
ration of  consciousness.  Hence,  the  corresponding  English  word 
"giddiness,"  and  still  more  the  loosei  term  "  dizziness,"  are  applied 
to  a  slight  dulling  of  consciousness,  not  amounting  to  actual  loss, 
although  there  is  no  sense  of  movement,  objective  or  subjective.  In 
pure  vertigo  there  is  no  actual  loss  of  consciousness,  although  con- 
sciousness may  be  obscured  at  the  height  of  an  intense  attack. 

Vertigo  is  a  frequent  symptom,  apart  from  organic  disease.  It 
results  from  many  causes,  and  is  therefore  described  more  fully  in  a 
later  part  of  this  volume.  Like  headache,  it  does  not  in  itself  suggest 
intra-cranial  disease,  and  derives  its  significance  chiefly  from  its  asso- 
ciations. Of  these,  vomiting  has  not  the  significance  which  it  has 
when  associated  with  headache.  intense  giddiness,  whatever  its 
origin,  usually  causes  vomiting,  and  this  does  not,  therefore,  do  more 
than  emphasise  the  fact  that  the  vertigo  was  severe.  This  symptom 
may  be  caused  by  disease  in  almost  any  part  of  the  brain,  and  especially 
by  that  of  the  auditory  nerve.  It  is  most  common  in  lesions  of  the 
cerebellum  and  of  the  pons,  especially  at  the  side  of  the  pons,  involving 
the  middle  peduncle  of  the  cerebellum.  A  lesion  here  sometimes 
causes  not  only  a  sensation  of  turning,  but  an  actual  rotation.  When 
due  to  disease  elsewhere  it  occurs  chiefly  as  a  symptom  of  irritation 
as  part  of  slight  "discharges."  This  association  is  seen  in  epilepsy, 
in  which  vertigo  is  frequently  the  earliest  subjective  indication  of  an 
attack,  severe  or  slight. 

Mental  Symptoms. — The  mental  functions  of  the  brain  are  fre- 
quently disturbed  in  organic  disease,  and  their  derangement  chiefly 
depends  on  disturbance  of  the  cortex.  Such  disturbance  may,  how- 
ever, be  produced  by  disease  at  a  distance,  as  well  as  by  organic 
changes  in  the  convolutions  themselves.  With  the  much-disputed 
question  of  the  relation  of  mind  to  brain  the  physician  has  nothing  to 
do.  It  is  enough  for  him  to  recognise  that  mental  manifestations 
and  cerebral  activity  invariably  coincide,  and  that  the  character  of 
cerebral  processes  in  some  way  determines  the  character  of  mental 
processes — in  some  way  determines  mental  states.  The  tendency  of 
advanced  psychology  in  the  present  day  is  to  keep  distinct  the  two 
series  of  phenomena.  In  the  study  of  diseases  of  the  brain  we  are 
concerned  only  with  cerebral  processes.  Unfortunately,  however,  the 
chief  terms  available  are  those  of  psychology,  and  we  are  obliged, 
therefore,  to  speak  of  mental  processes  when  all  that  we  need  to 
speak  of,  and  are,  indeed,  justified  in  speaking  of,  are  cerebral  pro- 
cesses. However  undesirable  such  a  confusion  may  be,  it  is  practically 
unavoidable. 

The  changes  which  occur  in  mental  processes,  as  a  result  of  organic 
brain  disease,  consist  for  the  most  part  in  exaltation,  perversion,  or 


SYMI'TOMS.  99 

defect;  and  these  are  often  combined.  These  changes  may  he  mani- 
fested by  loss  of  consciousness,  by  delirium  or  by  chronic  mental 
failure,  and  are  also  seen,  in  a  more  restricted  form,  in  cerebral  affec- 
tions of  speecb. 

Loss  of  Consciousness. — Tbe  big-best  general  function  of  the  con- 
volutions subserves  consciousness,  and  loss  of  consciousness  is  one  of 
the  most  important  and  most  frequent  symptoms  of  cerebral  disease. 
The  terms  "conscious"  and  "consciousness"  are,  however,  used  in 
two  senses  :  first,  to  signify  the  subjective  knowledge  of  the  occur- 
rence of  mental  processes  ;  secondly,  to  designate  the  outward  mani- 
festations of  such  processes.  In  medical  language  the  term  is  chiefly 
employed  in  the  latter  sense.  A  patient  is  said  to  be  "unconscious," 
or  to  bave  "  lost  consciousness,"  when  there  is  no  spontaneous  evi- 
dence of  mental  action,  and  none  can  be  elicited  by  sensory  stimula- 
tion. Heuce  the  term  "  insensible  "  is  often  used  in  the  same  manner. 
Another  confusion  is  introduced  by  the  frequent  relative  use  of  the 
words  "conscious  of"  in  the  sense  of  cognition  or  knowing.  Thus  a 
delirious  patient  may  be  said  to  be  unconscious  of  what  is  occurring 
around  him,  although  he  is  not  said  to  be  unconscious. 

Loss  of  consciousness  may  occur  suddenly  or  gradually,  and  may 
vary  in  degree,  as  is,  indeed,  implied  in  the  statement  that  its  onset 
may  be  gradual.  The  variation  may  be  in  the  degree  of  subjective 
consciousness,  or  in  the  external  manifestations  of  consciousness.  It 
is  to  the  latter  that  the  term  "  partial  loss  of  consciousness"  is  com- 
monly applied,  as,  for  instance,  in  the  case  in  which  a  patient  seems 
to  be  asleep,  but  opens  his  eyes  for  a  moment  when  spoken  to,  and 
then  relapses  into  his  former  state.  Such  state  of  partial  loss  is 
sometimes  termed  "  stupor."  Complete  loss  of  consciousness,  in  which 
a  patient  cannot  be  roused,  is  termed  "  coma  "  if  it  is  prolonged.  In 
stupor  the  reflex  action  in  the  limbs  is  preserved,  and  may  be  in- 
creased, the  lower  centres  being  in  an  over-active  state  from  the 
deficiency  of  cerebral  control,  and  the  patient  swallows  automatically 
liquids  placed  in  the  mouth.  In  coma  the  reflex  action  in  the  limbs 
may  be  preserved,  but  it  is  often  lessened  or  lost  in  the  more  severe 
degrees,  the  depressed  condition  of  the  highest  centres  being  appa- 
rently propagated  downwards  to  the  lower.  Swallowing  is  possible 
only  in  the  less  intense  degrees  of  coma.  In  severe  cases  muscular 
tone  throughout  the  body  may  give  place  to  flaccidity,  and  myotatic 
irritability  may  be  lost.  The  pupils  may  be  widely  dilated  or  small : 
in  stupor  they  act  to  light ;  but  in  deep  coma  they  are  motionless,  and 
the  conjunctivae  may  be  touched  without  the  occurrence  of  any  reflex 
contraction  of  the  eyelids.  When  the  reflex  action  of  swallowing  is 
lost,  the  palate  generally  shares  the  muscular  relaxation,  and,  moved 
by  the  respiratory  current  of  air,  causes  a  peculiar  "  stertor,"  which  is 
a  familiar  indication  of  the  depth  of  coma.  Even  the  respiratci-y 
movements   become  lessened,  apparently  in  consequence  of  lowered 


100  BRAIN. 

activity  of  the  respiratory  centre;  they  become  shallow,  infrequent, 
and  sometimes  present  other  variations,  such  as  the  "  Cheyue- Stokes 
rhythm;"  these  are  described  elsewhere.  The  lessened  respiratory 
movements  do  not  clear  the  air- passages  of  the  secretion  which  accu- 
mulates in  the  tubes,  and  finally  in  the  trachea,  causing  the  familiar 
"rattle"  which  is  popularly  and  rightly  recognised  as  a  frequent 
harbinger  of  death. 

Loss  of  consciousness  is  the  result  of  interference  with  the 
highest  functions  of  the  brain,  those  that  are  the  most  readily 
deranged,  and  it  may  be  produced  by  almost  any  one  of  the  morbid 
processes  to  which  the  brain  is  liable.  Chronic  diseases  cause  it  chiefly 
when  they  affect  a  considerable  area  of  the  cortex,  but  it  may  result 
from  sudden  lesions  in  any  part  of  the  brain ;  it  is  then  termed 
"apoplexy." 

Loss  of  consciousness  may  be  due,  however,  to  other  causes  than 
organic  disease.  It  is  one  of  the  most  common  elements  of  epileptic 
seizures,  and  also  occurs  when  the  action  of  the  nerve-cells  is  inter- 
fered with  by  an  imperfect  supply  of  blood  (as  in  acute  anaemia  and 
syncope),  when  the  renewal  of  the  blood  is  hindered  by  mechanical 
congestion,  and  also  when  the  blood  conveys  to  the  brain  toxic 
material  that  interferes  with  the  action  of  the  nerve-cells, — material 
either  engendered  within  the  body  (as  in  uraemia),  or  entering  from 
without  (as  in  various  forms  of  poisoning). 

Apoplexy. — When  coma  comes  on  suddenly  it  is  termed  "apoplexy." 
The  word  means,  by  its  etymology,  a  striking  off,  and  was  used  by 
the  Greeks,  and  is  still  used,  to  signify  sudden  abolition  of  conscious- 
ness and  power  of  motion  ;  and  this  in  popular  English  also  is  often 
called  a  stroke*  Cerebral  haemorrhage  being  the  most  frequent  cause 
of  this  condition,  "haemorrhage  into  the  brain"  aud  "apoplexy" 
came  to  be  used  as  synonymous  expressions.  Subsequently  the 
haemorrhage  was  itself  spoken  of  as  the  "  apoplexy,"  the  word  being 
thus  used  to  designate  the  pathological  condition  causing  the  sym- 
ptoms which  it  before  epitomised.  Ultimately  it  was  applied  to  a 
similar  pathological  state  elsewhere,  and  thus  haemorrhages  into  the 
substance  of  the  lung,  the  spleen,  or  the  retina  were,  and  still  are, 
termed  pulmonary,  splenic,  or  retinal  "apoplexies."  Such  a  use  of 
the  word  is  alike  needless,  inaccurate,  and  to  be  avoided. 

The  chief  cause  of  apoplexy  is  a  sudden  organic  cerebral  lesion,  and 
the  most  effective  is  intra-cranial  haemorrhage.  It  may  also  result 
from  laceration  of  the  brain,  from  simple  concussion,  and  also  from 
the  sudden  arrest  of  the  blood  supply  to  a  part  of  the  brain,  whether 
bv  a  clot  brought  from  a  distance  (embolism)  or  formed  at  the  spot 
(thrombosis).     It  probably  results,  in  rare  cases,  from  congestion  of 

*  We  have  here  a  relic  of  the  spiritualistic  pathology  at  one  time  dominant 
The  act  of  an  unseen  executioner  seems  to  be  suggested. 


SYMPTOMS.  101 

the  brain,  although  far  less  frequently  than  was  commonly  supposed.* 
A  similar  condition  may  come  on  in  the  old  without  any  visible  lesion 
by  which  it  can  be  caused.  This  has  been  termed  "  simple  apoplexy." 
In  the  old  the  brain  is  shrunken,  the  convolutions  are  small,  and  the 
spaces  between  them  are  occupied  by  serum.  Before  this  fact  was 
recognised,  undue  importance  was  attached  to  this  serum  in  the  cases 
of  "  simple  apoplexy  ;"  it  was  thought  to  be  the  cause  of  the  symptoms, 
and  the  condition  was  termed  "  serous  apoplexy,"  a  disease  that  has 
no  real  existence,  although  the  word  is  still  sometimes  to  be  heard  at 
inquests  and  to  be  seen  on  certificates  of  death. 

The  characteristic  feature  of  apoplexy  is  sudden  and  prolonged  loss 
of  consciousness,  not  due  to  failure  of  the  heart's  action.  The  onset 
may  be  so  sudden  that  the  patient,  without  warning,  falls  insensible, 
as  if  "  struck  down  "  by  some  unseen  hand.  Sometimes  it  is  attended 
with  a  convulsion.  Occasionally  it  is  slow  and  gradual,  occupying 
many  hours  in  development  ("ingravescent  apoplexy").  The  face 
may  be  flushed  or  pale,  but  it  is  rarely  very  pale.  The  heart  and 
arteries  beat,  often  with  greater  force,  and  sometimes  less  frequently 
than  normal  The  condition  is  that  of  coma,  already  described.  In 
a  case  of  moderate  severity  the  reflex  action  soon  returns,  and  the 
patient,  after  a  few  hours,  presents  some  indication  of  returning  con- 
sciousness, may  make  some  movement,  and  may  open  his  eyes  when 
spoken  to.  On  the  other  hand,  in  severe  cases  the  coma  may  continue 
and  deepen  in  intensity,  and  the  patient  dies,  usually  from  the  inter- 
ference with  breathing  described  in  the  account  of  coma,  less  com- 
monly from  arrest  of  the  action  of  the  heart.  Occasionally  death 
occurs  at  the  end  of  an  hour  or  two,  or  even  less  (see  "  Cerebral 
Haemorrhage"). 

It  is  not  often,  however,  that  there  is  only  this  general  loss  of  cere- 
bral function,  uniformly  distributed,  and  gradually  deepening  or 
passing  away.  Much  more  commonly  the  symptoms  of  a  local  cere- 
bral lesion  are  added  to  those  of  apoplexy.  Such  symptoms — uni- 
lateral weakness  or  convulsion — may  precede  the  loss  of  consciousness, 
or  they  may  be  recognised  during  the  attack  by  the  indications  men- 
tioned on  p.  78.  As  recovery  takes  place,  these  symptoms  become 
more  and  more  distinct,  and  the  patient  may  be  found  to  have  lost  the 
use  of  language. 

In  ingravescent  apoplexy  the  commencement  of  the  cerebral  mischief 
may  be  marked  by  symptoms  of  general  shock.  There  is  commonly 
pain  in  the  head,  and  there  may  be  other  local  symptoms.  In  the 
course  of  some  hours,  or  rarely  a  day  or  two,  consciousness  gradually 
becomes  impaired,  and  coma  comes  on  and  deepens.  This  form  of 
apoplexy,  first  described  by  Abercrombie,  is  usually  due  to  a  slowly  iu- 
creasingcerebral  haemorrhage;  the  local  symptoms  may  indicate  its  seat. 

*  The  possibility  of  congestive  apoplexy  lias  been  denied  on  theoretical  grounds, 
but  the  clinical  evidence  of  its  occurrence  is  strong.  See  the  chapter  on  "  Hy- 
pei'semia." 


102  BUAUN. 

The  tempevature  in  cerebral  apoplexy  is  at  first  lowered,  but  usually 
the  fall  is  small,  and  is  succeeded,  alter  twelve  to  twenty-four  hours, 
by  a  rise.  Its  exact  course  varies  considerably  according  to  the  cause 
of  the  apoplexy,  and  will  be  described  in  the  account  of  the  several 
lesions.  An  important  exception  to  the  initial  fall  is  presented  by 
some  cases  of  a  sudden  lesion  of  the  pons  or  medulla,  in  which  the 
temperature  at  once  begins  to  rise,  and  may  attain  a  hyperpyrexial 
elevation  in  the  course  of  two  or  three  hours. 

The  mechanism  by  which  apoplexy  is  immediately  produced  has 
been  much  debated.  The  state  was  formerly  ascribed  to  the  pressure 
exerted  by  the  clot  on  the  rest  of  the  brain,  .either  influencing  directly 
the  cerebral  tissue,  or  pressing  on  and  emptying  its  capillaries 
(Niemeyer).  That  such  pressure  is  exerted  by  a  large  haemorrhage  is 
unquestionable.  That  an  increase  of  the  intra-crauial  pressure  will 
cause  loss  of  consciousness  is  also  certain.  A  dog  becomes  unconscious 
when  there  is  a  pressure  on  the  surface  of  the  brain  equal  to  a  column 
of  mercury  130  mm.  high.  It  is  highly  probable  that  the  intensity 
of  apoplexy  is  due  in  part  to  this  cause.  But  this  will  not  explain 
the  occurrence  of  the  symptom  in  small  haemorrhages,  by  which  no 
general  pressure  is  exerted,  or  not  more  than  is  at  once  relieved  by 
the  displacement  of  the  mobile  fluid  which  surrounds  the  vessels. 
It  will  not  explain  the  occurrence  of  apoplexy  in  laceration  of  the  brain, 
or  the  early  loss  of  consciousness  in  severe  haemorrhage,  iu  which,  as 
Jaccoud  insists,  it  should,  if  merely  due  to  pressure,  be  a  late  rather 
than  an  early  symptom.  Moreover,  it  will  not  explain  the  apoplexy 
which  results  from  the  sudden  closure  of  a  large  vessel,  a  lesion  that 
involves  no  increase  in  the  intra-cranial  pressure.  There  can  be  little 
doubt,  from  these  considerations,  and  from  the  cases  in  which  there 
is  no  recognisable  brain  lesion,  that  the  increase  of  intra-cranial 
pressure  is  not  the  only,  and  perhaps  not  the  chief  causal  element. 
Apart  from  this  the  element  common  to  all  cases  of  apoplexy 
from  organic  disease  is  the  suddenness  of  the  lesion.  Hence  it 
has  been  generally  recognised  that  one  mechanism  of  sudden  apo- 
plexy must  be  an  arrest  of  function  in  the  cortex  ("inhibition  "  in 
current  phraseology)  by  the  irritation  of  the  sudden  lesion.  The 
more  suddenly  the  lesiou  is  produced,  the  more  energetic  will  be  this 
influence;  the  more  gradual  the  lesion,  the  slighter  the  inhibition. 
It  may  thus  be  absent  at  the  onset  of  a  slow  haemorrhage.  The 
increase  in  the  intra-cranial  pressure  is  effective  chiefly  in  haemorrhage ; 
it  develops  gradually,  and  doubtless  intensifies  and  maintains  the 
coma  in  severe  cases,  and  is  the  reason  why  this  is  deeper  and  more 
prolonged  in  haemorrhage  than  in  vascular  occlusion.  Moreover, 
pressure  is  most  effective  when  rapidly  developed.  Duret  has  shown 
that  compression  slowly  applied  has  to  be  ten  times  as  great  to 
produce  the  same  effect  as  when  it  is  sudden.  In  slow  haemor- 
rhage, pressure  may  be  the  chief  mechanism,  but  the  amount 
of  haemorrhage  has  to  be  greater ;   and  hence  when  consciousness 


SIMPTOMfci.  203 

]s  lost  in  such  cases,  the  patient  rapidly  passes  into  a  state  of  ^nat 
danger. 

Although  apoplexy  is  merely  a  symptom,  and  not  an  independent 
disease  of  the  brain,  it  is  convenient  to  consider  the  more  important 
elements  of  the  differential  diagnosis  of  the  condition.  Prom  the 
unconsciousness  due  to  cardiac  syncope,  apoplexy  is  easily  distinguished. 
In  the  former  the  heart's  action  fails,  the  pulse  is  weak  and  imper- 
ceptible, the  face  is  very  pale,  the  respiration  may  be  sichino-  and 
irregular,  reflex  action  is  rarely  abolished,  and  the  sphincters  are  not 
relaxed. 

From  the  several  forms  of  toxaemia  the  diagnosis  is  often  easy 
sometimes  extremely  difficult,  and  often  most  important.  It  is  easy 
when,  on  the  one  hand,  the  symptoms  of  apoplexy  are  preceded  or 
accompanied  by  those  of  a  local  cerebral  lesion ;  or  when,  on  the  other 
hand,  the  direct  or  circumstantial  evidence  of  poisonino-  is  clear  or 
the  symptoms  of  toxaemia  unmistakable.  Where  there  are  no  local 
symptoms,  and  where  no  guiding  history  is  to  be  obtained,  the  dia- 
gnosis is  difficult,  but  a  correct  opinion  may  commonly  be  formed  by 
an  attentive  comparison  of  the  symptoms  present.  There  may  be,  as 
just  observed,  indirect  evidence  of  toxaemia  ;  the  breath  may  smell 
of  opium  or  alcohol;  the  urine  may  contain  albumen.  But  albu- 
minuria or  a  smell  of  spirits  may  mislead.  Cerebral  haemorrhage 
often  occurs  after  drinking  ;  spirit  is  frequently  given  to  a  person  in 
a  fit.  A  smell  of  spirit  must  therefore  only  be  allowed  weight  in  the 
absence  of  any  evidence  of  .cerebral  mischief.  So,  too,  albumen  is 
always  present  in  the  urine  in  uraemia,  but  it  is  also  very  frequently 
present  in  cases  of  cerebral  haBinorrhage.  Alone,  this  evidence  of 
Bright' s  disease  is  of  little  value,  unless  there  is  general  oedema  and 
the  patient  is  yoUng ;  then  uraemia  is  more  probable  than  vascular 
degeneration  and  cerebral  haemorrhage.  But  with  other  symptoms 
that  indicate  uraemic  poisoning,  albuminuria  is  conclusive.  Hence 
the  age  of  the  patient  is  an  important  element  in  the  diagnosis.  Late 
life  is  in  favour  of  brain  disease.  The  history  of  a  fall  or  blow  on  the 
head  adds  weight  to  other  symptoms  of  cerebral  mischief. 

The  character  of  the  coma  will  sometimes  guide.  In  uraemia  and 
commonly  in  alcoholism,  it  is  less  profound  than  in  cerebral  disease. 
The  patient  can  be  roused,  at  least  partially.  In  apoplexy,  in  opium 
poisoning,  and  in  the  most  intense  alcoholic  poisoning,  the  coma  may 
be  profound.  On  the  other  hand,  the  patient  with  cerebral  haemor- 
rhage may  sometimes  be  roused  to  answer  questions.  This  is  still  more 
frequently  the  case  in  cerebral  softening.  Violent  struggling  is  strongly 
in  favour  of  drink.  The  mode  of  onset  is  important.  In  apoplexy  it  is 
usually  sudden  ;  in  m-aemia  it  is  usually  slow.  The  uraemic  patient  be- 
comes first  drowsy,  then  comatose.  But  with  convulsions,  uraemic  coma 
may  come  on  suddenly.  The  onset  of  the  coma  of  opium  and  .alcohol 
poisoning  is  also  slow.  Ingravescent  apoplexy  is  of  deliberate  onset, 
but  once  developed  a  profound  degree  of  coma  is  quickly  reached. 


104  BKA1N. 

General  convulsions  at  the  onset  exclude  drunkenness,  and  also 
opium  poisoning,  while  they  favour  uraemia.  Apoplexy  sometimes 
commences  with  a  convulsion,  and  if  the  convulsion  is  unilateral,  it 
is  strong  evidence  of  brain  disease.  Rigidity" of  limbs,  or  local  mus- 
cular twitching  during  the  coma,  is,  it  coustant  in  seat,  in  favour  of 
cerebral  mischief  ;  if  variable  in  position,  it  is  in  favour  of  uraemia. 
Post-epileptic  coma  is  of  course  preceded  by  a  convulsion,  and  should 
be  borne  in  mind. 

The  state  of  the  pupils  is  alone  of  little  importance.  Great  con- 
traction occurs  in,  and  suggests  opium  poisoning,  but  it  is  also  present 
in  haemorrhage  into  the  pons  Varolii.  The  pupils  may  be  normal  or 
dilated  in  ursmia,  in  alcoholic  or  opium  poisoning,  and  in  apoplexy. 
Inequality  of  pupils,  a  unilateral  symptom,  points  to  brain  mischief. 
The  retina  should  be  examined,  since  the  presence  of  albuminuric  re- 
tinitis, in  the  absence  of  the  signs  of  a  localised  cerebral  lesion,  points 
strongly  to  uraemia.  But  in  normal  sleep  the  pupils  are  usually  small, 
and  the  eyeballs  often  diverge  and  may  not  correspond  in  position. 

Lastly,  the  temperature  should  be  noted.  In  uraemia  there  is  per- 
sistent uniform  depression ;  in  cerebral  lesions  the  initial  depression 
is  succeeded  by  a  rise  to  a  point  above  the  normal.  But  it  should  be 
remembered  that  the  temperature  may  be  raised  in  uraemia  by  some 
local  inflammation,  such  as  pneumonia.  I  have  known  this  to  cause 
an  error  in  diagnosis.  Hence  it  is  most  important  that  the  examina- 
tion should  be  thorough. 

The  differential  diagnosis  of  the  cause  of  cerebral  apoplexy  will  be 
described  more  fully  under  the  heads  of  "  Cerebral  Congestion," 
"Haemorrhage,"  and  "Softening."*  "  Simple  apoplexy"  cannot  be 
diagnosed  during  life,  since  freedom  from  the  symptoms  of  a  local 
lesion  does  not  afford  ground  for  inferring  that  there  is  no  such  lesion. 
The  proguosis  and  treatment  of  the  condition  are  those  of  the  lesions 
causing  it,  and  are  described  in  the  account  of  those  diseases. 

Delirium. — Instead  of  arrest  of  the  manifestation  of  mental  pro- 
cesses these  may  be  perverted,  and  the  perversion  may  be  manifested 
in  speech  or  action.     This  condition  is  termed  delirium. 

The  characteristic  of  healthy  mental  processes  is  that  they  are  in 
harmony  with  the  actual  sensory  impressions  of  the  present  or  with 
the  memory  of  those  of  the  past.  In  delirium  this  concord  is  lost. 
Mental  processes  cease  to  correspond  to  reality.  There  are  false  ideas 
— "  delusions  ;"  or  sensory  images  arise  without  sensory  impressions 
— "hallucinations;"  or  actual  sensory  impressions  excite  erroneous 
sensory  images — "illusions,"  which  may  or  may  not  seem  to  the  patient 
to  be  true.f     The  condition  of  delirium  is  essentially  the  same  as  that 

*  A  reader  wlio  desires  a  description  of  the  general  diagnosis  of  the  cause  of 
apoplexy  will  find  it  in  my  lectures  on  '  Diagnosis  of  Diseases  of  the  Brain.' 

f  These  three  terms  have  heen  variously  used  hy  dili'ercnt  writers  on  mental 
disease,  and  the  resulting  confusion  has  heen  increased  by  still  greater  variety  of 
use  in  non-medical  writings,  and  of  definition  in  dictionaries.     The  term  "illusion" 


SYMPTOMS.  105 

which  constitutes  insanity,  but  the  term  "delirium"  is  usually  con- 
fined to  the  acute  mental  derangement  that  occurs  as  a  consequence 
of  organic  brain  disease,  of  pyrexia,  of  toxaemic  conditions,  or  of  inani- 
tion. In  these  conditions  the  disease  of  which  it  is  a  symptom  is 
otherwise  recognisable.  The  similar  mental  state  which  occurs  apart 
from  these  conditions,  and  which  constitutes  the  sole  evidence  of 
disease,  is  regarded  as  "insanity."  Delirium  is  due  to  brain  disease 
much  less  frequently  than  to  toxsemic  states. 

Delirium  may  be  "quiet"  or  "active."  In  quiet  delirium  there 
are  delusions  and  hallucinations  (especially  of  sight)  which  dominate 
the  patient's  ideas.  He  does  not  recognise  his  friends,  mistakes 
inanimate  objects  for  persons,  animals,  &c,  and  often  talks  almost 
continuously,  but  usually  in  a  low  monotonous  voice,  with  words 
imperfectly  finished,  so  that  considerable  attention  may  be  needed  to 
ascertain  what  is  said — a  condition  which  is  aptly  termed  "low, 
muttering  delirium."  On  the  other  hand,  in  "  active  delirium  "  the 
patient  tries  to  act  according  to  his  erroneous  ideas  ;  he  may  insist  on 
getting  out  of  bed,  going  downstairs  or  out  of  doors,  and  may  even, 
under  the  guidance  of  some  delusion,  jump  out  of  a  window,  or 
commit  suicide  in  some  other  way. 

Although  the  general  elements  of  delirium  are  identical  with  those 
of  the  mental  derangement  termed  insanity,  yet  certain  common 
features  of  insanity  are  rarely  seen  in  delirium.  Such  are  the 
extreme  and  persistent  emotional  depression  of  melancholia,  the 
exaggeration  of  idea  which  characterises  some  cases  of  general  para- 
lysis of  the  insane,  the  outrageous  delusions  of  personal  identity  met 
with  in  the  latter  and  in  some  cases  of  chronic  insanity ;  and,  lastly, 
the  rhetorical  loquacity  of  acute  mania  is,  to  say  the  least,  extremely 
rare  in  symptomatic  delirium. 

Among  organic  brain  diseases  that  cause  this  symptom,  the  most 
frequent  are  meningitis,  cerebritis,  tumours,  multiple  or  extensive 
softening,  and  multiple  or  diffuse  degeneration  (e.  g.  scleroses). 

is  widely  used,  and  is  certainly  needed,  to  express  erroneous  sensory  conceptions  in 
which  the  error  depends  on  the  nature  of  the  sense  impression  itself,  and  is  or  may 
be  recognised.  Thus  the  impression  of  relief  in  the  stereoscopic  image  is  an  illusion. 
It  is  mainly  in  this  sense  that  the  word  has  been  made  by  Sully  the  title  of  a  book 
('Illusions/  Internat.  Scientific  Series).  In  this  sense  the  word  was  used  by  Bacon 
and  by  Pope,  and  the  use  corresponds  with  the  original  meaning  of  the  word,  "a 
deception."  If  used  in  connection  with  morbid  mental  states  it  should  be  confined 
to  false  ideas  and  images,  the  falseness  of  which  the  patient  recognises ;  for  these 
a  word  is  needed,  and  some  writers  have  thus  limited  it.  "  Hallucination  "  by  its 
derivation  is  associated  with  mental  disease,  and  may  conveniently  be  restricted,  as 
was  suggested  by  Esquirol,  to  "  sensations  perceived  at  a  time  when  there  are  no 
appropriate  external  objects  to  excite  thtin."  This  also  is  not  inconsistent  with  old. 
usage.  "  If  vision  be  abolished,  it  is  called  ccecitas,  or  blindness  ;  if  depraved  and 
receives  its  objects  erroneously,  hallucination"  (Sir  J.  Brown,'  Vulgar  Errors,'  1646). 
The  use  of  "  delusion "  to  designate  erroneous  ideas,  and  not  merely  erroneous 
sensory  perceptions,  also  agrees  with  the  common  use  of  the  word,  but  it  is  a  term 
of  more  general  application  than  the  others. 


103  BBALN. 

There  is  little  in  the  mere  character  of  the  delirium  to  indicate 
which  of  its  many  causes  is  at  work.  In  toxic  delirium,  especially 
that  due  to  acute  alcoholism,"there  is  often  conspicuous  tremor  of  the 
hands  and  face,  and  there  are  usually  the  visual  hallucinations  that 
have  furnished  a  familiar  metaphor  by  which  it  is  popularly  known. 
Chronic  alcoholic  delirium  may  present  none  of  these  characteristics. 
The  chief  difficulty  is  the  distinction  between  the  delirium  due  to 
pyrexia,  and  that  symptomatic  of  organic  brain  disease.  If  delirium 
is  the  sole  nervous  symptom,  it  can  only  be  accepted  as  evidence  of 
brain  disease  when  the  temperature  is  normal,  or  at  least  is  not 
raised  more  than  oue  or  two  degrees.  Those  who  have  indulged 
excessively  in  alcohol  may  indeed  be  rendered  delirious  by  a  slight 
degree  of  pyrexia,  and  the  delirium  is  then  of  complex  origin;  but  in 
the  sober,  pyrexia!  delirium  scarcely  ever  occurs  unless  the  tempera- 
ture exceeds  101°.  In  the  presence,  therefore,  of  sufficient  fever  to 
account  for  delirium,  we  are  not  justified  in  assigning  it  to  a  primary 
disease  of  the  brain  unless  other  symptoms  of  such  disease  are  present. 
These  may  be  extremely  varied  in  character,  but  one  of  the  most  im- 
portant is  headache.  As  Sir  William  Jenner  insisted  forty  years 
ago,  the  headache  of  fever  ceases,  as  a  rule,  when  the  delirium  comes 
on,  and  if  the  two  co-exist  there  is  probably  encephalic  disease. 
Other  significant  symptoms  are  persistent  vomiting,  spasm  or  rigidity 
in  limbs  or  neck,  inequality  of  pupil,  strabismus  or  diplopia,  and 
optic  neuritis.  Optic  neuritis  now  and  then  succeeds  an  acute  specific 
fever  (especially  typhoid  and  scarlet  fevers),  but  it  does  not  come  on 
during  the  height  of  the  disease.  In  other  cases  the  early  symptoms 
of  the  disease  afford  important  help  in  estimating  the  significance  of 
delirium.  If  delirium  distinctly  precedes  fever,  it  has  evidently,  the 
same  significance  as  if  it  exists  alone.  If  it  succeeds  a  period  of  initial 
unconsciousness,  or  a  convulsion,  we  are  justified  in  assigning  to  it  a 
primary  iutra-cranial  cause.  The  only  exception  is  in  the  case  of 
acute  specific  diseases  in  children,  in  which  a  convulsion  may  occur 
at  the  onset ;  but  the  nature  of  such  cases  is  usually  clear. 

Obvious  as  these  rules  may  seem,  it  is  difficult  to  exaggerate  their 
practical  importance.  The  neglect  of  them  has  been,  and  still  is,  a 
frequent  source  of  error.  In  many  instances,  typhoid  fever,  or 
catarrhal  febricula  in  children,  has  been  thought  to  be  tubercular 
meningitis,  because  undue  weight  had  been  assigned  to  the  delirium. 
Grosser  errors,  indeed,  are  not  unknown.  On  the  other  hand,  care 
should  be  taken  to  avoid  the  opposite  mistake.  The  combination  of 
delirium  and  pyrexia  must  not  be  accepted  as  evidence  of  the  general 
nature  of  the  malady  until  the  observer  is  satisfied  that  there  are  no 
symptoms  of  nerve  disturbance  for  which  a  blood-state  will  not 
account.  The  records  of  every  fever  hospital  will  show  how  often 
acute  braiu  disease  has  been  mistaken  for  a  specific  fever,  because  the 
pyrexia  has  been  allowed  to  obscure  the  significance  of  other  indica- 
tions of  nerve  disturbance. 


SYMPTOMS.  107 

Simple  mental  failure  is  indicated  first  and  chiefly  by  defect  of 
memory,  "amnesia"  in  the  widest  sense  of  the  word.  There  is  a 
physical  side  to  memory  as  to  other  mental  processes.  All  functional 
action  of  nerve  elements  is  attended  by  molecular  changes  in  them, 
and  never  leaves  their  nutrition  in  exactly  the  same  condition  as 
before.  A  state  is  left,  for  a  time,  in  which  the  same  functional 
action  occurs  more  readily ;  there  is  a  diminution  of  resistance  in  the 
combination  of  nerve-elements  concerned,  and  this  residual  disposi- 
tion is  increased  by  repetition.  This  constitutes  the  basis  of  motor 
training,  in  which  facility  in  performing  complex  actions  is  acquired 
by  practice.  Such  actions  are  learned  by  a  sort  of  motor  memory, 
which  enters  but  little  into  the  region  of  consciousness.  A  similar 
condition  appears  to  constitute  the  physical  basis  of  memory,  pro- 
perly so  called.  During  various  mental  processes,  combinations  of 
nerve-cells  ai*e  in  action,  which  differ  according  to  the  diversity  of 
these  processes ;  and  the  residual  disposition  to  act  in  the  same  way, 
in  the  same  combination  and  degree,  renders  possible  a  perfect  revival 
of  the  original  activity,  and  on  the  side  of  mind  a  memory  of  a  past 
image. 

Thus  there  is  probably  no  special  faculty  of  memory,  physical  or 
psychical,  apart  from  the  general  cerebral  and  intellectual  processes. 
There  is,  however,  or  seems  to  us  to  be,  a  peculiar  power  of  voluntary 
revival  of  these  processes,  which  is  popularly  termed  "  recollection," 
and  fur  which  we  have  no  better  scientific  name. 

The  diseases  of  the  brain  that  affect  memory  are  extremely  numerous, 
and  comprehend  general  impairment  of  cerebral  nutrition,  as  by  an 
acute  fever,  severe  mental  shock,  and  especially  peculiar  functional 
conditions,  such  as  the  trance  state  of  hysteria.*  It  is  affected 
also  by  organic  diseases  that  damage  the  nutrition  of  the  cortex,  as 
meningitis,  extensive  local  lesions,  haemorrhage,  softening,  tumour  ; 
these  often  indirectly  impair  the  function  of  a  more  extensive  area 
than  is  structurally  damaged.  Loss  of  memory  results  also  from 
various  degenerative  processes,  which  are  for  the  most  part  classed  as 
forms  of  insanity,  e.  g.  senile  dementia  and  general  paralysis  of  the 
insane. 

The  defect  may  be  seen  only  in  the  inability  to  retain  new  impres- 
sions, although  those  acquired  up  to  the  time  of  the  commencement 
of  the  symptoms  may  be  preserved.  More  frequently  the  loss  is 
retrospective  as  well  as  present,  and  it  is  usually  the  later  processes 
that  cannot  be  revived,  the  recent,  not  the  remote,  past  that  is  for- 
gotten. The  loss  may  extend  back  for  a  few  days,  or  for  months  or 
years.  This  is  often  seen  in  degenerative  diseases  of  the  brain;  in 
senile  amnesia,  for  instance,  the  events  of  early  life  may  be  vividly 
remembered,  and  those  of  later  years  be  lost,  and  thus  we  have  the 
anomaly  that  "the   new  perishes,   the   old   endures"    (Ribot).     A 

*  Several  remarkable  cases  of  complete  loss  of  memory  after  such  attacks  have 
been  recorded  (see  Carpenter,  '  Brain/  vol.  i). 


1U8  BliAIN. 

clergyman  once  came  under  my  notice  who  had  lost  all  memory  of 
the  last  twenty  years  of  his  life,  and  maintained,  with  consistent 
perversity,  that  his  age,  length  of  parish  work,  &c,  were  just  twenty 
years  less  than  they  really  were.  In  rare  cases,  in  which  lost  memory 
has  been  regained,  recovery  has  occurred  in  the  reverse  order,  from 
the  past  towards  the  present.  Thus  a  man,  after  an  accident,  had 
forgotten  entirely  the  events  of  the  three  preceding  days,  and  each 
day  was  successively  remembered  until,  at  last,  the  accident  itself 
was  recalled.*  It  is  said  that  in  the  loss  of  memoiy  the  more  special 
acquisitions  are  first  lost,  the  most  general  are  preserved  longest. 
This  is  best  seen  in  the  case  of  words.,  among  which  proper  names 
are  first  lost  and  then  nouns,  and  then  names  of  qualities.  In  more 
general  loss  of  memory  the  order  is  difficult  to  trace.  Loss  of  memory 
is  sometimes  partial,  i.e.  there  is  considerable  or  complete  loss  of 
some  class  of  ideas,  as,  for  instance,  of  a  foreign  language.  These 
cases,  although  curious,  are  of  little  interest  from  a  medical  point  of 
view. 

Another  symptom  of  mental  failure,  with  which  indeed  the  loss  of 
memory  is  closely  connected,  is  deficient  power  of  attention — that  is, 
the  deficient  power  of  excluding  from  the  domain  of  consciousness  all 
but  one  subject.  This  is  often  mistaken  for  failure  of  memory :  in 
hypochondriasis,  for  instance,  there  is  often  thought  to  be  defect  of 
memory  when  there  is  only  defective  use  of  memory  owing  to  inability 
to  exclude  from  consciousness  the  physical  sensations,  &c,  that 
distress  the  patient.  Closely  connected  with  loss  of  memory  is  inco- 
herence of  ideas.  Instead  of  the  definite  sequence  of  mental  pro- 
cesses that  we  recognise  as  normal,  one  mental  image  excites  another 
by  some  accidental  association  (as  word- resemblance),  which  would 
be,  in  health,  subordinated  to  logical  sequence.  Often  the  connec- 
tions that  determine  the  morbid  sequence  are  so  subtle  as  to  evade 
detection.  This  incoherence  of  idea  is  portrayed  in  language.  It  is 
conspicuous  in  delirium,  and  is  also  frequent  in  simple  mental  failure. 

Defects  in  the  moral  sense  are  also  common  symptoms  of  mental 
failure,  although  not  always  present.  A  slight  defect  may  show  itself 
only  in  a  want  of  sense  of  propriety.  Such  defects  are  relative 
rather  than  absolute,  and  must  be  measured  by  their  deviation  from 
the  normal  conduct  of  the  individual.  Many  actions — such,  for 
instance,  as  spitting  about  a  room — would  be  more  distinctly  patho- 
logical in  a  man  of  refinement  than  in  an  ill-mannered  man  of  the 
lower  classes.  Some  actions  are  unequivocal  in  their  significance,  as 
when  a  patient  deliberately  micturates  on  the  floor,  or  exposes  himself 
indecently,  without  perceiviug  the  impropriety  of  the  action.  Urine 
and  stools  are  often  passed  into  the  bed,  in  cases  of  brain  disease,  in 
consequence  of  mental  failure,  when  there  is  no  incompetence  of  the 
sphincters.  This  always  indicates  a  considerable  depth  of  meutal 
change,  often  much  greater  than  appears  on  the  surface.  Hence  the 
*  Kompfen,  quoted  by  Kibot,  '  Disea:-es  of  Memory,'  p.  123. 


SYMPTOMS.  109 

symptom  is  of  grave  significance,  and  always  of  such  practical  impor- 
tance that  its  significance  cannot  be  too  strongly  insisted  on. 

Another  class  of  actions  which  result  from  mental  defect  are 
offences  against  morality  and  propriety,  and  these  often  seem  to 
depend  less  on  want  of  knowledge  of  the  nature  of  the  action,  than 
on  the  absence  of  motive  to  avoid  it.  They  occur  chiefly  in  the  defi- 
nitely "  insane,"  rather  than  in  the  subjects  of  organic  brain  disease. 

It  is  important  to  note  that  in  children  with  slight  mental  defect 
the  absence  of  natural  shyness,  and  the  difficulty  of  producing  any 
deterrent  sense  of  wrong  or  shame,  often  afford  more  conspicuous 
indications  of  the  mental  deficiency  than  actual  lack  of  intellectual 
processes.  The  children  are  unabashed  by  the  presence  of  strangers, 
and  are  disobedient,  mischievous,  meddlesome,  wantonly  injuring 
their  playthings,  and  even  their  playmates.  The  absence  of  shyness 
often  leads  to  a  pseudo-precocity  which  fond  parents  take  to  be  the 
dawn  of  genius. 

Affections  of  Speech* — Speech  is  deranged  in  various  ways  by 
disease  of  the  brain.  The  process  of  articulatiou  is  immediately 
influenced  by  a  mechanism  of  nerve-nuclei  situated  in  the  pons  and 
medulla,  but  these  are  excited  to  action  by  centres  in  the  cerebral 
cortex.  Thus  there  are  higher  and.  lower  nervous  mechanisms;  the 
former  is  cerebral,  the  latter  bulbar.  When  there  is  disease  of  the 
lower  mechanism,  the  elements  of  speech  are  correct  in  number  and 
order,  but  their  form  is  imperfect ;  there  is  defective  articulation.  In 
disease  of  the  higher  mechanism  the  form  of  the  elements  of  speech  may 
be  correct,  but  they  are  defective  in  number  and  arrangement.  There 
is,  however,  one  condition  in  which  disease  of  the  cerebrum  interferes 
with  articulation, — when  the  disease  involves  the  structures  concerned 
in  both  hemispheres.  One-sided  disease,  either  of  the  cortex  of  the 
brain  or  the  path  from  it,  may  interfere  with  articulation  for  a  time, 
but  the  loss  soon  passes  away,  because  it  is  soon  compensated  by  the 
other  hemisphere.  The  most  important  movements  are  bilateral,  and, 
like  other  bilateral  movements,  can  be  excited  from  either  hemisphere. 
But  symmetrical  disease  of  both  hemispheres,  if  it  involves  the  centres 
or  paths  for  the  muscles  concerned  in  speech,  may  permanently  derange 
or  abolish  articulation.      The  condition  is  termed    "  pseudo-bulbar 

*  The  most  important  writings  on  the  subject  of  defects  of  speech  are  those  of 
Trousseau  in  his  'Clinique  medicale'  (lect.  v'iii,  p.  218,  of  Bazire's  translation); 
Bastian,  'Mcd.-Chir.  Rev.,'  January  and  April,  1869;  Broadbent,  'Med.-Chir. 
Trans.,'  1872,  vol.  lv;  Bateman.  'On  Aphasia,'  London,  1870,  2nd  edit.,  1891  (a 
thoughtful  and  comprehensive  treatise) ;  Hughlings  Jackson,  in  many  places,  but 
especially  in  'Brain,'  vols,  i  and  ii;  Wernicke,  '  Der  Aphasische  Symptomen- 
Complex,'  Breslau,  1874;  Kussmaul's  article  in  Ziemssen's  '  Cyclopaedia'  (vol.  xiv 
of  the  American  translation) ;  and,  during  the  last  five  years,  a  series  of  writers 
too  numeious  to  mention,  the  most  important  of  whose  papers  will  be  found  pub- 
lished or  abstracted  in  the  'Neurologisches  Centralblatt '  and  'Cent,  fur  Nerven- 
heilkundc' 


110  BRAIN. 

paralysis,"  from  the  close  resemblance  which  it  hears  to  the  effect  of 
disease  of  the  medulla. 

Defects  of  Articulation. — The  changes  in  articulation  that  result 
from  disease  of  the  medulla  and  lower  part  of  the  pons,  vary  from  a 
slight  imperfection  to  a  loss  so  complete  as  to  leave  only  lai-yngeal 
tones  to  represent  articulate  speech.  This  defect  is  termed  anarthria 
or  dysarthria.  Considerable  loss  is  usually  associated  with  obvious 
palsy  of  the  parts  concerned  in  articulation.  The  most  important 
effects  of  such  definite  paralysis  are  these :  in  paralysis  of  the  lips 
the  labial  consonants,  which  depend  on  precise  closure  of  the  lips,  are 
defective';  p,  b,  and  m  are  transformed  into  /and  v.  In  palsy  of  the 
tongue  the  Unguals  I  and  t  are  imperfectly  pronounced,  and  tend  to 
become  y  and  th.  Palsy  of  the  palate  not  only  gives  an  undue  nasal 
resonance  to  the  voice,  but  impairs  the  pronunciation  of  the  explosive 
labials  p  and  b,  because  the  patency  of  thenares  prevents  the  needful 
compression  of  the  air  in  the  mouth  ;  and  these  explosives  are,  there- 
fore, transformed  into  the  continuous  labial  m. 

In  slighter  and  less  defined  disease  of  the  bulbar  mechanism,  ter- 
minal or  subordinate  consonants  and  syllables  are  imperfectly  pro- 
nounced, irrespective  of  their  character,  and  are  often  run  together 
or  elided,  in  what  is  termed  "  confluent "  or  "  elisive  "  articulation. 
Sometimes  consonants  that  require  delicately  adjusted  muscular  action 
are  omitted,  or  easier  sounds  are  substituted,  and  occasionally  con- 
sonants are  unintentionally  repeated.  The  r  is  especially  a  source  of 
stumbling  to  these  patients  ;  and  words  or  sentences  containing  this 
consonant  are  often  employed  as  tests,  e.  g.  "  extraordinarily," 
"  artillery."  In  other  cases,  again,  syllables  are  unduly  sepai'ated,  in 
what  has  been  termed  "  staccato  "  or  "  scanning  utterance." 

Cerebral  Defects. — The  defects  of  speech  that  result  from  dis- 
ease of  the  cerebral  hemisphere — defects  not  of  articulation,  but  of 
the  elements  of  speech — are  now  known  by  the  name  aphasia.  The 
word  has  become  current  as  a  general  designation  for  various  forms 
of  defect,  manifested  in  the  various  modes  of  expression,  just  as  the 
analogous  word  "  anaemia"  is  applied  to  various  forms  of  deficiency  of 
blood*  The  word  owes  its  currency  to  Trousseau,  who  summoned  it 
from  a  slumber  of  two  thousand  years,f  as  a  substitute  for  the  term 

*  The  inaccuracy  of  applying  an  absolute  negation  to  a  partial  effect  has  led  to 
the  suggestion  of  "  dysphasia "  as  a  substitute.  The  term  does  not,  however, 
seem  likely  to  come  into  use,  a  matter  for  little  regret,  since  the  word  has  not 
the  merit  of  unimpeachable  exactness,  and  it  has  an  unfortunate  resemblance  in 
sound  to  "dysphagia."' 

t  Trousseau  seems  to  have  been  unaware  of  the  antiquity  of  the  word.  It  was 
apparently  "  invented"  for  him,  in  1861,  by  a  Greek,  M.  Chrysaphis  (see  Trousseau's 
'Cliuique  me'd.,'  lect.  lxi,  and  the  foot-note  at  p.  218  of  Bazire's  translation).  The 
history  of  the  more  important  steps  in  the  discovery  of  the  cerebral  relations  of 
speech  is  briefly  this.  The  faculty  of  language  was  first  attributed  to  the  frontal 
lobes  by  Bouillaud  in  1825,  and  to  the  left  hemisphere,  near  the  island  of  Roil,  by 
Dax  in  1836.    The  title  of  Dax's  paper  is  worth  rre-crving.    It  was  "  Lesions  of  the 


SYMPTOMS.  Ill 

avliemia,  with  which  Broca  had  in  turn  displaced  the  alalia  of  Lordat. 
"  Aphemia"  is  sometimes  stili  employed  in  a  restricted  application  to 
articulate  speech.* 

The  subject  abounds  in  difficulty,  arising  partly  from  its  complexity 
and  partly  from  the  uncertainty  due  to  a  deficiency  of  facts,  and  the 
obscurity  produced  by  a  redundance  of  theory.  Precise  knowledge  of 
the  effects  of  local  disease  on  the  various  relations  of  language  is 
scanty,  and  the  possible  interpretations  of  the  conditions  observed 
during  life  are  numerous.  The  clinical  facts  may  be  and  have  been 
variously  explained  ;  and  it  is  almost  startling  to  find,  when  we  come 
to  weigh  the  evidence,  how  small  is  the  ground  on  which  some  theories 
are  based,  and  how  much  deficiency  of  fact  a  clear  diagram  may  hide. 
Hence  an  attempt  to  state  the  definite  knowledge  we  possess  may 
seem  to  be  at  once  meagre  in  scope  and  hesitating  in  assertion.  But, 
if  the  certain  knowledge  is  insufficient  to  enable  us  to  explain  all  the 
complex  phenomena,  it  furnishes  a  definite  starting-place  from  which 
to  investigate  tbem  ;  and  if  the  obscurity  is  recognised,  we  may  be 
saved  at  least  from  misplaced  confidence.  Hypotheses  unfortunately 
cannot  be  altogether  avoided,  but  it  is  desirable  that  they  should  be 
simple  in  nature  and  restricted  in  use  until  more  facts  have  been 
ascertained. 

Speech-processes  in  the  cortex  of  tJje  brain  are  sensory  and  motor. 
By  the  former  language  is  received,  and  by  the  latter  it  is  uttered. 
These  processes  go  on  chiefly  in  the  left  hemisphere  in  right-handed 
persons,  but  in  those  who  are  left-handed  the  processes  go  on  in  the 
right  hemisphere,  and  this  even  when  the  patient  uses  for  writing  not 
the  left  hand  but  the  right.  There  are,  however,  similar  structures  in 
each  hemisphere,  and  if  those  on  the  left  side  are  destroyed,  the  cor- 
responding parts  of  the  right  hemisphere  may  take  on  the  lost  func- 
tion, and  the  symptoms  of  the  loss  may  slowly  pass  away.  The  proof 
of  this  is  that,  in  several  cases  of  this  character,  a  fresh  lesion  in  the 
right  hemisphere  has  destroyed  the  reacquired  power,  and  there  has 
then  been  no  recovery.  It  is  probable,  moreover,  as  we  shall  presently 
see,  that  the  right  hemisphere  normally  takes  some  part  in  speech- 
processes,  and  that  the  part  it  takes  varies  in  different  persons  and  at 
different  periods  of  life.  Loss  of  speech  from  disease  of  the  left 
hemisphere  is,  as  a  rule,  quickly  recovered  from  in  children  by  the 
compensatoi'y  use  of  the  right  hemisphere ;  a  similar  recovery  takes 
place  in  some  adults  more  readily  than  in  others,  and  in  some  it  does 
not  take  place  at  all.  If  such  compensation  occurs — and  the  occur- 
rence is  unquestionable — it  is  evident  that  very  soon  after  the  left 

Left  Half  of  the  Brain  coinciding  with  Los*  of  Memory  of  the  Signs  of  Thought."' 
The  function  was  further  limited  to  the  third  frontal  by  Broca  in  1861.  The  local- 
isation of  the  auditory  centre  in  the  first  temporal  is  due  to  Meyuert  and  Wernicke, 
and  to  the  latter  belongs  also  the  credit  of  the  localisation  of  word-deafness  to  this 
region  of  the  left  hemisphere. 

*  "  Aphemia  "  was  rejected  by  Trousseau  and  by  Bi-oca  himself,  at  the  instance 
of  Littre,  because  its  Greek  significance  is  not  "speechlessness"  but  "infamy." 


112  BRAIN. 

hemisphere  has  lost  some  of  its  function,  the  right  hemisphere  must 
he  gin  to  co-operate  with  it  in  effecting  the  speech  that  quietly  returns. 
Such  co-operation,  admitted  when  the  damage  is  great,  probably 
occurs  also  when  the  damage  is  partial.  It  is  evident  that  we  have 
here  an  element  of  great  uncertainty.  If  the  actual  lesion  is  not 
known,  we  cannot  be  sure  to  what  extent  the  speech-processes  that 
return,  and  therefore  the  disorder  they  present,  are  to  be  ascribed  to 
the  left  hemisphere  or  to  both  hemispheres ;  and  we  must  incur  some 
error,  and  it  may  be  great  error,  if  we  fix  our  attention  exclusively  on 
the  left  hemisphere.     Examples  of  this  will  be  manifest  as  we  proceed. 

The  sensory  relations  of  speech  are  with  hearing  and  sight,  and 
also,  in  blind  persons,  with  touch.  The  relation  to  the  sense  of 
hearing  is  the  most  important ;  it  is  the  first  speech  relation  to  be 
developed  in  the  child,  who  can  understand  many  words  before  he 
can  utter  one ;  it  seems  to  lead  in  the  subjective  revival  of  speech- 
processes  which  we  call  "  recollecting  words."  The  part  of  the  brain 
concerned  in  the  auditory  perception  of  words  is  the  posterior  half  of 
the  first  temporal  convolution  on  the  left  side.  It  is  apparently  the 
auditory  centre  itself,  at  least  structures  at  present  inseparable  from 
this  centre.  If  this  region  is  diseased  on  either  side,  there  is  often 
transient  deafness  in  the  opposite  ear  (see  p.  24) ;  and  if  on  the  left 
side,  there  is  usually  persistent  inability  to  understand  the  meaning 
of  words,  although  they  are  still  heard  as  sounds.  This  condition 
causes  considerable  derangement  of  speech.  It  was  first  described 
by  Dr.  Bastian,  and  accurately  referred  by  him  to  destruction  of  the 
"  auditory  perceptive  centre."  Wernicke,  to  whom  belongs  the  credit 
of  discovering  the  precise  seat  of  the  disease  that  causes  the  sym- 
ptom,* proposed  for  the  disturbance  of  speech  the  term  sensory 
aphasia,  and  Kussmaul  afterwards  called  the  loss  word-deafness.  The 
loss  is  now  generally  known  by  the  latter  term,  and  the  former  is 
applied  to  the  general  disorder  of  the  use  of  words  that  results.  The 
dependence  of  this  symptom  on  disease  of  the  first  temporal  convolu- 
tion is  well  established.  This  part  was  diseased  in  every  one  of 
seventeen  cases  collected  by  Sepelli.f 

The  part  of  the  brain  concerned  in  the  perception  of  visual  word- 
svmbols  seems  to  be  in  the  lower  and  hinder  part  of  the  parietal  lobe, 
also  on  the  left  side  of  the  brain,  apparently  including  the  region 
rather  vaguely  described  as  that  of  the  "  angular  gyrus."  Disease 
of  this  part  has  caused  inability  to  read  even  the  simplest  word,  a 
condition  that  has  been  termed  "  word-blindness  "  (see  p.  5).  Of  the 
cases  collected  by  Sepelli,  in  each  one  in  which  word-blindness  co- 
existed with  word-deafness  the  disease  extended  into  this  part  of  the 
parietal  lobe.  This  region,  as  we  have  seen  (p.  22),  is  probably  the 
seat  of  the  "  higher  visual  centre,"  and  transient  "  mind-blindness  " 

*  '  Die  Aplm  sisclie  Sympfomen-Complex,'  1874,  a  work  of  remarkable  ability. 
t  Sepelli,   '  Rivista  Sper.  .di  Fren.,'  1884,  p.  94  (see  also  Auiidon,  'New  York 
Med.  Journal,'  January,  1S85). 


SYMPTOMS.  113 

Las  been  caused  by  its  disease,  i.  e.  an  inability  to  recognise  not  only 
words,  but  objects  also.     Such  mind-blindness  has  also  occurred  in  a 
few  cases  as  a  persistent  symptom,  but  we  are  not  sure  whether  it 
then  depends  on  a  uuilateral  lesion  or  on  bilateral  symmetrical  disease 
(see  "Affections  of  Vision  ").    The  extent  and  degree  to  which  visual 
word -processes   take   part  in    the    phenomena    of   ordinary  speech 
probably  vary  much,  according  to  the  education  of  the  individual, 
among  other  conditions.     Their  reality  is  readily  evident  on  self-obser- 
vation, and  is  demonstrated  only  too  clearly  by  cases  in  which  the  loss 
of  the  auditory  and  motor  word-pi'ocesses  (physical  memories)  leaves 
the  patient  unduly  dependent  on  those  connected  with  sight,  or  con- 
versely, in  which  the  loss  of  the  last  alone  has  given  rise  to  a  peculiar 
train  of  disturbances  of  speech.     These  are  rare,  but  some  instances 
have    been  lately    studied   and  described  under  the  term   "visual 
aphasia."*     The  symptoms  of  this  condition,  supposed  to  be  produced 
especially  by  disease  of  the  cortical  visual  centre  or  of  the  fibres  con- 
necting it  with  the  motor  speech-centre,  are  these  : — defect  in  the  right 
halves  of  the  visual  field,  inability  to  read  (alexia)  or  write  (agraphia), 
and  inability  to  name  objects  after  looking  at  them,  although  they 
can  be  named  if  the  patient  is  allowed  to  touch  and  handle  them. 
But  they  will  no  doubt  be  influenced  by  the  degree  of  education  of 
the  patient,  and  also  by  the  nature  of  the  speech-process  for  which 
they  are  employed  (see  also  p.  119).     The  pure  visual  difficulty  must 
be  distinguished  from  that  of  writing  with  which  it  may  be  combined. 
Further,  the  crossed  amblyopia,  which  results  from  extensive  disease 
in  this  part,  has  not  often  been  recognised  in  cases  of  impairment  of 
visual  word-processes.     The  speech-defect  interferes  with  the  detection 
of  the  visual  loss,  and  it  may  be  that  word-processes  are  related  to  only 
a  part  of  the  region  that  has  to  do  with  vision.     It  must,  however,  be 
noted — and  the  fact  very  much  increases  the  difficulty  of  the  subject 
— that  inability  to  read  does  not  prove  disease  of  this  part  in  the  same 
way  as  inability  to  understand  heard  words  proves  disease  of  the  first 
temporal.     The  mechanism  of  reading  is  complex,  and,  as  we  shall 
see,  it  may  be  deranged  indirectly, 

Motor  word -processes  take  place  in  the  posterior  part  of  the 
third  frontal  convolution,  and  in  the  adjacent  part  of  the  ascending 
frontal.  The  latter  contains  the  cortical  centre  for  the  movement  of 
the  tongue,  lips  and  larynx  generally,  to  which  the  motor  speech- 
centre  thus  corresponds.  The  path  from  it  passes  through  the 
white  substance  of  the  hemisphere  to  the  internal  capsule  at  the 
junction  of  its  two  parts,  in  front  of  the  fibres  of  the  pyramidal 
tract,  and  it  lies  to  the  inner  side  of  these  fibres  in  the  crus  cerebri. 
It  is  commonly  thought  that  the  path  from  the  speech-centre  is 
distinct  from  that  for  the  tongue  and  lips,  but  the  evidence  of  this  is 
insufficient.  It  is  more  probable  that  the  speech-path  is  that  for  the 
simple  movements  of  the  parts  concerned,  although  the  cortical 
*  See  especially  Prennd  ('Arch.  f.  Psy.,'  1889,  xx,  1,  2). 
VOL.  II.  8 


114 


RRA1N. 


centre  is  more  extensive.  "Whether  the  island  of  Eeil  forms  part  of 
the  speech-centre  is  still  uncertain  ;  speech- defect  from  disease  limited 
to  it  has  not  yet  been  observed,  but  its  position  between  the  motor 
and.  auditory  centres,  and  the  way  in  which  fibres  between  the  two 
pass  by  it,  have  led  Wernicke  and  others  to  regard  it  as  part  of  the 
speech-region.  All  the  cases  adduced  as  proof  of  the  dependence  of 
aphasia  on  disease  of  the  island  of  Reil  are  inconclusive,  either  because 
the  lesion  was  not  limited  to  it,  or  because  the  duration  of  the  case  , 
was  too  short  to  permit  indirect  symptoms  to  pass  away.* 

Destruction  of  the  motor  speech-region  on  the  left  side  causes  total 

or  almost  total  loss  of  voluntary 
speech.  Such  loss  has  resulted  from 
a  lesion  in  the  third  frontal  no  larger 
than  a  hazel- nut.  f  If  the  loss  is  old 
or  partial,  words  are  often  uttered 
but  are  wrongly  formed.  Such  defect 
has  been  termed  ataxic  apJiasia,%  but 
this,  as  a  distinctive  term,  is  inexact, 
since  a  very  similar  disorder  of  words 
may  arise  from  pure  word-deafness. 
Hence  it  is  far  better,  with  Wernicke, 
to  term  the  effect  of  disease  of  the 
motor  speech-region  ''motor  aphasia." 
Its  precise  characters  will  be  pre- 
sently described. 

Motor  aphasia    may  be    produced 

Am,  fibres  from  this  to  internal  by    disease    of    the    conducting    path 

capsule;   S    motor  speech-centre;  fr  th  fc  ag         u  as    fe      th 

S  C,  fibres  from  this  to  the  corpus  J 

callosum ;  and  S  m,  to  the  internal  disease    of    the    Cortex    itself. §       The 

capsule.     S  A,  fibres  from  speech-  ioss  from  disease  of  the  path  is  only 
centre  to  hand-centre.     A   lesion  ,        ,  ,,        ,  , 

at  mm  will  cause  only  transient  permanent    when   the   lesion   is   just 

aphasia,  the  speech-processes  being  beneath  the  cortex.     If  the  lesion  is 

able  to  pass  by  S  C  to  the  corpus  n  j       the  internal   capsule,  the 

callosum     and     opposite     speech-  '  .  ■    » 

region;  a  small  lesion  at  x  would  loss  passes  away  in  the  course  of  a  few 

cause  permanent  aphasia,  since  it  weeks.      The  explanation  of  the  differ  - 
involves   both   the    fibres    to    the  .  ,    ,  ,      ,  .       •t>ix.    j-i  fc*  r\ 

corpus  callosum  and  internal  cap-  ence  IS  probably  this  :  if  the  fibres  (S  C, 

sule,  but  would  not  abolish  expres-  Fig.  68)  from  the  left  speech-centre  to 

sion  by  writing,  the  fibres .  S  A  tb     corpus  callosum  are   intact,   the 
(coiinectinsr  the  speech-  and  hand-  r 

centres)  escaping.  speech-processes  arranged  on  the  left 


Fia.  68. — Diagram  of  probable  course 
of  fibres  from  motor  speech-centre. 
A,  hand-centre  in  the  middle  of 
the  ascending  frontal  convolution  ; 


*  Thus,  in  a  case  published  by  Dejerine,  as  evidence  that  motor  aphasia  may  be 
due  to  an  insular  lesion  ('Revue  de  Med.,'  1885,  p.  174),  the  patient  lived  for  a  few 
days  only,  and  the  lower  part  of  the  central  convolutions  was  likewise  destroyed. 
(Compare  also  the  case  mentioned  in  the  note  on  p.  116.) 

f  Rosenstein,  '  Berlin,  klin.  Wochensch.,'  1868,  p.  182. 

%  First  by  Sanders,  'Edin.  Med.  Journ.,'  March,  1866;  soon  afterwards  by  Ogle. 

§  Raymond  and  Artaud  collected  twenty-three  cases  of  aphasia  from  disease  of 
the  white  substance  (' Gaz.  med.  de  Paiis,*  1883,  No.  47). 


SYMPTOMS.  115 

side  can  find  expression  through  the  cor  res  pon  cling  centre  on  the 
right  side;  if  the  lesion  is  just  beneath  the  cortex  (as  at  x,  Fig.  08), 
these  callosal  fibres  are  interrupted,  as  well  as  those  to  the  internal 
capsule  (S  m),  and  the  loss  is  as  permanent  as  if  the  centre  were 
destroyed.  In  the  former  case,  a  second  lesion  in  the  motor  path  of 
the  right  hemisphere,  even  in  the  internal  capsule,  may  cause  perma- 
nent aphasia.*  , 

In  the  act  of  writing,  the  speech-processes,  arranged  in  the  motor 
centre,  pass  to  the  centre  for  the  hand  in  the  middle  of  the  ascending 
convolution,  and  thence  the  nerve-impulses  pass  by  the  pyramidal 
tracts  to  the  cord.  The  evidence  of  this  is  that  disease  of  the  motor 
speech-centre  abolishes  the  power  of  writing  (agraphia),  even  when  the 
hand-centre  is  intact  and  the  movements  of  the  arm  are  unimpaired. f 
The  same  result  follows  an  isolating  lesion  just  beneath  the  cortical 
speech-centre,  and  hence  the  path  to  the  arm-centre  must  be  by  the 
"associating  fibres"  of  the  subjacent  white  substance,  and  not 
through  the  grey  matter  of  the  cortex.  But  it  is  conceivable  that  a 
subcortical  lesion  may  be  so  placed  as  to  interrupt  the  paths  to  the 
internal  capsule  and  to  the  opposite  hemisphere,  and  not  that  to  the 
arm-centre  (see  Fig.  68).  In  such  a  case  there  would  be  permanent 
loss  of  uttered  speech  without  loss  of  the  power  of  writing.  Such  a 
condition  has  actually  been  observed.  J 

Disease  limited  to  the  motor  speech-region  sometimes  abolishes  the 
power  of  reading  (alexia),§  sometimes  it  does  not.  The  difference 
depends  in  part  on  the  degree  to  which  motor  speech-processes 
are  concerned  in  the  comprehension  of  visual  speech  symbols.  In 
persons  accustomed  to  reading,  the  intellectual  images  may  perhaps 
be  aroused  directly  by  the  visual  processes,  without  the  intervention 
of  the  motor  processes.  In  those  who  are  imperfectly  educated,  the 
motor  processes  are  essential ;  the  lips  may  even  be  seen  to  move 
during  the  process  of  reading.  It  must  be  remembered  that  children 
learn  to  read  aloud  words  they  do  not  understand  ;  indeed,  the  early 
effort  of  a  child  is  merely  to  pronounce  the  seen  words.  || 

In  addition  to  the  two  leading  varieties  of  aphasia,  the  motor 
and  sensory,  there  is  another  in  which  the  patient,  without  loss  of  the 

*  This  appears  to  have  been  the  case  in  an  instance  recorded  by  Luys,  'L'Ence 
phale,'  1885,  No.  3. 

■f  In  Roseustein's  case  ('Berlin.  Min.  Wochenschr.,'  1868,  p.  182),  in  which 
aphasia  resulted  from  a  haemorrhage  the  size  of  a  hazel-nut  in  the  third  frontal,  the 
power  of  writing  was  lost  as  well  as  speech.  The  impairment  of  writing  in  motor 
aphasia  is  a  matter  of  daily  clinical  observation. 

X  Wernicke,  'Neurol.  Cent./  1886,  p.  124. 

§  Alexia,  be  it  remembered,  is  the  loss  of  the  power  of  understanding  written  or 
printed  words,  not  merely  a  loss  of  the  power  of  reading  aloud. 

||  At  the  same  time  it  is  doubtful  whether  the  observed  differences  in  the  influence 
of  motor  aphasia  on  the  power  of  reading  can  be  altogether  explained  by  the  degree 
of  education  and  of  practice  in  reading.  We  need  more  facts  regarding  the  patho- 
logical lesions  in  these  cases. 


116  BRAIN. 

motor  processes,  and  without  word-deafness,  has  a  difficulty  in  recall- 
ing words,  and  uses  wrong  words.  This  has  been  termed  "  amnesic 
aphasia,"  or  "loss  of  memory  for  words."  It  has  been  referred  by 
Wernicke  to  an  interruption  of  the  path  between  the  motor  and 
sensory  centres,  by  disease  of  the  island  of  Reil,  and  he  has  termed  it 
"conduction-aphasia  "  ("  Leitungsaphasia  "),*  He  assumes  that  the 
interruption  prevents  the  direct  action  of  the  sensory  on  the  motor 
centre  which  is  necessary  for  its  guidance. f  The  defect  that  accom- 
panies "  word-blindness  "  has  been  termed  "visual  apliasia."  As  a 
last  variety,  "total  aphasia"  has  been  described — the  form  in  which 
both  auditory  and  motor  centres  are  destroyed,  and  all  use  of  words 
is  lost. 

A  variety  of  paroxysmal  recurring  difficulty  in  reading  has  been 
called  dyslexia,  and  compared  with  the  "intermitting  lameness" 
mentioned  in  vol.  i,  p.  297.  The  difficulty  is  considerable  or  absolute, 
comes  on  suddenly,  and  passes  off  gradually,  being  at  first  readily 
reproduced,  although  afterwards  the  patient  is  free  until  another 
attack.  Most  subjects  have  been  in  advanced  life.  It  is  important 
because  usually  the  harbinger  of  grave  and  progressive  disease,  gene- 
rally due  to  arterial  degeneration.  J 

Motor  Aphasia. — In  a  case  of  motor  aphasia  from  destruction  of 
the  motor  speech-region  the  patient  is  at  first  speechless,  and  even 
expressions  by  signs  may  be  impaired.  He  may  shake  his  head  when 
he  means  "yes."  Before  long,  expression  by  gestures  becomes 
accurate,  and  the  patient  regains  the  power  of  uttering  a  few  simple 
words,  as  "yes  "  or  "  no,"§  and  often  other  words  are  at  times  uttered 
under  the  influence  of  some  emotion,  or  some  word  may  be  repeated 
on  every  attempt  to  speak.  The  patient  is  able  to  understand  what- 
ever is  said  to  him,  but  cannot  repeat  it.  He  cannot,  of  course,  read 
aloud,  and  he  is  generally  unable  to  understand  seen  words,  such,  for 
instance,  as  a  written  or  printed  direction  to  perform  some  simple 
action.  He  cannot  write,  even  if  his  hand  is  unaffected.  He  may  be 
able  to  copy,  and  even  to  translate  printed  letters  into  written  cha- 

*  Thnt  defects  in  speech  may  be  due  to  interruption  of  the  "  set  of  effereut  fibres 
emerging  from  the  auditory  perceptive  centre  having  to  do  with  the  iucitation  to  the 
muscular  acts  of  speech"  was  suggested  by  Dr.  Bastian  in  1869  (loc.  cit.).  Apart 
from  the  question  of  accuracy,  the  term  "conduction-aphasia"  does  not  very  aptly 
express  the  assumption  that  conduction  is  arrested. 

f  There  is  at  present  no  actual  proof  of  the  truth  of  this  assumption.  Lichtheim 
has  published  a  case  ('  Deut.  Arch,  f .  kliu.  Med  ,'  Bd.  xxxvi,  Case  1)  which  he  describes 
as  an  "  undoubted  example  of  this  form  of  aphasia,"  but  the  lesion  involve  d,  besides 
the  island  of  Reil,  \\  cm.  of  the  third  frontal  and  part  of  the  middle  of  the  first 
temporal.     (See  also  note  on  p.  114.) 

+  See  Berlin,  '  Neurol.  Cent.,'  18S3,  p.  296,  and  1886,  p.  355;  also  Nieden,  ibid., 
1S87,  p.  105,  and  Pick,  ibid,  1891,  p.  130. 

§  I  have  only  seen  one  case  in  which  a  patient,  nine  months  after  the  onset,  was 
absolutely  wordless.  There  was  considerable  word-deafness  as  well  as  absolute 
motor  aphasia.     Expressiou  by  signs  was  extensive. 


SYMPTOMS.  117 

racters.  If  the  right  hand  is  paralysed,  the  patient  may  try  to  write 
with  the  left  hand  and  may  try  to  form  words  with  separate  letters, 
but  the  latter  is  a  rather  severe  test  because  it  is  an  unfamiliar  process. 
Processes  of  thought  are  little  interfered  with,  and  the  patient  is 
perfectly  aware  of  his  errors  in  utterance.  The  use  of  figures  is 
usually  interfered  with  as  well  as  the  use  of  words,  but  to  this  rule 
curious  exceptions  are  met  with,  the  significance  of  which  we  are  not 
yet  able  to  understand.  Thus,  in  oue  case  of  considerable  motor 
aphasia  recorded  by  'Volland,  a  high  degree  of  arithmetical  ability 
was  preserved.* 

In  some  cases  this  condition  persists  unchanged  for  years.  More 
often  there  is,  after  some  months,  a  slow  recovery  ;  first  one  word  and 
then  another  is  uttered,  and  considerable  power  of  speech  may  be 
ultimately  regained  by  the  "  re-education"  of  the  right  hemisphere. 
In  other  cases,  however,  in  which  the  disease  is  partial,  the  loss  of 
speech  is  found  to  be  incomplete  when  the  immediate  effect  of  the 
lesion  has  passed  away,  but  many  mistakes  are  made  in  the  forms  of 
words  and  in  their  use. 

In  the  conditions  thus  sketched  there  are  two  elements:  (1)  loss 
of  speech  ;  (2)  retention  of  speech,  or  at  least  of  utterance  of  words, 
with  more  or  less  error.  The  loss  is  due  to  the  lesion  ;  the  retention  and 
error  are  due  to  the  imperfect  action  of  the  remaining  motor  speech- 
centres,  probably  on  both  sides  of  the  brain  if  the  disease  is  partial, 
or  on  the  right  only  if  it  is  complete.  It  is  obvious  that  when  there  is 
complete  destruction  of  the  left  motor  speech-centre,  the  utterance 
that  remains  must  be  by  the  right  hemisphere.  This  remaining  power 
of  expression  may  be  of  several  kinds  : — (1)  Expression  by  gesture, 
which  may  be  at  first  impaired  but  is  soon  regained.  (2)  Some 
general  propositional  utterance,  as  "  yes  "  and  "  no,"  which  may  be 
at  first  used  wrongly.  (3)  Some  special  utterance,  which  recurs  on 
all  attempts  to  speak,  and  may  be  a  word  or  words,  or  an  uumeaning 
combination  of  syllables.  (4)  Combinations  of  words  which  express 
some  strong  emotion,  and  not  the  proposition  to  which  their  form 
corresponds,  such  as  an  oath — "dead  propositions,"  Hughlings 
Jackson  has  aptly  called  them.  (5)  Words  as  the  vehicles  for  tone 
in  singing.  A  patient  who  can  only  say  "  yes  "  and  "  no  "  may  sing 
a  song,  and  in  doing  so  may  utter  every  word  of  the  song  although  he 
is  quite  unable  to  speak  it.f  Often  words  can  be  uttered  in  a  half- 
automatic  manner,  e.  g.  in  combination  with  other  words  or  under 
emotion,  and  not  by  a  deliberate  voluntary  effort.  Thus  a  patient 
with  slight  aphasia  was  told  to  say  "no,"  and  after  one  or  two  inef- 

*  'Munch,  med.  Wochensch.,'  18S6,  and  'Neurol.  Centralb.,'  p.  274.  The 
patient  was  a  boy  aged  fifteen.  After  a  fall  on  the  head  there  was  complete  motor 
aphasia,  only  the  recurring  utterance  "Anna  ''  persisting.  Recovery  was  very  slow, 
and  the  defect  had  not  entirely  disappeared  six  years  later.  From  the  first  the  boy 
could  add,  subtract,  and  multiply,  and  at  school  he  progressed  steadily  in  arithmetic. 

t  See  '  Lancet,'  1875,  vol.  ii,  p.  794.  For  an  interesting  discussion  of  this  condi- 
tion see  paper  by  Knoblauch  in  '  Brain,'  18'Jl. 


118  BRAIN. 

fectual  attempts  said,  "I  can't  say  no,  sir."  Thus  likewise  I  have 
known  a  patient  to  be  unable  to  put  out  his  tongue  when  told, 
although  he  automatically  put  it  out  and  licked  his  lips  to  facilitate 
the  process,  and  afterwards  was  still  unable  to  protrude  it  by  a 
deliberate  effort.  An  oath  uttered  in  anger  cannot  be  repeated  with- 
out the  emotion. 

The  "  recurring  utterances  "  are  very  curious.  They  seem  to  be 
either  the  words  the  patient  was  about  to  utter  when  taken  ill 
(Hughlings  Jackson),  or  more  probably  the  last  words  actually 
uttered.  A  woman  who  told  a  cabman  to  drive  her  to  "Mrs. 
"Waters,"  and  became  speechless  a  few  minutes  afterwards,  had  the 
recurring  utterance,  "  Missis."  The  recurring  utterance  of  a  girl, 
seized  when  riding  on  a  donkey,  was  "  gee  gee  "  (Jackson)  ;  that  of 
a  signalman,  taken  ill  at  his  post,  was  "  Come  on  to  me ;"  that  of  a 
librarian  was  "List  complete"  (Enssell).  The  phenomena  of  recur- 
ring utterances,  which  must  be  effected  by  the  right  hemisphere,  seem 
to  show  that  this  hemisphere  takes  some  part  in  normal  speech. 
Fresh  processes  for  words  cannot  be  energised  through  the  will,  but 
the  residual  disposition  of  those  last  energised  voluntarily,  leads  to 
their  excitation  by  an  attempt  to  speak.  As  Hughlings  Jackson  has 
insisted,  the  loss  of  speech  from  disease  of  the  left  motor  region  is 
essentially  a  loss  of  voluntary  speech.  When  speech  is  slowly  regained 
by  the  right  hemi.-phere,  many  of  the  errors  in  utterance  may  be 
traced  to  the  defective  voluntary  influence,  and  to  a  tendency  to  the 
re-energising  of  nerve-processes  recently  in  activity.  Consonants  are 
repeated  instead  of  the  proper  consonant  being  uttered,  and  those  of 
a  recurring  utterance  may  crop  up  in  wrong  places.  When  the  patient 
whose  recurring  utterance  was  "Missis"  acquired  more  speech,  the"  s" 
was  constantly  cropping  up  in  other  words.  Ultimately  almost  perfect 
recovery  may  occur,  and  there  may  remain  only  slight  and  occasional 
errors  in  the  form  of  words,  with  a  difficulty  in  finding  the  word 
desired,  and  a  tendency  to  use  wrong  words. 

In  motor  aphasia  the  inability  to  write  is  usually  even  greater  than 
the  inability  to  speak.  In  writing,  speech  symbols  are  again  sym- 
bolised, and  in  the  double  symbolism  there  is  more  room  for  error. 
The  patient  may  be  unable  to  form  a  siugle  letter,  or  letters  may  be 
formed  but  combined  wrongly,  or  there  may  be  merely  mistakes  of 
letters  in  words  that  are  otherwise  correct.  The  patient  can  often 
sign  his  own  name — which  is  almost  an  automatic  performance —when 
he  cannot  express  a  proposition  in  writing.  As  an  instance  of  this, 
and  also  of  the  fact  that  errors  in  writing  are  greater  than  in  speech, 
may  be  given  the  case  of  a  mau  who,  alter  signing  his  name,  James 
Slim,  correctly,  was  told  to  write  down  "  how  he  came  to  the  hospital," 
and  wrote  cgng  legig  kiyan,  but  in  answer  to  the  same  question  said, 
"  Rail,  clab,"  and  when  asked  "  How  else  ?  "  replied  "  No  way."  The 
tendency  to  repetition,  to  the  re-energisiug  of  processes  recently  in 
activity,  causes  many  of  the  errors  in  writing  as  well  as  in  speech,  and 


SYMPTOMS.  119 

is  seen  in  the  above  sentence.  Glacj  for  "glad"  is  another  instance. 
Other  mistakes  in  written  letters  are  due  to  a  similarity  of  the  mus- 
cular (and  therefore  nervous)  action  in  pronouncing  them,  as  the  sub- 
stitution of  I  for  p  and/  for  v  (observed  errors)  —a  proof,  if  proof  were 
needed,  that  the  written  words  are  first  energised  in  i  he  speech-centre 
Loss  of  the  power  of  understanding  seen  words,  that  is  loss  of 
the  power  of  reading — "alexia" — often,  but  not  always,  accompanies 
motor  aphasia.  This  has  been  already  mentioned,  and  it  has  been 
pointed  out  that  the  difference  probably  depends  on  the  extent  to 
which  the.patient  is  dependent  on  the  motor  processes  for  the  com- 
prehension of  the  visual  symbols.  In  some  persons  the  latter  arouse 
the  nerve-processes  for  "  ideas  "  directly,  in  others  only  by  the  ener- 
gising of  the  motor  structures.  In  the  former  case  even  disease  of 
both  temporal  and  frontal  speech-centres  may  not  destroy  the  power 
of  reading,  although,  of  course,  the  patient  cannot  read  aloud.* 

Sensory  Aphasia. — In  word-deafness,  due  always  to  disease  of  the 
first  temporal  convolution,  heard  words  are  not  understood.  This  is 
best  tested  by  letting  the  patient  perform  some  simple  action  which  is 
not  anticipated.  Word-deafness  is  seldom  absolute,  and  an  expected 
sentence,  such  as  "  Put  your  tongue  out  "  from  a  doctor,  is  understood 
when  an  unexpected  sentence  is  not.  Expectation  involves  lowering 
of  resistance  in  a  certain  nerve  combination,  and  then  perhaps  the 
right  hemisphere  may  suffice.  Word-deafness  always  causes  con- 
siderable derangement  of  speech.  This  depends  on  the  fact  that  the 
subjective  revival  of  word-processes  takes  place  chiefly  in  the  auditory 
centre.  All  the  residual  dispositions — motor,  auditory,  visual — con- 
stitute physical  memories  for  word-processes,  but  as  auditoiy  word- 
processes  are  the  first  to  be  developed  in  the  child,  so  they  continue 
the  most  important  through  life.  If  they  are  lost  the  patient  is  thrown 
on  his  motor  memory,  and  this  often  misleads. f  Hence  there  is  often 
error  in  the  words  used  and  in  their  form.  But  it  is  especially  the 
voluntary  revival  of  words  that  is  lost,  and  words  may  still  be  revived 
automatically,  just  as  it  is  voluntary  utterance  that  is  lost  in  motor 
aphasia,  and  words  may  still  be  uttered  automatically,  as  in  singing 

*  As  in  a  case  reported  by  Kahler, '  Cent.  f.  Nerv./  1885,  p.  393.  The  statement 
in  the  text  is  only  a  probable  explanation.  We  need  more  facts  as  to  the  influence 
of  definite  lesioDS  on  reading. 

f  In  educated  persons  the  visual  memory  may  aid  in  the  revival,  and  probably 
develops  with  the  demand  upon  it.  An  accomplished  man  recovered  slowly  from 
complete  word-deafness  (with  persistent  hemiplegia).  He  said  that  if  he  had  a 
difficulty  in  realising  the  meaning  of  a  word,  he  would  repeat  it  over  and  over,  and 
at  last  seemed  to  see  the  letters  of  the  word,  and  its  meaning  flashed  upon  him 
This  is  an  interesting  instance  of  the  way  in  which  one  centre  may  reinforce 
auother.  A  different  example  of  similar  help  was  presented  by  a  patient  who  could 
write,  but  could  only  understand  a  word  seen  if  he  traced  the  letters  with  his  finger 
in  the  air  (Charcot,  '  Leeons/  t.  iii,  p.  161,  1887).  The  same  case  has  been 
recorded  by  Herczel.  So,  too,  a  patient  of  Wernicke's  was  able  to  read  writing  only 
by  tracing  over  the  letters  (f  Gehirnkr.,'  i,  p.  338). 


120  BRAIN. 

a  song.  Hence  these  patients  have  often  an  extensive  use  of  words, 
especially  general  words,  which  they  utter  promptly,  and  in  an  auto- 
matic manner,  but  they  have  difficulty  in  the  deliberate  revival  of  special 
terms.  "  If  I  have  to  say  a  thing  I  must  say  it  at  once,  or  I  cannot 
say  it  at  all,"  one  patient  observed.  It  is  probable  that  the  automatic 
revival  of  words  in  disease  of  the  left  hemisphere  is  subserved  by  the 
centres  on  the  right  side.  It  is  certain  that  slow  recovery  of  the 
power  of  comprehension  of  spoken  words  is  by  the  "  re-education  "  of 
the  right  hemisphere,  since  such  regained  power  has  been  again  lost 
in  right-sided  disease.  The  readiness  with  which  such  recovery  takes 
place  seems  to  vary  much  in  different  persons,  as  is  the  case  also  in 
motor  aphasia.  In  some  there  is  no  recovery.*  As  a  rule,  however, 
recovery  occurs  more  readily  than  in  motor  loss. 

The  disorder  of  speech  in  word-deafness  varies  much  in  different 
cases.  As  a  rule,  considerable  use  of  words  remains,  but  chiefly  in 
half -automatic  spontaneous  speech.  Parts  of  speech  in  more  general 
use,  prepositions,  adjectives,  verbs,  &c,  are  readily  uttered,  but  there 
is  great  difficulty  in  more  special  words,  such  as  nouns.  The  patient 
often  employs  a  circumlocution  of  more  general  words  instead  of  the 
special  word  that  he  cannot  revive.  Instead  of  the  word  "knife  "  he 
may  say,  "  something  to  cut  with."  In  extreme  cases  there  may  be 
much  error  in  the  forms  of  words,  and  these  errors  are  often  distinctly 
due  to  the  inadequacy  of  the  motor  memory  on  which  the  patient  has  to 
rely.  Sometimes,  indeed,  there  is  as  much  formal  disorder  and  "  ataxy  " 
of  speech  as  in  motor  aphasia — one  of  the  considerations  that  militate 
against  the  use  of  this  term  as  a  designation  for  the  motor  variety. 
Iu  very  rare  cases  extensive  disease  of  the  sensory  region  has  caused 
an  almost  absolute  loss  of  expression  by  words,  greater  indeed  than 
can  be  altogether  explained,  and  such  as  to  resemble  the  loss  in  disease 
of  the  motor  region. f  The  effect  of  disease  of  both  temporal  lobes  is, 
of  course,  to  preclude  recovery,  and  great  derangement  of  speech 
results.  In  one  case  of  complete  deafness  from  cerebral  disease,  in 
which  such  a  double  lesion  probably  existed,  speech  was  almost 
unintelligible.  J 

"Word-deafness  renders  the  patient  unaware  of  his  errors — a  striking 

*  As  in  a  case  recorded  by  Rosental,  in  which  word-deafness  remained  absolute 
until  the  death  of  the  patient,  two  and  a  half  years  after  the  onset  ('Gazeta 
lekarska,'  1883,  and  Virchow's  '  Jahresb.,'  1883,  ii,  p.  85). 

f  Thus,  in  a  case  recorded  by  D'Heilly  ('Prog.  Med.,'  1883,  No.  2),  arterial 
thrombosis  in  the  course  of  phthisis  caused  softening  of  the  left  first  and  second 
temporal  convolutions  and  of  part  of  the  angular  gyrus,  without  implicating  the 
motor  speech-region;  the  patient,  during  the  nine  weeks  she  lived,  only  uttered  the 
words  ''purceque,'"'  "le  plan,"  and  "  oui,  monsieur."  She  understood  no  words,  but 
comprehended  signs  readily.  She  had  lost  the  power  of  reading  and  writing.  In  a 
case  of  Charcot's,  described  by  Trousseau,  in  which  the  lesion  involved  only  the  first 
and  second  temporal  convolutions  and  the  posterior  half  of  the  island  of  Eeil,  the 
patient  uttered  only  "  ta-ta-ta  '*'  during  eight  months. 

J  Wernicke  and  Friedlander,  '  Foitschritte  d.  Med.,'  1883. 


SYMPTOMS.  121 

difference  from  the  motor  form,  in  which  the  patient  at  once  recog- 
nises his  mistakes,  and  is  annoyed  at  them.  In  absolute  word- deaf- 
ness the  patient  is  unable  to  repeat  words  uttered  to  him,  but  in 
partial  loss  he  is  able  to  repeat,  often  with  some  formal  errors. 

The  patient  is  also  unable  to  read  in  many  cases  of  word-deafness, 
but  it  is  probable  that  this  is  the  result  of  the  auditory  loss,  or  is 
due  to  damage  to  the  visual  centre,  which  is  supplied  by  the  same 
artery  as  the  auditory  centre,  and  often  suffers  in  the  same  lesion. 
Inability  to  read,  as  an  isolated  symptom,  is  probably  always  due 
to  a  lesion  of  the  supra-marginal  and  angular  convolutions.*  It 
is  not  often  that  there  is  actual  mind-blindness,  an  inability  to 
recognise  not  only  words  but  any  object  until  some  other  sense  than 
that  of  sight  is  employed  (see  "  Affections  of  Vision  ").  In  some  cases 
the  patient  has  been  able  to  read  aloud  correctly,  but  not  to  under- 
stand what  he  read.  The  effect  on  writing  is  similar  to  the  effect  on 
speech,  but  greater,  owing  to  the  double  symbolism  and  the  extension 
of  error  thus  produced. 

We  have  seen  that  in  partial  word-deafness,  partial  from  the 
beginning  or  partial  by  recovery,  a  condition  exists  in  which  there 
is  great  difficulty  in  the  voluntary  revival  of  words,  especially  of 
the  more  special  words,  such  as  nouns.  This  is  "  verbal  amnesia," 
or  "  amnesic  aphasia."f  As  already  stated,  it  sometimes  constitutes 
the  sole  defect  from  the  beginning,  and  is  then  commonly  regarded  as 
a  distinct  variety  of  aphasia,  and  has  been  ascribed  to  interruption 
of  the  conducting  path  between  the  auditory  and  motor  centres  (see 
above,  p.  116).  Whether  the  condition  is  actually  thus  produced,  and 
whether  a  simple  interruption  of  this  path  can  produce  this  effect, 
remain  to  be  proved.  The  condition  is  often  conjoined  with  .slight 
word-deafness,  and  then  is  probably  due  to  a  partial  lesion  of  the 
auditory  word-centre.  It  may  not  only  be  a  residual  condition  left  by 
partial  recovery  from  a  considerable  degree  of  word-deafness,  but,  as 
we  have  seen  (p.  118),  it  may  be  left  by  recovery  from  complete  and 
pure  motor  aphasia.  The  fact  that  a  typical  "  amnesic  aphasia  "  may 
be  merely  a  residual  condition  left  by  a  pure  motor  aphasia  is  very 
important.  It  is  proved  by  several  recorded  cases  in  which  an  autopsy 
was  obtained  £  Another  important  fact  is  that  the  loss  follows  a 
regular  law  from  the  special  to  the  general.  These  facts  suggest  that 
the  essential  condition  for  the  production  of  this  defect  is  that  the 
speech-processes  go  on  in  structures  relatively  incompetent.  In  some 
cases  the  structures  concerned  may  be  those  of  the  right  hemisphere, 
imperfectly  re-educated.     This  form  can  only,  therefore,  be  admitted 

*  As  in  a  case  recorded  by  Henschen,  '  Neurol.  Cent.,'  1886,  p.  464. 

t  The  use  of  the  word  amnesia  in  this  restricted  sense  is  open  to  the  objection 
pointed  out  by  Hughlings  Jackson  and  Kussinaul,  that  there  is  more  than  one 
memory  for  words  (see  p.  119). 

X  One  is  recorded  by  Batty  Tuke  and  Fraser  ('  Journ.  of  Mental  Science/  April, 
1872)  ;  another  by  Sanders  ('  Edin.  Med.  Journ.,'  1866,  p.  811). 


122  BRAIN.  • 

as  a  pathological  variety  of  aphasia  with  some  reservation,  until  more 
evidence  is  obtained  regarding  the  lesion  that  causes  it  as  a  primary 
and  independent  defect. 

Inability  to  read,  alexia,  as  we  have  seen,  may  have  more  than  one 
mode  of  origin.  It  may  be  part  of  a  pure  motor  aphasia  in  those  in 
whom  visual  word-processes  can  only  arouse  mental  images  through 
the  agency  of  the  motor  speech-centre.  It  seems  strange  that  the 
motor  process  should  directly  arouse  the  nerve- processes  for  the  mental 
conception,*  but  there  is  no  evidence  that  the  auditory  processes  inter- 
vene. On  the  contrary,  the  loss  of  these  processes  does  not  necessarily 
abolish  the  power  of  reading,  as  would  certainly  be  the  case  if  the  motor 
centre  acted  on  consciousness  only  through  the  auditory  centre. t  In 
other  cases  of  motor  aphasia  the  power  of  reading  is  unimpaired, 
presumably  because  the  visual  processes  arouse  directly  those  for 
"  ideas."  Without  motor  aphasia,  loss  of  the  power  of  reading 
seems  to  be  due  only  to  disease  of  the  posterior-inferior  region  of  the 
parietal  lobe,  the  region  of  the  higher  visual  centre.  We  have  seen 
that  in  all  the  fatal  cases  of  word-deafness  in  which  the  power  of  read- 
ing was  lost,  the  disease  was  found  to  extend  into  this  region.  Hence 
we  are  justified  in  assuming  that  when  alexia  exists  as  an  isolated 
condition,  the  disease  is  in  this  part.  This  isolated  loss  of  the  power 
of  comprehending  visual  word-symbols  has  been  termed  by  Kussmaul 
"  word-blindness."  It  may  or  may  not  be  accompanied  by  "  mind- 
blindness,"  which  necessarily  involves  alexia.  (See  also  p.  116,  visual 
aphasia.)  Wo  I'd- blindness  is  indeed  partial  mind- blindness.  In  this 
condition  there  may  be  ability  to  speak  and  to  write,  but  the  patient 
writes,  as  one  of  Charcot's  patients  expressed  it,  "  as  if  with  the  eyes 
closed,"  and  this  patient  did  actually  write  as  well  when  his  eyes  were 
closed  as  when  they  were  open. %  Moreover  he  could  understand 
written  words  if  his  hand  were  made  to  trace  the  letters  in  passive 
movement.  Such  loss  of  visual  word-symbols  has  been  met  with  in 
a  few  cases  of  hemianopia ;  it  is  not  a  necessary  consequence  of 
hemianopia  even  when  this  is  of  cortical  origin,  and  probably  indi- 
cates that  the  lesion  extends  beyond  the  limits  of  the  occipital  lobe 
into  the  parietal  cortex. §     The  lesion  causing  alexia  is  always  on  the 

*  I.e.  it  may  setm  strange  that  a  centrifugal  process  should  have  au  influence 
which  seems  to  he  centripetal ;  hut  a  similar  influence  attends  other  motor  processes, 
e.g.  our  estimate  of  position  by  the  movements  of  the  ocular  inuscli  s  (see  "  Diseases 
of  the  Third  Nerves").  All  motor  pi  oeesse?  seem  to  influence  consciousness,  whether 
as  a  "  stns-ation  "  or  only  as  a  vague  conception  or  sense  of  the  effect. 

f  In  this  connection  it  is  instructive  to  note  that  even  the  motor  processes  for 
writing  may  assist  in  arousing  the  mental  images,  as  in  the  case  mentioned  in  the 
note  on  p.  119.  Wernicke  and  Kussmaul  assume  that  the  auditory  centre  inter- 
venes, and  that  the  uneducated  man,  who  can  only  read  by  the  help  of  his  motor 
centre,  "  has  to  read  aloud  to  himself"  in  order  to  understand — an  assumption 
opposed  to  facts. 

J  Charcot,  '  Lecons/  tome  iii,  p.  160. 

§  A  lesion  of  the  white  substance  involving  the  optic  radiation  may  also  involve 
the  parietal  cortex. 


SYMPTOMS.  123 

left  side  of  the  brain  in  right-handed  persons,  on  the  right  side  in 
left-handed  persons.*  The  varying  character  of  the  symptoms  due 
to  disease  of  this  part  of  the  parietal  lobe  may  be  dne  to  the  fact 
that  its  blood-supply  is  often  derived  from  two  different  ai'terial  sys- 
tems, and  the  area  supplied  by  each  seems  to  be  subject  to  considerable 
variations.  Hence  partial  disease  is  the  rule,  complete  destruction  the 
rare  exception. 

Inability  to  write,  agraphia,  as  we  have  seen,  results  from  destruc- 
tion of  the  motor  speech -centre,  and  is  then  usually  absolute,  even 
when  the  right  hand  is  not  paralysed.  Spontaneous  writing,  and 
writing  from  dictation,  are  alike  abolished,  and  hence  it  would  seem 
that  there  is  no  direct  path  from  the  auditory  word-centre  to  the  arm- 
centre,  but  that  the  word-processes  must  first  be  energised  as  for 
articulate  speech.  But  the  patient  is  able  to  copy,  usually  only  in  the 
characters  that  are  before  him ;  sometimes,  however,  by  a  translation 
of  printed  into  written  characters.  It  is  certain  that,  very  often,  the 
words  so  copied  are  not  understood.  In  word-deafness,  as  we  have 
just  seen,  the  ability  to  write  persists,  but  not  to  write  from  dicta- 
tion. In  word- blindness,  the  patient  can  write,  spontaneously  or  from 
dictation,  but  cannot  copy.  The  difficulty  in  writing,  as  before  stated, 
is  often  greater  than  in  other  forms  of  expression,  but  it  is  very 
seldom  that  it  so  far  preponderates  as  to  resemble  isolated  agraphia. 
The  possibility  of  isolated  agraphia  has  been  doubted,  and  is,  indeed, 
difficult  to  understand.  But  a  curious  case  of  partial  agraphia  has 
been  recorded  by  Pitres.f  In  a  syphilitic  man,  right  hemiplegia 
without  anaesthesia  came  on  suddenly ;  it  disappeared  under  treat- 
ment, leaving  some  rigidity,  and  there  remained  also  right  hemianopia 
with  inability  to  write.  Speech  was  never  affected.  The  patient 
could  copy  in  fac-simile,  but  could  not  write  a  single  word,  spon- 
taneously or  from  dictation,  with  his  right  hand.  Nevertheless  he 
could  write  easily  with  his  left,  and  then  copy  what  he  had  written 
with  his  right  hand.  He  could  read  either  printed  or  written  words 
with  perfect  facility.  This  strange  case  seems  to  prove  the  possibility 
of  an  isolated  partial  agraphia.  A  lesion  separating  the  left  arm- 
centre  from  the  motor  speech-centre,  leaving  the  callosal  fibres  intact, 
affords  perhaps  the  best  explanation  of  the  symptoms,  but  this  or  anv 
explanation  must  be  purely  speculative ;  and  it  may  be  added,  the 
possibility,  and  even  probability,  of  more  than  one  lesion  prevents  any 
conclusion  from  the  combination  of  symptoms. 

Persistent  aphasia,  motor  or  sensory,  may  be  produced  by  anv 
kind  of  lesion  (even  a  tumour  or  the  rare  chronic  senile  softening), 
but  it  is  due  to  acute  softening  more  frecpuently  than  to  haemor- 
rhage, on  account  of  the  greater  frequency  with  which  the  former 
lesion  involves  the  cortex ;  it  is,  however,  sometimes  due  to  haemor- 

*  In  the  case  recorded  by  Bernheim  ('Revue    de   Med.,'    1' 85,  p.   625)   of  left 
bemianopm  and  mind-b  indness  in  a  left-banded  man,  ale::ia  was  necessarily  present, 
f  '  Revue  de  Med.,'  1884,  p.  825. 


1 24  BltAIN. 

rliage,  and  transient  aphasia  is  often  caused  by  this  process  in  the 
central  ganglia. 

The  region  of  the  cortex  in  which  the  speech-centres  are  situated  is 
supplied  by  the  middle  cerebral  artery  (see  Pig.  48,  p.  64),  and  obstruc- 
tion of  this  is  the  most  frequent  cause  of  aphasia.  Motor  aphasia  is 
produced  by  the  softening  due  to  obstruction  of  the  first  branch  of  the 
artery,  sensory  aphasia  by  that  of  the  fourth  branch.  Since  the  second 
branch  supplies  the  chief  part  of  the  central  convolutions,  hemiplegia 
is  often  associated  with  motor  aphasia.  Another  occasional  association 
is  visual  loss.  The -occurrence  of  hemianopia  with  word-blindness  has 
been  already  mentioned.  Hemianopia  is  also  sometimes  associated 
with  motor  aphasia,  but  the  affection  of  sight  in  such  cases  usually 
depends  on  a  lesion  near  the  internal  capsule,  generally  a  haemor- 
rhage or  softening  extending  back  as  far  as  the  posterior  part  of  the 
capsule,  so  as  to  involve  the  fibres  of  the  optic  radiation.  Softening 
in  this  position,  e.g.  near  the  thalamus,  may  also  extend  outwards  to 
the  first  temporal  convolution,  or  forwards  and  outwards,  through  the 
lenticular  nucleus,  to  the  island  of  Eeil  and  third  frontal  convolution. 

Loss  of  speech,  occurs  in  children  from  the  same  causes  as  in  adults.* 
Some  of  these  are  exceedingly  rare  in  childhood,  while  other  causes 
are  more  common  in  early  than  in  later  life.  One  of  the  latter  is 
tubercular  disease,  which  is  a  comparatively  frequent  cause  of  aphasia 
in  children,  tubercular  meningitis,  probably  in  consequence  of  irrita- 
tive inhibition  (which  may  also  cause  motor  paralysis),  and,  less 
commonly,  tubercular  growths.  If  recovery  occurs  from  an  organic 
lesion  that  has  destroyed  the  motor  speech-centre,  the  power  of  speech 
seldom  remains  absent  for  more  than  a  few  weeks,  compensation  by 
the  right  hemisphere  occurring  with  great  readiness.  In  cases  of 
persistent  aphasia  in  children  it  will  geuerally  be  found,  on  careful 
investigation,  that  the  defect  of  speech  is  part  of  a  general  mental 
defect,  and  not  true,  pure  aphasia. 

Aphasia  may  be  due  to  functional  disturbance  of  the  brain  as  well 
as  to  organic  disease.  It  may  thus  form  part  of  various  functional 
disorders,  combined  with  other  svmptoms,  and  it  may  also  occur 
alone.  When  right- sided  convulsions  occur  from  any  cause,  but 
especially  from  organic  disease,  there  is  often  transient  inability  to 
speak,  and  this  may  continue  for  a  quarter  or  half  an  hour,  or  even 
longer,  after  the  fit.  It  is  especially  common  when  the  convulsion 
begins  in  the  face  or  tongue,  and  may  occur  when  the  spasm  is  very 
slight,  aud  even  when  there  is  no  convulsion,  but  merely  a  sensory  dis- 
charge, tingling,  <fcc.  Aphasia  is  also  met  with  as  part  of  attacks  of 
migraine,  chiefly  in  those  in  which  sensory  disturbance  occurs  in 
the  limbs  of  the  right  side.  A  patient  who  has  such  sensory  dis- 
turbance, sometimes  on  one  side,  sometimes  on  the  other,  will  have 
aphasia  when  the  disturbance  is  on  the  right  side  and  not  when  it  is 

*  Ninety  cases  of  aphasia  in  children  have  been  collected  by  Stcffen  (' Jahrb.  fur 
Kinderneilk.,'  Bd.  xxiii,  p.  127). 


SYMPTOMS.  125 

on  the  left.  As  an  isolated  symptom,  functional  aphasia  occurs 
chiefly  in  children.  It  has  been  excited  by  emotion,  by  some  peri- 
pheral irritation  in  the  intestinal  tract  or  elsewhere,  and  in  the  course 
of  acute  specific  diseases,  especially  of  typhoid  fever.  Many  examples 
of  this  have  been  recorded.  Transient  aphasia  was  due,  in  one  case, 
to  the  irritation  of  a  tapeworm.*  In  cases  of  peripheral  injury  it  is 
uncertain  whether  the  chief  influence  has  been  reflex  or  emotional. 
A  child  became  speechless  during  the  division  of  a  tendon  without 
ansesthesia,  and  continued  speechless  for  eight  days.f  Aphasia  coming 
on  during  the  course  of  typhoid  fever  has  certainly  been  sometimes 
due  to  organic  disease,  for  it  has  been  associated  with  characteristic 
symptoms  such  as  hemiplegia.  But  in  other  cases  it  has  occurred 
alone,  and  after  lasting  for  a  few  days,  or  for  one  or  two  weeks,  it 
has  passed  away  suddenly.  Such  cases  suggest  that  the  loss  was  due 
to  an  influence  of  the  blood-state  on  the  brain.  It  has  come  on  as 
early  as  the  first  week,  and,  in  one  recorded  case,  it  continued  until 
the  seventh  week.  It  occurs  chiefly  in  severe  cases,  but  does  not 
seem  to  render  the  prognosis  more  grave.  The  aphasia  has  generally 
presented  the  characters  of  the  motor  variety  ;  very  rarely  those  of 
the  sensory  foimi.J  The  variety  of  functional  disturbance  termed 
"  dyslexia"  has  been  already  described. 

Cases  that  can  be  regarded  as  congenital  aphasia  are  extremely 
rare.  In  most  instances  there  have  been  signs  of  a  bilateral  lesion 
of  the  brain,  involving  the  motor  centres  for  the  tongue  and  lips, 
movement  of  which  is  usually  distinctly  defective.  The  cause  is 
probably  meningeal  haemorrhage  during  birth,  symmetrical  and 
seated  over  the  lower  part  of  the  motor  regions. 

A  very  important  question  in  connection  with  aphasia  is  its  influ- 
ence on  testamentary  capacity.  It  must  depend,  in  any  given  case, 
on  the  ability  to  understand  perfectly  what  is  put  before  the  tes- 
tator, and  to  express  at  least  assent  and  dissent  with  certainty. 
Word-deafness  is  incompatible  with  will-making,  because  it  is 
impossible  to  know  whether  the  testator  really  understands  what  is 
said  to  him.  With  perfect  comprehension  of  spoken  words,  a  valid 
will  might  be  made  if  there  was  the  power  to  express  assent  or  dissent 
by  signs,  even  if  the  testator  was  speechless. 

The  treatment  of  aphasia,  so  far  as  it  is  possible,  is  described  in 
the  chapter  on  softening  of  the  brain. 

General  Symptoms. 

Besides  the  symptoms  that  depend  on  a  derangement  of  the  mental, 
motor,  and  sensory  functions  of  the  brain,  cerebral  disease  may  cause 

*  J.  A.  y  Tusset, '  Estud.  Clin.,'  1884,  and  'Cent.  f.  Nervenh.,'  1884,  p.  491. 
t  Demme,  '  Wien.  Med.  Blatt,'  1884,  No.  51. 

X  The  subject  of  aphasia  in  typhoid  lever  has  been  discussed  by  Kuhn,  '  Deut. 
Arch.  f.  kl.  Med.,'  xxxiv,  56,  and  by  Longuet,  'L'Union  Med.,'  1884,  No.  60. 


126  EEA1N. 

symptoms  that  are  general,  or  consist  in  disturbance  of  other  organs 
of  the  body.  These  may  be  conveniently  considered  together, 
although  they  bear  different  relations  to  the  cerebral  disease,  and  the 
relation  of  the  same  symptom  may  vary  in  different  cases. 

Temperature. — Elevation  of  temperature  is  frequent  in  cerebral  dis- 
ease, and  is  an  instance  of  the  difference  of  relation  just  mentioned. 
(1)  It  may  be  merely  associated  ;  the  two  symptoms,  the  cerebral 
disease  and  the  pyrexia,  being  the  result  of  a  common  cause.     In  ulce- 
rative endocarditis  we  may  have  elevation  of  temperature  from  the 
alteration  in  the  blood,  &c,  and  cerebral  symptoms  in  consequence  of 
embolism  in  the  arteries  of  the  brain.     In  many  cases  we  may  be  in 
doubt  to  what  extent  the  pyrexia  is  due  to  the  general  or  the  cerebral 
disease,   as,  for  instauce,  in  general  tuberculosis  with  a  tubercular 
tumour  of  the  brain  or  tubercular  meningitis ;  and  in  pyaemia  with 
secondary   abscess  of  the   brain   or  secondary  meningitis.      Recent 
obseiwations,  indeed,  make  it  probable  that  the  cause  of  the  brain 
disease,    e.  g.    meningitis  (especially  in  the  sporadic   cerebro-spinal 
form  allied  to  pneumonia  and  due  to  a  blood-state),  is  the  cause  of 
pyrexia,  formerly  ascribed  to  the  inflammation,  much  more  frequently 
and  to  a  much  greater   degree.      But   it  is   often  most  difficult  to 
determine  the  extent  to  which  this  cause  is  the  effective  one,  and  it  is 
equally  important  to  bear  in  mind  its  possible  operation.     (2)  The 
elevation  of  temperature  may   be   due  directly  to  the  pathological 
process,  which  would  have  a  similar  effect  if  it  were  in  any  other 
situation.      Meniugitis    is   an   example ;    the   attendant   pyrexia   is 
generally  the  result  of  the  inflammation.     There  are  two  importaut 
facts  to  be  remembered  regarding  this  consecutive  elevation  of  tem- 
perature.    First,  it  may  be  absent ;  the  effect  of  the  disease  of  the 
nervous  system  is  to  prevent  the  pyrexia  which  the  morbid  process 
would  otherwise  cause.     Secondly,  and  connected  with  the  last,  is  the 
fact  that  the  pulse  may  not  present  the  acceleration  that  usually 
accompauies  pyrexia,  and  may  even  be  abnormally  infrequent.     Hence 
the  absence  of  pyrexia  does  not  exclude  intra-cranial  inflammation, 
while  elevation  of  temperature  has  additional  significance  if  the  pulse 
is  not  quickened.     (3)  The  pyrexia  may  be  the  direct  result  of  the 
cerebral  lesion,  that  is  of  the  disturbed  function  of  the  nervous  system, 
not  of  the  pathological  process  by  which  that  function  is  disturbed. 
This   effect   is    produced    especially    by   lesions   of    the    pons    and 
medulla  ;*  in  these  the  temperature  may  rise  to  104°,  106°,  or  108°, 
and  with  the  hyperpyrexia  there  is  usually  an  abundant  secretion  of 
sweat.     In  some  severe  cases  of  hemorrhage  into  other  parts  of  the 
brain  there  is  also  an  initial  and  considerable  rise  of  temperature,  to 
103°  and  104°  (Bourneville).     Such  cases  are  usually  rapidly  fatal. 

*  Experiments  on  animals  (Oit,  •  Journ.  New.  and  Ment.  Diseases,'  18S7,  p.  152; 
Hale  White,  '  Brit.  Med.  Journ./  1S89,  i,  1401)  show  that  lesions  in  the  region  of 
the  corpus  striatum  cause  a  great  rise  of  temperature,  and  that  there  are  piobably 
controlling  centres  in  the  cortex. 


SYMPTOMS.  127 

Iu  some  cases  of  meningitis  the  temperature  becomes  very  high  just 
before  death,  apparently  from  a  similar  mechanism.  The  pyrexia 
that  accompanies  the  peculiar  apoplectiform  attacks  in  general 
paralysis  of  the  insane  is  probably  of  this  nature,  since  it  is  too  brief, 
in  proportion  to  its  degree,  to  be  ascribed  to  the  pathological  process 
causing  the  attack.  Perhaps  the  brief  fever  that  may  attend  the 
migrainous  headaches  of  children  is  due  to  a  similar  mechanism.  (4) 
The  temperature  may  be  raised  as  a  secondary  effect  of  the  disturb- 
ance of  cerebral  function.  When  severe  convulsions  are  frequently 
repeated,  whatever  be  their  cause,  the  temperature  rises,  apparently 
in  consequence  of  the  muscular  exertion. 

Depression  of  temperature  is  less  common,  and  is  met  with  chiefly 
at  the  onset  of  cerebral  haemorrhage.  It  is  then  accompanied  by 
other  signs  of  severe  shock.  When  there  is  a  large  hemorrhage,  or 
when  several  haemorrhages  occur  in  quick  succession,  this  fall  may 
progress  until  death  occurs,  and  the  rectal  temperature  may  fall  to 
90°.  A  moderate  depression  is  sometimes  observed  at  the  onset,  or 
in  the  course,  of  meningitis. 

These  effects  may  be  variously  combined,  and  the  temperature  in 
cerebral  disease  may  consequently  present  very  irregular  and  mys- 
terious variations,  now  high  and  now  low,  without  any  corresponding 
variation  in  other  symptoms. 

Vaso-mntor  and  trophic  disturbance  occurs  most  frequently  in  cases 
of  hemiplegia,  iu  the  account  of  which  it  has  been  already  described. 
It  is  also  met  with  in  meningitis  and  some  other  diseases,  and  may 
even  be  so  pronounced  as  to  be  of  diagnostic  importance  in  chronic 
or  subacute  cases,  the  symptoms  of  which  are  otherwise  equivocal. 

The  pulse  may  be  increased  in  frequency  when  there  is  febrile  dis- 
turbance, whether  this  is  a  consequence  of  the  brain  disease  or  merely 
associated  with  it ;  but,  as  we  have  seen,  the  acceleration  that  usually 
attends  inflammatory  pyrexia  may  be  absent,  and  the  pulse  may  even 
be  less  frequent  than  normal,  although  there  is  intra- cranial  inflam- 
mation. As  a  direct  effect  of  the  brain  disease  on  the  cardiac  centre 
of  the  vagus,  the  action  of  the  heart  may  also  be  accelerated,  retarded, 
or  rendered  irregular.  This  influence  is  exerted  most  frequently 
when  the  disease  is  near  the  medulla  oblongata,  but  sometimes  when 
it  is  distant.  When  intra-cranial  disease  raises  the  temperature  to  an 
extreme  degree  the  pulse  often  becomes  very  frequent  and  soft. 
Irregularity  is  sometimes  an  early  indication  of  meningitis,  especially 
in  children.  Eetardation  to  fifty,  forty,  or  thirty  beats  per  minute 
may  occur  in  -meningitis  and  apoplexy,  and  sometimes  in  cases  of 
tumour,  abscess,  and  of  increased  intra-cranial  pressure,  and  also 
in  some  rare  and  mysterious  functional  affections.  It  may  also 
be  retarded  in  some  toxic  blood-states,  as  during  influenza.      The 


128  BE  AIM". 

retardation  is  probably  due  to  over-action  of  the  centre  that  normally 
restrains  the  heart's  action. 

Respiration  also  is  occasionally  disturbed,  When  the  cerebral  func- 
tions are  lowered,  as  in  stupor  or  coma,  the  respirations  are  lessened 
in  frequency  and  iucreased  in  depth.  In  meningitis  and  apoplexy 
(especially  in  cerebral  haemorrhage)  the  peculiar  "  Cheyne-Stokes 
breathing  "  sometimes  occurs,  and  is  usually  the  precursor  of  death. 
The  respirations  present  a  cycle  of  increasing  and  decreasing  depth  ; 
the  fall  goes  on  to  actual  cessatiou  of  breathing,  and  after  a  pause 
slight  respiratory  movements  recommence,  at  first  scarcely  perceptible, 
gradually  increasing  in  intensity,  until  deep  dyspnceal  breathing  marks 
the  acme,  and  the  respirations  again  lessen.  During  the  pause  the 
pupils  often  contract,  and  the  heart's  action  becomes  less  frequent. 
The  period  of  arrest  lasts  from  five  to  forty  seconds,  and  the  duration 
of  each  cycle  may  be  from  fifteen  to  seventy-five  seconds,  and  may  vary 
from  day  to  day.  The  number  of  respirations  in  each  cycle  never 
exceeds  thirty.  This  peculiar  phenomenon  is  met  with  in  other  dis- 
eases besides  those  of  the  brain.  It  occurs  in  heart  disease  (in  con- 
nection with  which  it  was  first  studied)  and  in  uraemia,  and  has  also 
been  observed  (chiefly  in  children)  in  rare  cases  of  typhoid  fever, 
scarlet  fever,  diphtheria,  influenza,  pneumonia,  whooping-cough  with 
inanition,  and  opium  poisoning.  In  general  maladies  it  is  a  less  grave 
sign  than  in  disease  of  the  brain,  and  several  cases  of  recovery  are  on 
record.  In  brain  disease  the  patient  is  almost  always  comatose,  but 
in  other  cases  consciousness  has  been  retained,  and  the  symptom  has 
been  known  to  continue  for  as  long  as  three  months.* 

A  form  of  respiration  which  must  be  distinguished  from  that  just 
described  consists  of  periods  of  deep  and  energetic  breathing,  which 
begin  suddenly;  the  respirations  gradually  lessen  in  depth  until  they 
cease,  and  after  a  period  of  stillness  energetically  recommence.  The 
sudden  commencement  is  the  distinction  of  this  form.  In  another 
variety,  seen  by  Biotf  iu  meningitis,  the  periods  of  deep  breathing  not 
only  commence  suddenly  but  end  suddenly. 

Many  attempts  have  been  made  to  explain  the  Cheyne-Stokes 
breathing,  none  of  which  are  quite  satisfactory.  WalsheJ  first  sug- 
gested that  it  is  due  to  lessened  excitability  of  the  respiratory  centre, 
a  theory  afterwards  stated,  in  more  definite  form,  by  Traube§  and  bv 
Eosenbach.||     It  is  difficult  to  understand  how  the  gradual  character 

*  West,  '  Trans.  Clin.  Soc.,'  1890.  In  a  correspondence  which  ensued  in  conse- 
quence of  the  publication  of  this  case,  a  remarkable  instance  was  mentioned  ('  Lancet,' 
1S90,  i,  776)  in  which  the  phenomenon  had  persisted  during  several  years. 

f  '  Sur  la  Resp.  de  Cheyne-Stokes,5  Paris,  1878. 

X  '  Diseases  of  the  Heart,'  3rd  ed.,  1S62,  p.  345. 

§  Fraeutzel,  Report  of  Clinique,  *  Berl.  kl.  Wochenschr.,'  No.  27,  1869. 

||  '  Zeitscbrift  f.  klin.  Med.,'  Bd.  i,  Heft  3.  Rosenbach's  theory  is  often  spoken 
of  as  distinguishable  from  Traube's,  from  which  it  differs,  however,  only  by 
ascsibing  the  lessened  excitability  to  altered  "  interchange  of  material  in  the  cells." 


SYMPTOMS.  129 

of  both  tiie  onset  and  the  decline  of  the  breathing  can  be  due  to 
simple  lowered  excitability,  although,  since  rhythmical  action  seems  a 
character  of  the  centre  itself,*  it  is  just  conceivable  that  the  larger 
rhythm  with  gradual  change  may  be  due  solely  to  the  functional 
characteristics  of  the  centre,  working  under  altered  conditions.  The 
chief  attempt  to  give  a  more  complete  explanation  has  been  made  by 
Filehne,f  who  found  that  the  breathing  could  be  produced  in  animals 
under  the  influence  of  morphia  by  making  them  inhale  ether  or  chloro- 
form. He  observed,  during  the  pause,  an  increase  of  blood-pressure 
with  some  pallor  of  the  mucous,  membranes,  and  ascribed  these  to 
arterial  spasm,  due  to  stimulation  of  the  vaso-motor  centres  by  the 
asphyxial  blood.  He  assumed  that  a  lowered  irritability  of  the  re- 
spiratory centre  renders  it  less  excitable  than  the  vaso-motor  eeutre, 
that  the  consequent  arterial  spasin  in  the  arteries  of  the  medulla  pro- 
longs the  stimulation  of  the  respiratory  centre  (and  also  that  of  the 
vaso-motor  centre)  by  hindering  the  access  of  the  oxygenated  blood. 
Thus  the  respiratory  movements  continue  energetic  after  the  blood 
has  become  well  oxygenated.  In  support  of  this  vascular  theory  he 
adduced  two  other  facts.  He  was  able  to  produce  perfect  Cheyne- 
Stokes  breathing  (even  to  the  changes  in  the  pupils)  by  gradually 
constricting  and  then  releasing  the  arteries  conveying  blood  to  the 
head ;  and  secondly,  he  found  that,  in  a  patient  with  this  breathing, 
nitrite  of  amyl,  which  dilates  the  vessels,  arrested  the  phenomena. 
Filehne's  theory  has  been  criticised  adversely,  and  some  of  his  facts 
have  even  been  called  in  question,  but  chiefly  by  those  who  have 
vested  interests  in  other  hypotheses.  On  the  whole,  it  may  be  said 
that,  unless  the  simple  rhythmical  tendency  of  the  depressed  centre  is 
adequate  to  produce  the  phenomena,  they  can  be  best  explained  by 
the  assumption  that  this  rhythmical  tendency  is  modified  by  some 
other  periodical  influence,  of  which  vaso-motor  spasm  is  the  only  one 
which,  according  to  our  present  knowledge,  can  be  conceived  as  acting 
and  adequate.  J  The  gradual  onset  of  the  respirations  may  be  due  to 
the  fact  that  the  vaso-motor  dilatation  exceeds  the  normal  (as  it  often 
does  after  contraction),  and  thus  the  quantity  of  blood  reaching  the 
respiratory  centre  lessens  the  stimulating  influence  of  its  quality. 

Respiration  is  arrested  at  once  by  a  sudden  lesion  in  the  respiratory 
centre  of  the  medulla,  and  more  slowly  by  disease  that  gradually  im- 
pairs the  action  of  the  centre,  such  as  the  effusion  of  blood  into  the 
fourth  ventricle.  Indeed,  the  extensive  connection  of  this  centre  with 
the  brain,  seen,  for  instance,  in  the  readiness  with  which  its  action  is 
altered  by  emotion,  makes  it  sensitive  to  any  considerable  depression 
of  the  cerebral  functions,  and  in  many  brain  diseases  death  is  thus 

*  See  '  Foster's  Physiology,'  5th  ed.,  pt.  ii,  p.  596. 

t  *  Berl.  kl.  Wochenschrif  t,'  1874,  Nos.  13,  14,  32,  and  35. 

%  The  superficial  analogy  of  the  phenomena  to  the  eft'ects  of  "interference"  in 
the  action  of  two  series  of  rhythmical  events,  as  the  waves  of  sound,  can  scarcely 
fail  to  occur  to  an  observer,  but  of  course  no  direct  inference  can  be  drawn  from  it. 
VOL.  II.  9 


130  BRAIN. 

brought  about.  Lesions  near  the  centre  may  cause  other  disturbances 
of  breathing  than  those  described,  such  as  simple  irregularity,  or 
paroxysmal  cough,  which  may  be  semi-convulsive  in  character.  On 
account  of  the  gravity  of  lesions  in  this  part,  such  disturbance  of 
breathing  is  generally  a  fatal  omen. 

In  all  conditions  in  which  the  cerebral  functions  are  profoundly 
depressed,  such  as  coma,  secretion  accumulates  in  the  air  passages  ; 
bronchial  and  tracheal  rales  are  thus  produced,  and  are  often  erro- 
neously regarded  as  the  indication  of  bronchitis.  The  accumulation  is 
due  chiefly  to  the  depression  of  the  respiratory  centre,  in  consequence 
of  which  the  secretion  is  not  removed  as  in  health,  and  its  amount 
is  perhaps  increased  by  passive  congestion.  Such  congestion  of  the 
lungs  is  very  common  in  these  cases,  and  is  a  frequent  cause  of  death. 

Digestive  Organs. — Anorexia  is  common  in  febrile  states,  and  in 
various  organic  diseases,  acute  or  chronic,  but  no  special  significance 
can  be  attached  to  it.  It  is  said  that  bulimia  is  sometimes  met  with, 
but  it  very  rarely  occurs  as  a  symptom  of  organic  lesions,  although  met 
with  in  hysteria  and  epilepsy. 

Vomiting,  however,  is  one  of  the  most  frequent  and  most  important 
symptoms  of  intra-cranial  disease.  It  is  frequent  in  meningitis, 
tumour,  abscess,  at  the  onset  of  hemorrhage,  in  cases  of  increased 
intra-cranial  pressure,  in  various  toxsemic  states  acting  on  the  medulla, 
and  also  in  the  functional  disturbance  of  hysteria.  It  may  result  from 
disease  in  any  part  of  the  brain,  but  is  especially  common  when  the 
cerebellum  is  affected.  This  symptom  often  occurs  early,  and  may  be 
produced  by  disease  of  very  limited  extent.  The  immediate  cause  of 
vomiting  is  doubtless  an  increased  irritability  of  the  gastric  part  of  the 
vagus  centre,  and  its  occurrence  in  disease  in  various  parts  of  the  brain 
is  another  indication  of  the  wide  extent  of  the  central  relations  of  the 
vagus.  It  cannot  be  ascribed  in  all  cases  either  to  irritation  of  the 
membranes  or  to  increased  intra-cranial  pressure,  although  these  con- 
ditions are  certainly  capable  of  producing  it. 

In  cerebral  vomiting,  food  is  generally  rejected  soon  after  it  has 
been  taken ;  there  are  no  local  gastric  symptoms  ;  no  discomfort  or 
pain  is  produced  by  the  presence  of  food  in  the  stomach,  a  symptom 
which  almost  always  attends  the  quick  rejection  of  food  from  gastric 
disease.  Cerebral  vomiting  may  be,  and  often  is  unattended  by  nausea, 
but  this  is  not  an  invariable  characteristic.  In  some  cases  nausea 
is  distressing.  Occasionally  the  patient  vomits  when  there  is  no  food 
in  the  stomacb,  but  this  is  not  common.  The  disease  increases  the 
irritability  of  the  centre,  but  stimulation  of  the  peripheral  nerves  by 
food  is  usually  necessary  to  excite  the  act.  The  cerebral  conditions 
that  cause  vomiting  usually  also  cause  headache,  and  the  co-existence 
of  persistent  pain  in  the  head  with  frequent  vomiting  should  always 
raise  a  suspicion  of  cerebral  disease.  Optic  neuritis  is  also  a  common 
result   of    the    same   cerebral   condition,    and  the  eves   should   be 


SYMPTOMS.  131 

examined,  in  every  suspicions  case.  For  a  long  time  there  may  be  no 
other  symptoms.  It  is  most  important,  however,  to  note  that  in  the 
early  stage  of  disease,  when  the  excitability  of  the  centre  is  but  little 
augmented,  some  exciting  cause  may  produce  the  first  vomiting,  and 
the  cause  may  seem  adequate  to  account  for  it.  Before  the  increased 
irritability  of  the  centre  reaches  such  a  degree  as  to  cause  spontaneous 
vomiting  it  may  be  sufficient  to  lead  to  the  rejection  of  an  injudicious 
meal.  Such  explicable  vomiting  is  often  the  first  sign  of  intra- cranial 
disease,  especially  in  children.  The  first  symptom  of  a  glioma  of 
the  p>ons  was  vomiting  after  swallowing  a  piece  of  slate  pencil 
Patients  who  vomit  without  other  indications  of  gastro-intestinal  dis- 
turbance should  be  carefully  watched.      (See  "  Tumour.") 

Constipation  frequently  attends  intra-cranial  disease,  such  as  tumour, 
meningitis,  &c,  although  it  rarely  exists  until  other  symptoms  are 
apparent. 

Urinary  Organs. — The  ui'ine  is  seldom  altered  in  composition  by 
organic  brain  disease,  although  polyuria  rarely,  and  glycosuria  occa- 
sionally, have  been  produced  by  disease  of  the  pons  or  medulla 
oblongata.  Albuminuria  occasionally  occurs  from  the  same  cause, 
and  may  be  a  transient  effect  of  lesions  elsewhere  in  the  brain,  or  of 
meningitis.  But  albuminuria,  it  must  be  remembered,  is  a  frequent 
concomitant  of  vascular  lesions  in  the  brain,  because  kidney  disease 
is  one  of  the  most  potent  causes  of  vascular  degeneration.  The 
amount  of  albumen  excreted  in  these  cases  is  often  greatly  increased 
for  a  few  days  by  a  cerebral  lesion. 

Retention  of  urine  and  overflow  incontinence  are  common  in  con- 
ditions of  lowered  cerebral  function,  from  whatever  cause;  but  there 
is  not  the  paralytic  incontinence  that  is  met  with  in  spinal  disease 
(see  vol.  i,  p.  225).  Urine  and  fseces  are  often  passed  into  the  bed, 
&c,  in  cases  of  mental  impairment,  without  any  actual  loss  of  power 
over  the  sphincters,  and,  as  already  stated,  this  symptom  is  always 
indicative  of  a  considerable  degree  of  mental  change. 

Ophthalmoscopic  Symptoms. 

Morbid  appearances  in  the  fundus  oculi  are  frequent  in  cases  of 
organic  brain  disease,  and  are  of  great  practical  importance.  Some  of 
these  are  associated,  the  result  of  the  cause  of  the  cerebral  lesion ; 
others  are  consecutive,  and  are  the  effect  of  the  brain  disease.  The 
two  kinds  are  sometimes  conjoined. 

1.  The  associated  changes  are  due  to  the  constitutional  condition, 
that  is,  to  the  ultimate  cause  of  the  brain  disease,  and  are  sometimes 
of  the  same  nature  as  the  cerebral  lesion.  The  following  are  the  most 
important: — (1)  Albuminuric  retinitis,  acute  and  chronic;  it  is  asso- 
ciated chiefly  with  arterial  degeneration,  causing  either  cerebral 
haemorrhage  or  softening  from  thrombosis.  (2)  Syphilitic  disease, 
usually  choroiditis,  or  the   atrophy  that   such  intiainmation    leaves. 


132  BRAIN. 

This  is  often  to  be  seen  in  cases  of  brain  disease  due  to  either 
inherited  or  acquired  syphilis.  (3)  Tubercular  disease.  Tubercles 
of  the  choroid  are  sometimes  met  with  in  cases  of  tubercular  menin- 
gitis. Very  rarely  massive  tubercle  forms  within  the  eye,  in  cases  of 
tubercular  growths  in  the  brain.  Other  forms  of  associated  growth 
are  so  rare  as  not  to  be  of  practical  importance.  (4)  Vascular  lesions 
in  the  retina  sometimes  coincide  with  similar  lesions  in  the  brain. 
Thus  embolism  of  the  central  artery  may  occur  in  the  same  patient, 
and  even  at  the  same  time,*  as  embolism  of  a  cerebral  artery.  Miliary 
aneurisms  on  the  retinal  arteries  have  been  observed  to  coincide  with 
cerebral  haemorrhage,  probably  due  to  similar  aneurisms  in  the  brain. 
They  are,  however,  extremely  rare.f  Haemorrhages  in  the  retina  are 
more  common,  and  are  of  some  significance.  They  occur  especially  in 
albuminuria,  in  gout  that  has  profoundly  affected  the  system,  in  leu- 
cocythaemia,  profound  anaemia,  purpura,  and  also  in  ulcerative  endo- 
carditis, and  other  forms  of  septicaemia.  In  the  latter  they  often  have 
white  spots  in  the  centre,  and  are  the  result  of  capillary  serjtic  embolism. 
Haemorrhages,  identical  in  aspect,  are  sometimes  found  in  the  same 
cases  in  the  pia  mater.  Another  associated  lesion  (to  which  we  shall 
return)  is  simple  atrophy  of  the  disc,  which  sometimes  coincides  with 
degenerative  lesions  of  the  brain. 

2.  The  consecutive  changes,  which  are  not  merely  associated  with  the 
cerebral  disease,  but  are  its  consequence,  comprehend  neuritis  and 
atrophy. 

Neuritis  or  "  papillitis,"  inflammation  of  theintra-ocular  end  of  the 
optic  nerve,  is  manifested  by  swelling  and  increased  vascularity  of  the 
"  optic  papilla."  It  will  be  remembered  that  the  end  of  the  nerve  is 
visible  in  the  fundus  as  the  "  optic  disc,"  the  boundary  of  which  is  the 
oval  opening  in  the  sclerotic  with  the  corresponding  openiug  in  the 
choroid.  The  fibres  radiate  from  the  nerve  on  to  the  retina,  but  not 
equally  on  all  sides,  being  few  on  the  temporal  side.  The  nerve-elements 
are  so  translucent  that  they  do  not  obscure  the  edge  of  the  disc,  except 
sometimes,  to  a  slight  extent,  above  and  below,  where  they  are  more 
numerous.  The  disc  is  rarely  uniform  in  its  surface,  because  the 
separation  of  the  nerve-fibres  leaves  a  central  hollow,  in  which  there 
are  few  or  no  vessels,  and  which  is  therefore  pale,  while  the  periphery 
of  the  disc  has  a  rosy  tint  from  the  minute  vessels  that  lie  among  the 
nerve-fibres  (Fig.  69).  This  central  "  physiological  cup  "  varies  much 
in  size,  and  may  be  absent.  The  vascular  portion  of  the  disc  also 
varies  in  extent  (inversely  as  the  cup),  and  varies  so  much  intinttbat 
no  inference  can  be  drawn  from  its  colour  unless  this  is  observed  to 
change  in  the  course  of  time.  Mere  congestion,  therefore,  consisting 
only  of  increased  vascularity  of  the  disc,  is  very  difficult  to  recognise,. 
and  although  it  probably  occurs,  it  is  rare,  as  an  isolated  condition, 

*  See  '  Med.  Ophthalmoscopy,'  Case  47  (p.  332,  2nd  ed.). 

f  For  an  instance,  see  *  Medical  Ophthalmoscopy,'  pi.  xii,  fig.  1,  and  Case  42 
(2nd  ed.,  p.  326). 


SYWi'TOMS. 


133 


and  is  of  small  practical  importance.  An  actual  pathological  change, 
however  slight  in  degree,  is  usually  attended  by  some  swelling  of  the 
papilla,  and  especially  by  lessened  transparency  of  its  structures.  The 
effect  of  this  change  is  first  to  lessen  the  sharpness  of  the  edge  of  the 
disc,  and  then  to  obscure  the  edge  altogether  (Fig.  69).  It  is  to  this 
point,  therefore,  that  attention  must  be  chiefly  directed.  The  effect  of 
a  morbid  change  on  the  distinctness  of  the  edge  is  greater  when  the 
disc  is  examined  by  the  direct  than  by  the  indirect  method ;  on  the 
other  hand,  if  the  indistinctness  is  apparent  and  not  real — is  due  to 
the  tint  of  the  disc  being  nearly  that  of  the  choroid,  and  not  to  lessened 
transparency  of  the  structures  in  front  of  it — the  edge  appears  more 
distinct  in  the  direct  than  in  the  indirect  method  of  examination. 
This  is  a  very  important  practical  point.  In  the  early  stage  of 
neuritis  the  edge  of  the  disc,  seen  by  the  indirect  method,  may 
appear  a  little  blurred,  and  surrounded  by  a  pale  halo,  while 
by  the  direct  method  the  halo  is  resolved  into  a  striated  semi- 
opaque  layer  completely  concealing  the  edge.  The  early  change 
is  greatest  on  the  nasal  side,  which  may  be  obscured  when  the 
temporal  edge  of  the  disc,  on  which  there  are  few  nerve-fibres,  is  still 
sharp.  As  the  change  advances,  it  involves  the  whole  circumference 
of  the  disc,  and  the  swelling  rapidly  encroaches  on  the  physiological 
•cup,  which  is  ultimately  obliterated  (Fig.  69),  although  a  slight 
dej>ression  usually  remains  in  the  middle  of  the  swollen  papilla.  The 
prominence  of  the  swelling  is   readily  recognised  by  the  apparent 


Fio.  69. — Commencing  optic  neuritis,  from  a  case  of  caries  of  the  sphenoid 
bone  with  secondary  meningitis.  The  left  figure  shows  the  normal  right 
optic  disc,  with  clear  outline,  and  a  deep  central  cup.  The  right  figure.,  of 
the  left  papilla,  shows  well-marked  neuritis ;  the  edge  of  the  disc  is  con- 
cealed by  a  swelling  which  extends  beyond  the  normal  limits  of  the  disc. 
The  central  cup  is  encroached  on,  but  not  yet  quite  obliterated ;  before  the 
neuritis  commenced  the  cup  was  similar  to  that  in  the  other  eye.  Some 
of  the  vessels  are  partly  concealed  at  their  emergence,  and  the  veins  lose 
their  central  reflection  as  they  curve  down  the  sides  of  the  swelling. 


134 


BRAIN. 


change  in  relative  position  of  the  structures  that  are  on  different  levels 
when  the  observer  moves  his  head  from  side  to  side  or  up  and  down 
in  the  direct  examination,  or  moves  the  lens  in  a  like  manner  in  the 
indirect  examination.  The  prominence  is  also  shown  by  the  loss  of  the 
central  reflection  of  the  vessels  where  they  course  down  the  sides 
of  the  swelling,  and  their  plane  ceases  to  be  at  right  angles  to  the  line 
of  the  observer's  vision.  The  tint  of  the  swollen  papilla  becomes  a 
full  red,  or,  more  commonly,  a  greyish  red,  to  the  indirect  examina- 
tion, but  the  direct  method  shows  a  fine  striated  vascularity.  As  the 
prominence  increases,  the  swelling  becomes  wider  in  extent,  until  it 
may  be  two  or  three  times  the  diameter  of  the  normal  disc.  White 
spots  may  appear  on  its  surface  (Fig.  70),  due  to  the  accumulation  of 
products  of  degeneration.  At  first  the  retinal  vessels  present  little 
change  in  size,  but  as  the  swelling  increases,  the  compression  causes 
the  veins  to  become  broader  and  the  arteries  narrow,  and  extravasa- 
tions of  blood  may  be  visible  on  the  surface  or  margins  of  the  swolh  n 


Fl&.  70. —  Optic  neuritis  in  cerebral  tumour.  The  swelling  is  great,  and 
occupies  an  area  at  least  twice  the  diameter  of  the  normal  disc.  The 
arteriee  are  concealed  in  the  substance  of  the  new  tissue,  and  the  veins  are 
tortuous,  and  lose  their  reflection  as  they  pass  down  the  side  of  the  swell- 
ing. The  products  of  degeneration  of  the  nerve-fibres  have  caused  white 
6pots  near  the  margin  of  the  inflamed  papilla. 


SYMPTOMS.  135 

area.  The  process  varies  much  in  the  rapidity  with  which  it  is 
developed  ;  it  may  reach  a  considerable  intensity  in  a  fortnight,  or  be 
still  moderate  in  degree  at  the  end  of  three  or  four  months.  As  a 
rule,  the  more  quickly  it  is  developed  the  more  inteuse  does  it  become. 
Commenciug  subsidence  is  indicated  by  a  diminution  in  the  vascularity, 
still  greater  contraction  of  the  arteries,  and  later,  contraction  of  the 
veins  also.  If  the  degree  of  neuritis  has  been  considerable,  the  swell- 
ing remains,  for  some  time,  pale  and  soft-edged,  and  slowly  sinks  until 
the  edges  of  the  disc  appear.  For  a  long  time  the  substance  of  the 
disc  is  occupied  by  new  tissue,  which,  with  the  narrowed  arteries, 
affords  evidence  of  the  preceding  inflammation.  Other  indications  of 
this  are  often  to  be  seen  in  damage  to  the  adjacent  edge  of  the  choroid. 
Only  when  the  neuritis  has  been  moderate  in  degree  does  the  disc 
resume  a  perfectly  normal  aspect.  When  much  new  tissue  has  been 
formed,  this,  by  its  cicatricial  changes,  leaves  the  disc  white  and 
atrophied,  in  the  condition  of  "consecutive  atrophy,"  or  "neuritic 
(papillitic)  atrophy,"  as  it  is  also  termed.  When  the  papillitis  has 
been  very  intense,  and  the  swelling  wide  in  area,  the  adjacent  retina 
may  suffer  in  its  nutrition,  and  products  of  degeneration  may  remain 
as  white  spots,  especially  near  the  macula  lutea,  simulating  the  aspect 
of  albuminuric  retinitis. 

The  substance  of  the  swollen  papilla  presents,  under  the  microscope, 
distended  vessels,  numerous  capillaries  and  nuclei,  with  accumulations 
of  leucocytes  in  the  tissue  and  perivascular  sheaths.  In  the  early  stage, 
the  nerve-fibres  and  connective-tissue  elements  may  be  separated  by 
cedematous  effusion.  Subsequently  the  nerve-fibres  present  degene- 
rative changes,  moniliform  enlargements  containing  myelin  globules, 
and  aggregations  of  the  products  of  degeneration  into  "granule- 
corpuscles,"  while  the  walls  of  the  arteries  may  be  conspicuously 
thickened.  Similar,  although  slighter,  changes  maybe  traced  back  iu 
the  substance  of  the  optic  nerves,  or  in  their  sheaths,  to  the  chiasma, 
and  they  may  be  even  more  intense  in  front  of  the  chiasma  than  they 
are  midway  between  this  and  the  eye.  The  outer  sheath  of  the  optic 
nerve  is  often  distended  by  liquid,  so  as  to  form  a  pyriform  swelling 
behind  the  globe.  The  space  within  this  sheath  is  continuous, 
behind,  with- the  subarachnoid  space  around  the  brain,  and  in  front, 
with  the  lymphatic  spaces  in  the  optic  papilla. 

A  slight  and  even  considerable  degree  of  optic  neuritis  may  cause 
no  symptoms.  Acuity  of  vision  may  be  unimpaired,  colour  vision 
normal,  the  visual  fields  unrestricted.  But  when  intense,  sight  suffers 
in  each  of  these  characters,  and  may  be  entirely  lost.  The  damage  to 
vision  is  often  greater  during  the  stage  of  subsideni  e  than  it  is  during 
the  active  period  of  inflammation,  probably  because  the  nerve-elements 
suffer  from  the  cicatricial  contraction  of  the  tissue- elements  formed 
during  the  inflammation.  But  the  affection  of  sight  is  not  necessarily 
due  to  the  visible  papillitis  ;  it  may  be  the  result  of  more  intense 
inflammation    behind    the    eye,   or   the   effect   of    the    intra-crauial 


136  BRAIN. 

disease.  To  decide  this,  the  degree  of  neuritis  and  the  degree  of 
affection  of  vision  must  be  compared,  and  the  character  of  the 
failure  of  sight  must  be  considered.  The  latter  is  described  in  the 
chapter  on  affections  of  the  optic  nerve.  After  the  neuritis  has  quite 
subsided  some  improvement  in  sight  often  takes  place,  from  the 
recovery  of  some  of  the  damaged  fibres.  But  there  may  remain  con- 
siderable amblyopia,  and  even  absolute  blindness,  and  often  very 
irregular  changes  in  the  fields  of  vision,  both  for  white  and  coloured 
light. 

Optic  neuritis  may  result  from  many  diseases  of  the  brain,  but 
its  most  frequent  cause  is  tumour,  and  a  considerable  degree  of 
neuritis  is  rarely  due  to  any  other  cause.  Next  in  frequency  is 
meningitis,  especially  affecting  the  base  of  the  brain,  but  the  papillitis 
cansed  by  meningitis  is  usually  less  intense  than  that  of  tumour, 
perhaps  on  account  of  the  briefer  duration  of  the  disease.  Cerebral 
abscess  is  another  cause.  Optic  neuritis  scarcely  ever  results  from 
cerebral  haemorrhage  or  from  thrombotic  softening,  but  it  has  been 
several  times  observed  in  cases  of  softening  from  embolism  when  the 
source  of  the  obstructing  plug  was  acute  endocarditis,  perhaps  because 
the  material  carried  from  the  valves  is  of  an  irritant  septic  character, 
aud  determines  a  greater  degree  of  secondary  inflammation  in  the 
softening  pi-oduced.  It  has  also  been  met  with  in  a  case  in  which 
no  naked-eye  lesion  of  the  brain  existed,  but  in  which  the  microscope 
revealed  general  slight  inflammatory  changes — diffuse  cerebritis.  In 
all  these  diseases  the  neuritis  is,  as  a  rule,  double,  although  it  may 
develop  more  rapidly  in  one  eye  than  in  the  other.  Occasionally 
it  is  one-sided,  and  then  it  is  generally  on  the  side  opposite  the 
lesion.  Unilateral  optic  neuritis  is  much  more  frequently  due  to 
various  diseases  at  the  back  of  the  orbit,  or  at  the  optic  foramen, 
than  to  disease  of  the  brain  itself. 

It  must  be  remembered,  however,  that  optic  neuritis  may  result 
from  other  causes  than  intra-cranial  disease.  It  is  very  seldom 
primary ;  but  it  occm*s  in  chlorosis,  albuminuria,  lead-poisoning, 
anaemia,  and  after  certain  acute  fevers,  especially  scarlet  fever  and 
typhoid ;  in  many  of  these  conditions  its  occurrence  is  associated 
with  some  cerebral  symptoms.  When  neuritis  preponderates  over 
the  other  changes  in  albuminuria,  for  instance,  there  is  usually  much 
pain  in  the  head,  and  in  lead-poisoning  it  is  usually  associated  with 
the  acute  cerebral  symptoms  which  have  been  called  "  encephalo- 
pathia  saturnina."  This  fact  sometimes  increases  the  difficulty  in 
diagnosis. 

The  mechanism  by  which  optic  neuritis  is  produced  is  a  subject  on 
which  various  opinions  have  been  held.*  It  is  sufficient  here  to  say 
that  the  early  theory  that  neuritis  is  clue  to  increased  intra-cranial  pres- 
sure, acting  mechanically,  has  proved  erroneous.  I  have  known  slow 
increaseof  intra-cranial  pressure  to  separate  the  sutures  without  causing 

*  A  full  account  of  these  will  he  found  in  '  Medical  Ophthalmoscopy,'  3rd  ed. 


SYMPTOMS.  137 

papillitis.  In  a  large  number  of  cases  there  is  distinct  evidence  of  a 
descending  inflammation,  either  along  the  trunk  of  the  optic  nerve  or 
along  its  sheath,  and  in  cases  of  meningitis  such  descending  inflamma- 
tion is  invariable.  The  distension  of  the  optic  sheath  is  not  essential 
for  the  production  of  neuritis  ;  it  is  sometimes  absent,  and  its  occur- 
rence is  related  especially  to  the  presence  of  an  excess  of  subarachnoid 
fluid.  The  signs  of  mechanical  "  strangulation,"  which  are  to  be  ob- 
served in  cases  of  intense  neuritis,  are  no  evidence  that  the  inflam- 
mation was  caused  by  any  mechanical  process.  The  cause  of  the 
strangulation  is  the  compression  of  the  veins  by  the  inflammatory 
products  within  the  swollen  papilla,  and  not,  as  was  at  first  thought, 
compression  within  the  sclerotic  ring  or  behind  it,  by  the  distension 
of  the  sheath.  Within  the  ring,  the  vessels  after  death  never 
exhibit  any  sign  of  narrowing,  whereas  within  the  papilla  their 
compression  is  usually  distinct.  The  conclusion  is  that  optic  neu- 
ritis is  probably  rarely  due  to  a  single  factor,  that  the  most  potent 
element  is  the  descent  of  a  process  of  tissue-irritation,  which,  when  it 
reaches  the  papilla,  sets  up  a  more  intense  inflammation ;  that  in 
some  cases  this  factor  is  alone  effective ;  that  in  many  others  its  in- 
fluence is  aided  by  the  effect  of  distension  of  the  sheath,  hindering  the 
escape  of  effete  Hquids,  increasing  the  oedema,  or  even  conveying  irri- 
tating material.  The  distinction  between  optic  neuritis  and  "  choked 
disc  "  is  one  of  degree,  not  of  cause.  So  far  as  optic  neuritis  has  any 
single  significance,  it  is  that  of  the  presence  of  an  irritative  process 
within  the  skull. 

There  is  an  important  relation  between  the  chronicity  of  the  neuritis 
and  that  of  the  intra-cranial  process.  A  chronic  cerebral  process  may 
cause  an  acute  neuritis,  but  a  chronic  neuritis  never  results  from  an 
acute  process,  and  the  degree  of  the  chronicity  of  the  neuritis  is  an 
indication  of  the  degree  of  chronicity  of  the  intra-cranial  disease. 
When  the  cerebral  process  begins  to  improve,  the  neuritis  lessens,  and 
the  commencing  subsidence  of  the  neuritis  is  often  the  first  indication 
of  the  improvement  in  the  brain  lesion.  Hence  the  process  often 
gives  valuable  prognostic  information  as  well  as  diagnostic  guidance. 

Atrophy. — Of  the  three  forms  of  atrophy  of  the  optic  nerve,  primary, 
secondary  (to  disease  of  the  nerve  further  back),  and  consecutive  (to 
neuritis),  only  the  latter  two  occur  as  a  result  of  uncomplicated 
intra-cranial  disease.  Apparent  exceptions  to  this  are  disseminated 
sclerosis  and  general  paralysis  of  the  insane:  in  both  of  these  affec- 
tions primary  atrophy  may  occur,  but  in  these  there  is  wide-spread 
degeneration,  usually  involving  the  spinal  cord  as  well  as  the  brain, 
and  the  atrophy  must  be  regarded  as  associated  with,  rather  than  the 
result  of,  the  brain  disease.  Consecutive  (neuritic  or  papillitic)  atrophy, 
the  characters  of  which  have  been  already  described,  has  the  same 
causes  and  the  same  significance  as  the  inflammation  of  which  it  is 
the  consequence. 

Secondary  atrophy  is  the  result  of  damage  to  the  optic  nerve  behind 


138  CRANIAL    NERVES. 

the  eye,  or  to  the  optic  chiasiua.  Its  characteristic  is  that  the  signs 
of  atrophy  follow  instead  of  accompanying  the  failure  of  sight. 
Especially  important,  on  account  of  the  diagnostic  difficulty  it 
presents,  is  the  form  of  secondary  atrophy  that  follows  temporal 
hemianopia  of  slow  onset,  due  to  chronic  disease  at  the  optic  chiasma. 
The  causes  of  this  form  of  atrophy  will  be  described  in  the  chapter  on 
diseases  of  the  optic  nerve. 


DISEASES   OF   THE    CRANIAL   NERVES 

AND  DERANGEMENT  OF  TKEIFL  FUNCTIONS. 


Many  symptoms  of  organic  brain  disease  consist  in  derangement  of 
the  functions  of  the  cranial  nerves,  and  it  is  convenient  to  consider 
these  together  with  the  diseases  of  the  nerves  themselves.  Such  an 
arrangement  is  not  strictly  logical,  but  its  practical  convenience  is 
great,  since  much  needless  repetition  is  thereby  avoided,  and  those 
symptoms  can  be  described  together  that  are  of  the  same  character, 
and  have  to  be  considered  together  in  practical  diagnosis.  The  paths 
of  the  cranial  nerve-fibres  within  the  brain  have  been,  already  de- 
cribed,  and  need  not  be  here  repeated,  except  in  so  far  as  they  have  a 
bearing  on  special  points. 


OLFACTORY  NERVE— AFFECTIONS   OF    SMELL. 

The  olfactory  bulb  contains  many  nerve-cells,  and  has  been  thought 
by  some  to  be  analogous  to  the  nuclei  of  the  other  cranial  nerves, 
by  others  to  be  a  detacht  d  portion  of  the  cerebral  cortex.  The  bulb  is 
connected  with  the  cerebral  hemispheres  by  the  olfactory  nerve,  the 
central  connections  of  which  have  been  described  at  p.  56.  We  have 
seen  that  each  nerve  seems  to  be  related  to  both  hemispheres,  since 
the  sense  of  smell  on  one  side  may  be  deranged,  not  only  by  disease 
of  the  hemisphere  (uncinate  gyrus)  on  the  same  side,  but  also  by  a 
lesion  of  the  hinder  part  of  the  internal  capsule  on  the  opposite  side, 
and  probably  also  by  disease  of  the  convexity. 

The  sense  of  smell  includes  more  than  is  popularly  assigned  to  it. 
It  includes  not  only  the  recognition  of  odours,  but  also  that  of  flavours. 
When  the  olfactory  nerves  are  influenced  through  the  anterior  nares 
the  sensation  is  termed  an  "  odour  ;"  when  through  the  posterior  nares 
it  is  termed  a  "  flavour."  In  the  latter  case  the  sensations  are  blended 
Avith  those  of  taste  proper,  bitter,  sweet,  sour,  &c,  and  a  mixed  sen- 


SYMPTOMS.  139 

sation  is  the  result.  If  the  sense  of  smell  is  lost,  all  perception  of 
flavours  is  lost  with  it,  but  the  true  gustatory  sensations  remain. 
The  two  functions  of  the  olfactory  nerve  seem  to  be  separated  at  the 
cortex,  and  the  impressions  of  flavour  to  be  perceived  through  the 
same  centre  as  those  of  taste,  since  this  relation  is  always  preserved  in 
the  aura  of  epilepsy.  Hence  patients  who  have  lost  smell  usually 
say  that  they  have  also  lost  taste,  and  sometimes  they  only  mention 
the  loss  of  "  taste,"  which  is  to  most  persons  the  more  serious 
deprivation.* 

In  testing  the  sense  of  smell,  care  must  be  taken  to  employ  only  sub- 
stances (such  as  musk,  asafcetida,  or  oil  of  cloves)  that  act  on  the 
olfactory  nerve  alone,  and  it  is  best  to  use  such  odours  as  are  readily 
identified  and  named.  If  volatile  pungent  substances  are  used,  such 
as  ammonia  or  acetic  acid,  which  also  stimulate  the  fifth  nerve  in  the 
nasal  mucous  membrane,  the  patient  may  perceive  that  which  he 
cannot  smell. 

Loss  of  the  sense  of  smell,  anosmia,  is  less  frequently  due  to  a  lesion 
of  the  nerve  than  to  disease  of  the  mucous  membrane  of  the  nose, 
chronic  inflammation,  nasal  polypus,  &c.  It  may  also  he  caused 
indirectly  by  paralysis  of  the  fifth  nerve  and  consequent  trophic 
changes  in  the  membrane,  or  dryness  from  lessened  secretion. 
Excessive  secretion  may  also  produce  it.  If  the  nose  be  filled  with 
rose  water  no  smell  is  excited,  and  smell  remains  in  abeyance  for 
some  time.  The  olfactory  nerves  may  be  damaged  by  falls  or 
blows  on  the  front  or  back  of  the  head ;  the  delicate  filaments  are 
torn  from  the  bulb,  or  are  lacerated  in  their  passage  through  the 
ethmoid  bone.  The  olfactory  bulbs  sometimes  suffer,  by  compression 
or  inflammation,  in  cases  of  tumour  in  the  anterior  fossa  of  the  skull, 
or  elsewhere  within  the  cranial  cavity,  even  in  the  cerebellum,  caries 
of  adjacent  bone,  and  local  meningitis,  syphilitic  or  other.  They 
may  also  be  comp>ressed  by  internal  hydroctphalus.f  ^In  these  cases 
the  bulbs  may  be  distinctly  involved  in  the .  disease,  or  may  be 
flattened  and  wasted.  Tumours  have  been  supposed  to  cause  an 
olfactory  neuritis,  analogous  to  optic  neuritis.  In  locomotor  ataxy, 
anosmia  occasionally  occurs,  although  not  frequently.  Primary 
atrophy  of  the  bulbs  is  occasionally  met  with  in  old  age  (Prevost). 
Lastly,  excessive  stimulation  of  the  olfactory  nerves  has  caused  their 
paralysis,  just  as  blindness  has  resulted  from  a  very  brilliant  light; 
in  several  cases,  after  exposure  to  an  exceedingly  strong  odour,  the 

*  The  word  flavour  originally  meant  smell.  The  nomenclature  given  above  is 
that  of  Milton,  who,  speaking  of  wine,  says, — 

"The  flavour  or  the  smell, 
Or  taste  that  cheers  the  hearts  of  gods  or  men." 

Samson  Agonistes,  544. 

Skeat,  it  is  true,  thinks  Milton  may  have   meant   colour,  "flavor"  in  low  Latin 
meaning  yellow;  but  no  contemporary  example  of  this  use  is  given, 
t  Quincke,  '  Cor.  Bl.  f .  Schweiz.  Aerzte,'  1S82,  No.  9. 


140  CEAXIAL   NERVES. 

sense  of  smell  lias  been  permanently  lost.  Thus  an  officer  in  Ireland 
superintended  the  emptying  of  a  cesspool  at  the  bottom  of  which 
some  weapons  were  said  to  be  concealed ;  the  odour  was  most  offen- 
sive. Next  day  he  found  that  his  sense  of  smell  was  gone,  and  it 
never  returned.  Other  similar  cases  are  on  record.  It  has  been  con- 
jectured that  the  odour  causes  congestion  and  haemorrhage  into  the 
mucous  membrane,  because,  if  the  musk  deer-hunters  do  not  stuff  up 
their  nostrils  before  extracting  the  musk  gland,  they  suffer  from 
epistaxis.*  But  it  is  unlikely  that  capillary  haemorrhage  into  the 
mucous  membrane  would  cause  complete  anosmia,  or  would  occur 
without  epistaxis.  More  probably  the  loss  of  smell  is  the  direct 
result  of  the  over-stimulation  on  the  nutrition  of  the  nerve-elements. 

In  diseases  of  the  cerebral  hemisphere  loss  of  smell  is  rare.  It  has 
occurred  with  symptoms  of  embolism  of  the  middle  cerebral  (Hugh- 
lings  Jackson),  perhaps  from  damage  to  the  root-fibres  at  the  com- 
mencement of  the  fissure  of  Sylvius,  since  the  loss  of  smell  has  been 
on  the  same  side  as  the  lesion.  It  has  also  been  observed,  on  the 
opposite  side,  in  cases  of  disease  of  the  "  sensory  crossway,"  at  the 
hind  part  of  the  internal  capsule, f  and  in  at  least  one  case  of  exten- 
sive disease  of  the  convexity. J  Functional  loss  occurs  only  in  hys- 
terical hemianesthesia.  The  olfactory  nerves  are  sometimes  congeni-  • 
tally  absent.  Dr.  Sharpey,  in  his  lectures  on  physiology,  used  to 
mention  the  instance  of  a  chief  scavenger  of  the  city  of  Leipzig,  who 
was  knuwn  to  have  no  sense  of  smell,  and  in  whose  brain  no  trace  of 
olfactory  nerves  could  be  found.  A  few  similar  anatomical  facts  are 
on  record ;  in  most  cases  a  minute  grey  prominence  marked  the  place 
from  which  the  nerve  normally  springs.  Congenital  absence  has  been 
known  to  descend  from  father  to  son  (Bi-eschet).  It  does  not  seem 
certain,  however,  that  the  absence  of  the  nerves  invariably  entails 
absence  of  the  sense. §  Possibly,  as  suggested  by  Duval, ||  the  fifth 
nerve  subserved  the  olfactory  function. 

Injury  may  cause  partial  loss,  sometimes  curious.  One  intelligent 
man,  after  concussion,  could  only  perceive  a  certain  "  scent,"  and  of 
flavours,  that  only  of  raspberry  jam,  even  strawberry  jam  being 
■unrecognised.     The  state  was  permanent. 

The  diagnosis  of  an  affection  of  the  nerve  depends  first  on  the 
detection  of  the  loss  of  smell,  and  secondly  on  the  exclusion  of  disease 
of  the  mucous  membrane.  In  the  latter  case  purulent  discharge  has 
generally  occurred  at  some  period,  aud  a  history  of  such  dischai-ge 
always  affords  strong  reason  for  suspecting  a  local  cause.  Loss  of 
smell,  with  ability  to  recognise  flavours,  is  always  due  to  such  disease, 

*  Althaus,  'Lancet,'  1881,  vol.  i,  p.  771,  where  some  interesting  information  on 
the  history  of  our  knowledge  of  anosmia  will  be  found.  f  See  note  on  p.  20. 

X  The  case  of  Demange,  p.  18. 

§  Case  of  Bernard,  quoted  by  Althaus,  'Lancet,'  1881,  i,  772;  and  of  Lebec, 
*  Prog  Med.,'  No.  48,  18S3. 

II   '  Bull,  de  la  Soc.  de  Biol.,  Paris,'  No.  17,  1883. 


SYMPTOMS.  141 

sometimes  partial  in  extent.  The  importance  of  a  local  examination  is 
obvious.  A  lad  was  ouce  sent  to  me  who  was  said  to  have  lost  smell, 
taste,  and  hearing ;  I  was  asked  where  the  brain  disease  was  likely 
to  be  to  cause  these  effects.  There  were  scrofulous  inflammation  of 
the  nasal  mucous  membrane,  caiies  in  both  ears,  and  neither  loss  of 
taste  proper  nor  any  evidence  of  intra- cranial  mischief. 

Besides  the  ordinary  tests  of  smell,  the  nerves  can  be  stimulated  by 
voltaic  electricity,  a  phosphorus-like  odour  being  perceived.  This  is 
proof  of  their  integrity,  but  the  application  is  very  painful  unless 
the  nose  is  filled  with  water,  or,  better,  with  a  weak  saline  solution, 
in  which  the  rheophore  is  placed.  In  health  the  order  of  response 
has  been  thus  found  to  be  similar  to  that  of  other  nerves  :  (1)  ECO, 
(2)  AOC.  The  induced  current  has  no  effect.  An  electrical  exami- 
nation can  very  seldom  be  necessary.  The  fact  that  disease  of  the 
fifth  nerve  may  cause  considerable  anosmia  must  not  be  forgetten  in 
diagnosis. 

The  prognosis  of  disease  of  the  olfactory  nerve  is  generally  unfavor- 
able. Considerable  improvement  has  been  observed  only  in  cases  of 
syphilitic  disease  of  short  dm*ation,  and  in  some  traumatic  cases. 

The  treatment  is  mainly  that  of  the  cause  of  the  anosmia.  The 
local  application  of  strychnia  to  the  mucous  membrane  has  be  n 
recommended — as  a  solution  in  olive  oil  (Brunniche),  or  as  snuff .  -^ 
grain  mixed  with  sugar  (Altbaus).  In  cases  in  which  there  is  reason 
to  believe  that  the  active  disease  has  ceased,  voltaic  electricity  has- 
been  recommended,  the  positive  pole  being  placed  behind  the  mastoid 
process,  the  negative  to  the  nasal  bones.  Only  a  few  cells  can  be 
used,  or  unpleasant  giddiness  will  be  produced.  In  one  recorded 
case,  after  a  fall  on  the  back  of  the  head,  considerable  improvement 
followed  two  applications  (Jacob).  Of  course,  all  that  electricity  can 
do  is  to  excite  the  nerve-elements  that  are  structurally  perfect,  but 
for  some  reason  functionally  inactive,  and  in  most  cases  of  anosmia  it 
is  useless.  Iodide  of  potassium  has  also  been  recommended,  but  its 
value,  except  in  cases  of  syphilitic  origin,  is  doubtful. 

Increased  sensitiveness  of  the  olfactory  nerves — "  olfactory  hyper- 
sesthesia,"  "  hyperosmia " — is  occasionally  met  with.  It  occurs 
chiefly  in  hysteria,  in  which  remarkable,  almost  animal,  acuteness 
of  the  sense  is  sometimes  present,  so  that  not  only  objects  but 
persons  have  been  discriminated  by  this  means.  In  insanity  the 
same  condition  is  sometimes  met  with.  It  is  usually  associated  with, 
and  has  to  be  distinguished  from,  an  altered  appreciation  of  odours, 
shown  in  the  abnormal  enjoyment  of,  or  disgust  at,  the  odours  which 
are  recognised  with  natural  or  preternatural  acuteness. 

The  condition  rarely  calls  for  special  treatment.  Morphia  in  snuff 
or  hypodermic  injection  has  been  suggested,  but  the  local  application 
of  cocain  will  probably  be  found  more  effective. 

Subjective  Sensations  of  Smell. — Subjective  sensations  of  smell  occur 
from  central  disease,  or  from  irritation  of  the  nerve.     In  the  insane, 


142  CRANIAL    NERVES. 

olfactory  hallucinations  occur,  though  less  commonly  than  those 
of  the  optic  or  auditory  nerve.  Schlager  met  with  them  in  five 
cases  out  of  six  hundred.  In  epilepsy  subjective  sensations  of  smell 
occur  as  occasional  warnings  of  fits,  and  disease  in  such  a  case  has 
been  found  to  involve  the  olfactory  region  in  the  anterior  part  of  the 
temporo-sphenoidal  lobe.  It  was  so  in  a  case  of  tumour,  recorded  by 
Sauder,  and  also  in  one  of  softening  of  this  region.*  In  a  case  re- 
corded by  Dr.  Hugh  lings  Jackson  and  Dr.  Beevorf  the  aura  consisted 
of  a  crude  sensation  of  smell  and  the  so-called  "  dreamy  state."  There 
was  no  impairment  of  the  sense  of  smell,  but  the  autopsy  revealed  a 
tumour  involving  the  aftterior  part  of  the  right  temporo-sphenoidal 
lobe.  A  subjective  sensation  (usually  resembling  that  of  phosphorus, 
and  such  as  is  produced  by  electrical  stimulation  of  the  nerve)  some- 
times precedes  loss  of  smell  trom  organic  disease,  as  by  a  tumour.  It 
was  so  in  a  case  of  loss  of  smell  in  tabes  recorded  by  Althaus.  Doubt- 
less the  sensation  is  due  to  the  irritation  of  the  nerve-elements  by  the 
morbid  process  which  ultimately  destroys  them. 

Perversion  of  the  Sense  of  Smell. — This  is  a  rare  condition,  which 
occasionally  results  from  irritation  of  the  nerve  or  central  organ.  Iu 
a  case  recorded  by  Legg,  some  time  after  an  injury  to  the  head,  all 
substances  "  tasted "  of  gas  or  paraffin,  and  there  was  marked 
diminution  in  the  acuteness  of  the  sense  of  smell.  In  a  case  of  tabes 
recorded  by  ErbenJ  there  was  perversion  of  smell  and  a  similar  condi- 
tion of  taste. 


OPTIC   NERVE  AND  VISUAL   SYMPTOMS. 

The  central  relations  of  the  optic  uerve  have  been  described  at 
p.  54,  and  the  cortical  centres  for  vision  at  p.  21.  The  fibres  from  the 
region  of  the  macula  lutea  are  at  first  in  the  outer  part  of  the  nerve, 
and  reach  its  axis  near  the  optic  foramen.  Each  optic  tract  contains 
the  fibres  from  the  same-named  half  of  each  retina,  i.  e.  from  the 
temporal  half  of  the  retina  on  the  same  side,  and  the  nasal  half  of  the 
retina  on  the  other  side,  and  hence  disease  of  the  tract  causes  loss  of 
vision  in  the  opposite  half  of  each  field,  the  temporal  half  of  the  one, 
the  nasal  half  of  the  other.  This  is  termed  homonymous  hemianopia,^ 
or  lateral  hemianopia. 

Why  do  more  fibres  cross  to  the  opposite  tract  than  pass  to  the 
tract  on  the  same  side,  if  the  two  sets  come  from  equal  retinal  areas  ? 
Because  the  prominence  of  the  nose  shuts  off  the  rays  from  the  peri- 

*  Hamilton,  'New  York  Med.  Journ ,'  June,  1S82. 

f  '  Brain,'  vol.  xii,  354. 

%  'Wien.  Med.  Blatter,'  1886,  pp.  43,  44. 

§  It  was  formerly  called  "  hemiopia,"  but  the  anomaly  of  the  use  of  the  terns 
"half-sight"  in  the  sense  of  "half-blindness"  has  led  to  a  general  endeavour  to 
employ  the  more  exact  "hemianopia"  or  "hemianopsia."  Although  it  is  seldon. 
desirable  to  change  a  familiar  word,  the  alteration  is  trifling  anl  removes  a»„ 
inaccuracy. 


SYMPTOMS.  143 

pheral  part  of  the  temporal  half  of  the  retina,  and  the  power  of  sight 
extends  but  little  further  than  the  area  habitually  stimulated. 
Hence,  while  the  retinal  halves  are  of  equal  size,  the  functional  area 
is  smaller  on  the  temporal  side,  and  fewer  nerve-fibres  proceed  from 
it.*  The  fibres  from  the  temporal  side  are  those  that  do  not  cross, 
and  hence  the  crossing  fibres  are  more  numerous  than  those  that  pass 
in  the  tract  without  decussating.  The  fibres  which  cross  occupy  the 
middle  of  the  chiasma,  the  direct  fibres  lie  on  each  side.  Fibres  from 
the  macula  lutea  and  region  around  it  pass,  in  most  individuals  at 
least,  to  both  optic  tracts.  The  division  between  the  two  halves  of 
the  retina  (from  which  fibres  pass  to  the  respective  tracts)  is  generally 
in  the  vertical  line  of  the  macula  lutea,  but  it  probably  varies  in  its 
precise  direction  in  different  individuals,  and  seems  sometimes  to  be 
slightly  oblique.  These  two  facts  will  be  considered  more  fully  in  the 
description  of  the  symptoms.  The  fibres  which  pass  from  one  tract  to 
the  other  by  the  posterior  part  of  the  commissure  (and  are  probably 
connected,  by  the  internal  geniculate  bodies,  with  the  corpora  quadri- 
gemina)  have  not,  at  present,  any  medical  importance. 

We  have  seen  that  the  visual  path  passes,  on  each  side,  by  the  optic 
tract  to  the  optic  thalamus,  and  thence  by  the  optic  radiation  to  the 
cortex  of  the  occipital  lobe.  This  constitutes  a  half-vision  centre 
which  seems  to  be  double,  for  light  and  for  colours.  The  two  half- 
vision  centres  are  probably  blended  in  a  higher  visual  centre  in  front 
of  the  occipital  lobe.  The  arrangement  is,  however,  very  complex  ;  in 
each  centre  both  fields  are  represented,  but  chiefly  that  of  the  opposite 
eye.  Each  higher  visual  centre  can  supplement  its  fellow  to  some 
extent  and  compensate  its  loss,  but  in  the  half-vision  centres  there  is 
no  power  of  supplemental  action,  and  no  compensation  for  loss  is 
possible.  The  effects  of  destruction  of  the  path  or  centre  (when  the 
results  of  the  slighter  damage  have  passed  off)  are  permanent.  This 
is  strikingly  shown  by  Fig.  80. 

Etiology. — The  numerous  affections  of  the  optic  nerve  within  the 
eye  do  not  come  within  the  province  of  this  book,  nor  does  the  primary 
atrophy,  which  so  often  accompanies  certain  degenerative  diseases  of 
the  spinal  cord,  and  occasionally  complicates  similar  diseases  of  the 
brain.  Optic  neuritis,  or  "  papillitis,"  such  as  results  from  intra-cranial 
tumours,  is  rather  a  general  symptom  of  cerebral  disease  than  a 
special  affection  of  the  nerve,  and  has  been  considered  with  other 
symptoms  of  the  same  class  (p.  132).  Moreover,  many  diseases  of 
the  nerve  itself  behind  the  eye,  such  as  interstitial  neuritis,  or  hsemor- 

*  Semi-decussation  of  the  optic  nerve  is  not  the  invariable  rule  in  the  animal 
kingdom.  In  some  creatures  there  is  a  total  decussation.  The  amount  of  decussation 
seems  to  be  roughly  proportioned  to  the  amount  of  separation  of  the  fields  of  vision. 
In  man  the  fields  half  overlap  when  the  eyes  are  directed  forwards,  and  there  is  a 
half-decussation.  In  those  animals  in  which  the  fields  are  totally  distinct  and 
cannot  be  made  to  overlap,  as  fishes,  there  is  a  total  decussation. 


144  CRANIAL    NERVES. 

rliage  into  the  substance  of  the  nerve,  also  fall  chiefly  into  the  pro- 
vince of  ophthalmology. 

The  diseases  that  are  of  medical  significance  affect  the  nerve,  the 
chiasma,  the  tract,  or  the  path  from  this  to  the  cortex,  or  the  cortex 
itself.  This  classification  corresponds  to  an  important  difference  in 
the  symptoms  produced. 

(1)  The  nerve  itself  may  be  damaged  by  tumours  within  the  orbit 
or  "within  the  skull.  The  intra-cranial  coui'se  of  the  nerve  is  indeed  so 
shor~t  that  it  is  seldom  thus  affected,  but  it  is  occasionally  compressed 
by  a  tumour  of  the  pituitary  body,  or  by  one  springing  from  the  bone. 
The  nerve  may  be  damaged  by  an  aneurism  of  the  ophthalmic  artery 
within  the  orbit,  or  of  the  internal  carotid  within  the  skull.  It  is 
occasionally  the  seat  of  inflammation,  interstitial  or  arising  in  the 
sheath  or  spreading  to  it  from  an  adjacent  focus,  such  as  caries  of  the 
sphenoid  bone  or  an  orbital  abscess.  It  often  becomes  inflamed  in 
meningitis,  but  symptoms  result  chiefly  through  the  agency  of  papil- 
litis. A  rare  but  important  form  is  rheumatic  inflammation.  Of  this 
I  have  seen  several  instances,  chiefly  in  women,  and  two  had  previously 
suffered  from  a  neuritis  of  the  facial  nerve,  and  all  from  other  mani- 
festations of  rheumatism.  The  symptoms  followed  exposure  to  cold. 
In  some  cases  the  nerves  to  the  eyeball  muscles  were  also  involved, 
and  from  this  it  is  pi*obable  that  the  seat  of  this  inflammation  is  at 
the  back  of  the  orbit.  The  optic  nerve  is  occasionally  injured  in  falls  on 
the  head,  either  by  laceration  at  the  optic  foramen  or  by  haemor- 
rhage. 

(2)  The  chiasma  is  damaged  most  frequently  by  tumours  arising 
in  its  neighbourhood,  especially  by  those  springing  from  the  pituitary 
body,  sometimes  by  tubercular  or  syphilitic  growths,  in  its  substance  or 
outside  it,  rarely  by  chronic  inflammation  in  its  vicinity,  commencing 
in  the  dura  mater  and  leading  to  thickening  of  the  tissues  about  the 
commissure.  Another  occasional  cause  of  damage  is  internal  hydro- 
cephalus; the  distended  infundibulum  of  the  third  ventricle  presses 
on  the  middle  of  the  chiasma  and  flattens  it,  as  Cheselden  noted  a 
century  and  a  half  ago.*  It  is  probable  that  it  is  sometimes  the  seat 
of  interstitial  inflammation,  of  which  inherited  gout  may  be  the 
apparent  cause.  Similar  symptoms  occur  in  rare  cases  of  tabetic 
atrophy  of  the  optic  nerve,  and  may  develop  slowly  or  rapidly.  This 
process  may  conceivably  be  sometimes  more  intense  at  the  chiasma 
than  elsewhere,  even  in  slow  atrophy,  and  may  even  assume  the 
character  of  a  secondai-y  inflammation  in  some  cases  (see  "  Tabes," 
vol.  i).  In  one  case  which  I  have  recorded  the  characteristic  loss  of 
sight  came  on  quite  suddenly,  and  has  been  observed  in  other  cases 
of  tabes  ;  it  suggests  a  secondary  vascular  lesion.  Interstitial  haemor- 
rhage has  been  actually  observed.f 

*  'Phil.  Trans./  No.  337,  p.  2S1. 

f  For  details  of    lesions  see  Wilbrand,  'Hemianopsie,'  Berlin,    1881,   and  Hill 
Griffith,  '  Med.  Chronicle,'  January,  1887. 


OPTIC   NERVE. 


]45 


(3)  The  ojjtic  tract  is  chiefly  damaged  by  tumours  either  of  the  base 
or  springing  from,  the  inner  part  of  the  temporo-sphenoidal  lobe, 
which  may  either  compress  the  tract  or  invade  it.  An  instance -of 
such  compression  is  shown  in  Fig.  71,  although  it  is  doubtful  whether 
the  hemianopia,  from  which  the  patient  suffered,  was  thus  produced, 
since  the  disease  began  in  the  hemisphere  in  the  neighbourhood  of 
the  optic  radiation,  and  the  hemianopia  was  an  early  symptom.  (The 
cerebral  growth  is  figured  in  the  chapter  on  "  Intra-cranial  Tumours.") 
If  the  growth  invades  the  tract,  it  generally  spreads  also  to  the  cms, 
as  in  a  case  in  which  such  a  tumour  caused  first  hemianopia  and  then 
hemiplegia.*  The  tract  is  seldom  damaged  by  softening  or  haemor- 
rhage ;  softening  in  the  lenticular  nucleus  has  invaded  the  tract,  and 
partial  softening  has  been  observed  to  result  from  thrombosis  of  the 
internal  carotid.  It  is  sometimes  the  seat  of  an  islet  of  disseminated 
sclerosis. 


FlG-.  71. — Tumour  of  right  teinporo-splienoidal  lobe,  compressing  the 
right  optic  tract,  but  previously  interrupting  the  optic  radiation. 
(See  chapter  on  "  Intra-cranial  Tumours.") 

The  intra- cerebral  path  may  be  damaged  by  softening,  haemorrhage, 
tumours,  or  traumatic  lesions.  These  may  involve  the  thalamus, 
posterior  part  of  the  internal  capsule,  white  substance  of  the  occipital 
lobe,  or  cortex. 

Investigation  op  the  Functions  op  the  Optic  Nerve. — The 
manifestations  of  disease  consist  in  alterations  in  the  fundus  oculir 
and  in  impairment  of  vision  or  of  the  reflex  action  of  the  iris  to  light. 
All  these  should  be  carefully  examined  in  every  case  ;  and  it  is  often 
necessary  also  to  ascertain  the  state  of  refraction  in  the  eye,  lest  a. 
defect  of  sight  should  be  ascribed  to  disease  of  the  visual  path  or 
centre,  when  it  depends  solely  on  an  error  in  refraction.  This  is  of 
great  importance,  especially  since  a  considerable  deviation  from  the 
normar refraction  is  apt  to  set  up  other  functional  disturbances,  pain, 
*  '  Cent.  f.  med.  Wiss.,'  187S,  Xo.  31. 
VOL.   II.  10 


146  CKANIAL    NERVES. 

&c,  wbicli  may  lead  to  a  suspicion  of  organic  disease.  The  suspicion 
may  be  apparently  confirmed  by  tbe  impairment  of  sigbt.  On  tbe 
importance  of  an  opbtbalmoscopic  examination  it  is  needless  to 
insist;  without  it,  amblyopia  may  be  ascribed  to  brain  disease  when 
it  is  of  purely  ocular  origin,  and  many  morbid  processes  in  the  brain 
reveal  themselves  in  the  optic  papilla.  The  more  important  changes 
in  the  fundus  have  been  already  mentioned  (p.  131).*  The  mode  of 
testing  the  action  of  the  pupil  Avill  be  described  in  the  chapter  on 
-'  Diseases  of  the  Third  Nerve." 

The  examination  of  vision  includes  several  points,  each  of  which  needs  care- 
ful investigation.  (1)  The  acuity  of  vision,  for  which  test-types  are  employed, 
and  the  result  is  expressed  in  a  fraction  of  which  the  denominator  is  the  distance 
at  which  the  type  can  be  read  by  a  normal  eye,  and  the  numerator  is  the  farthest 
distance  at  which  it  can  be  read  by  the  patient.  (2)  Colour  vision  may  be 
tested  in  two  ways  :  (a)  by  the  method  of  "  confusion,"  in  which  the  patient 
selects  from  a  series  of  coloured  objects  those  that  are  of  the  same  kind  of 
colour  as  the  standard,  and  reveals  a  defect  by  picking  out  tints  that  are  essen- 
tially different ;  (b)  by  asking  the  patient  to  name  certain  colours.  This  is  open 
to  the  fallacies  that  a  name  may  be  given  accurately  when  a  colour  is  not  rightly 
perceived,  and  that  the  patient  may  not  be  familiar  with  the  names  of  colours. 
The  former  fallacy  is  especially  dangerous  in  cases  of  congenital  colour-blind- 
ness, in  which  colours  may  appear  different,  and  be  associated  with  certain  names 
in  the  mind,  when  they  are  not  rightly  perceived.  The  method  of  naming 
colours  is,  however,  more  often  useful  in  medical  than  in  ophthalmic  work. 
If  a  patient  is  known  to  have  previously  had  good  colour  vision,  or  if  one 
eye  only  is  affected,  and  the  vision  with  it  can  be  compared  with  that  of  the 
other  eye,  the  method  of  naming  colours  often  gives  valuable  information, 
especially  as  to  the  character  of  the  sensation  excited.  (3)  The  fields  of  vision 
must  be  examined,  and  if  any  defect  is  found,  they  should  be  mapped  out,  if 
possible,  by  means  of  a  "  perimeter."  The  field  may  be  roughly  tested  by 
moving  some  object  midway  between  the  observer  and  the  patient,  the  eye 
tested  being  fixed  on  that  of  the  observer,  who  can  thus  readily  detect  any 
movement  of  the  patient's  eye  from  the  fixing-point  towards  the  object,  and  at 
the  same  time  can  use  his  own  field  of  vision  as  a  standard.  For  a  very  rough 
examination  the  hand  may  be  employed,  but  it  is  better  to  use  a  small  piece  of 
white  paper  one  third  of  an  inch  square,  fixed  on  the  end  of  a  dark-coloured  rod, 
such  as  a  penholder.  With  a  little  care  very  exact  observations  can  thus  be  made, 
although  the  result  cannot  be  recorded  so  precisely  as  by  means  of  a  perimeter. 
In  this  instrument  an  object  is  made  to  move  along  a  quadrant  of  a  circle, 
divided  into  degrees,  and  rotating  on  one  of  its  extremities  (at  which  is  the 
fixing-point),  so  that  the  quadrant  can  be  placed  in  each  radius  of  a  hemisphere 
of  which  the  patient's  eye  is  at  the  centre.  The  result  is  recorded  on  a  chart  in 
which  are  concentric  circles  divided  by  radii,  at  intervals  of  ten  or  more  degrees. 
The  field  does  not  extend  equally  in  all  directions,  being  limited  above  by  the 
projecting  eyebrow,  and  on  the  inner  side  by  the  nose.  In  the  diagrams  here 
given  only  that  part  of  the  chart  is  shown  which  is  included  within  the  average 
normal  field,  and  for  the  sake  of  simplicity  only  the  radii  and  concentric  circles 
at  30°  distance  are  represented,  although  many  more  were  employed  in  taking 
the  fields. 
*  The  reader  will  find  a  full  account  of  them  in  '  Medical  Ophthalmoscopy,'  3rd  ed. 


OPTIO    K'ERVJfi.  147 

It  is  important,  in  testing  vision,  to  know  that  in  conditions  of  functional 
feebleness  of  the  nervous  system,  such  as  hysteria  and  so-called  neurasthenia, 
the  sensibility  of  the  peripheral  parts  of  the  retina  lessens  considerably  after 
attention  has  been  directed  to  them  for  a  short  time,  so  that  even  normal  fields 
become  smaller  when  taken  several  times  consecutively,  the  reduction  being 
confined  to  the  part  tested.  This  effect  is  still  more  marked  when  there  is  a 
pathological  contraction.  It  seems  to  be  produced,  not  in  the  retina,  but  at  the 
centre,  because,  if  one  part  of  the  field  is  tested  for  a  short  time  and  becomes 
narrower  in  consequence,  the  same  narrowing  is  found  to  have  taken  place  in 
the  corresponding  part  of  the  field  of  the  other  eye.* 

It  is  necessary,  in  a  complete  examination,  to  test  the  field  for  colours  as  well 
'  as  for  white,  since  defects  may  be  found  in  the  colour-fields  where  none  exist 
for  white.  Small  pieces  of  coloured  paper  may  be  employed  in  the  same  way 
as  a  white  object.  The  normal  fields  for  colours  are  smaller  than  those  for 
white,  and  vary  for  each  colour  ;  beyond  their  limit  the  object  can  still  be  seen, 
but  appears  grey  instead  of  coloured.  The  fields  for  red  and  green  are  the 
smallest,  and  undergo  most  narrowing  in  morbid  states  ;  it  is  therefore  gene- 
rally necessary  to  test  only  these  fields.  If  the  power  of  distinguishing  objects 
is  lost  in  any  part  of  the  field,  it  is  desirable  to  ascertain  further  whether  light 
can  still  be  perceived  in  the  amblyopic  region.f 

Symptoms. — Optic  Nerve. — Disease  of  the  nerve  impairs  or  abolishes 
vision  in  one  eye,  and  lessens  the  reflex  action  of  the  pnpil  in  pro- 
portion to  the  interference  with  vision.  The  ophthalmoscopic  appear- 
ances may  be  at  first  normal,  but  if  the  damage  is  considerable  the 
optic  disc  slowly  passes  into  a  condition  of  atrophy.  This  is  termed 
"  secondary  atrophy"  to  distinguish  it  from  the  "  consecutive  atrophy  " 
which  follows  papillitis.  When  the  nerve  is  damaged  by  inflam- 
mation, it  is  not  uncommon  for  slight  neuritis  to  be  visible  within  the 
eye ;  but  this  is  usually  too  trifling 
in  degree  to  account  for  the  loss. 
The  impairment  of  sight  involves 
acuity  of  vision,  and  commonly  also 
the  field.  A  frequent  change  in 
the  field  is  concentric  contraction, 
because  the  peripheral  lay  r  of  the 
nerve,  near  the  optic  foramen,  is 
most  damaged  by  processes  which 
begin  outside  it.      It  is  not  rare  to 

have  an  irregular  defect,  as  in  Fig.  72,   FlG-   72.— Limitation   of   R.,  field, 
P  ~  x1  ,.     ,  .  greatest  in  right  half,  due  to  or- 

from  one  of  the  cases  of  rheumatic       |ital  neuritis?  onset  acute,  with 

neuritis  mentioned  on  p.  144.     In  the       palsy  of    ocular   muscles   and   a 
others  the  loss  of  sight  was  absolute       n?rmal  disc;1  subseflufnt  recovery 

~      .   .,  ,  ,  ot  the  muscles,  and  slow  atrophy 

and  lasting.       In  all,  visible  atrophy       0f  the  disc. 

of  the  nerve  slowly  supervened,  with- 
out any  recognisable  papillitis.     A  central  loss  is  much  less  common, 

*  Schiele,  'Archiv  f.  Augenheilk.,'  Bd.  xvi. 

t  It  has  been  recently  asserted  that  the  perception  of  light  depends  on  a  different 
centre  from  the  perception  of  form  (Wilbrand).  It  is  not  yet  certain  that  this  is 
so,  but  observations  on  this  point  are  desirable. 


148 


CRANIAL   NERVES. 


and  is  due  to  what  is  termed  "  axial  neuritis,"  inflammation  (or 
degeneration)  in  the  centre  of  the  nerve.  The  affected  fibres  only- 
occupy  the  centre  of  the  nerve  at  the  back  of  the  orbit;  farther  for- 
wards they  come  to  (or  near)  the  surface  on  the  temporal  side.* 
This  form  is  met  within  "tobacco  amblyopia,"  and  it  sometimes 
complicates  degenerative  diseases  of  the  brain,  but  does  not,  strictly 
speaking,  result  from  them. 

Chiasma — The  characteristic  symptom  of  disease  of  the  chiasmais. 
"temporal  hemianopia,"  a  loss  of  the  outer  half  of  each  field  of  vision 
or  of  part  of  this  half.    This  temporal  hemianopia  (shown  in  Pigs.  73,. 


Fl<J.  73. — Temporal  hemianopia,  gradual  onset;  no  other  symptoms- 
Not  progressive. 


Fig.  74. — Temporal  hemianopia  without  other  symptoms  than  some 
headache;  possibly  a  tumour  of  the  pituitary  body. 

74,  and  75)  is  the  usual  symptom,  because  the  morbid  processes- 
which  damage  the  chiasma  act  chiefly  on  its  central  portion,  and 
affect  the  decussating  fibres  from  the  nasal  half  of  each  retina.  In 
many  cases,  however,  the  morbid  influence  does  not  remain  limited  to 
the  central  portion,  but  involves  one  side  of  the  commissure,  or  one 
tract  just  behind  the  commissure,  or  less  frequently  one  optic  nerve 
in  front  of  it.  In  either  case  the  result  is  the  same ;  on  the  side 
towards  which  the  morbid  process  extends  the  non-decussating  fibres 
are  involved,  and  the  corresponding  eye  becomes  totally  blind,  while  in 
the  other  eye  the  loss  remains  limited  to  the  temporal  half-field. 
Often  the  whole  chiasma  ultimately  suffers,  and  then  the  impairment 

*  Nettleship  and  Edmunds,  'Trans.  Oph.  Soc.,'  vol.  i,  p.  124;  Ssimelsohn,  'Cent. 
f.  med.  Wiss.,'  1880,  418,  and  'Trans.  Med.  Congress,  1881;'  Vossius,  ' Archiv  f. 
Oph.,5  xxviii. 


OPTIC    NERVE. 


149 


Fig.  75. — Temporal  heinianopia,  with  concentric  reduction  of  the  re- 
maining half- fields,  greater  in  the  right.  In  the  latter,  vision  after- 
wards failed  entirely,  but  the  left  remained  stationary  under  the 
treatment,  which  was  based  on  the  assumption  that  the  lesion  was 
chronic  inflammation  at  the  chiasma. 

•of  vision  progresses  through  the  stages  just  mentioned  to  total  loss 
in  both  eyes. 

The  rarest  of  all  symptoms  of  disease  of  the  chiasma  is  nasal 
hemianopia.  It  can  only  result  from  a  lesion  which  involves  each 
side  of  the  chiasma,  and  spares  the  central  portion, — a  bilateral 
external  influence,  or  a  symmetrical  interstitial  affection.  It  has  been 
d.ue  to  the  pressure  of  calcified  carotids  (Knapp).  In  tabetic  atrophy 
the  changes  seem  sometimes  greatest  at  the  chiasma,  and  irregular 
nasal  hemianopia  may  be  found.  The  only  case  that  has  come  under 
my  own  observation  was  of  this  form.  In  one  eye  there  was  a 
complete  loss  of  the  lower  nasal  quadrant,  extending,  however, 
beyond  the  middle  line ;  in  the  other  a  well-defined  amblyopia  of  cor- 
responding situation  (see  Fig.  76). 


\ 


Fig.  76. — Partial  nasal  hemianopia  in  a  case  of  optic  nerve  atrophy. 
The  quadrantic  loss  in  the  left  field  was  not  absolute;  in  the  right 
the  darker  shading  indicates  the  absolute  loss. 


In  the  ordinary  form  of  temporal  hemianopia  the  dividing  line  is 
seldom  exactly  vertical.  The  loss  in  the  two  eyes  sometimes  corre- 
sponds closely ;  more  often  there  is  a  difference  between  the  two  fields. 
Strict  correspondence  depends  on  the  strictly  central  position  of  the 
lesion,  which  seldom  obtains  in  the  case  of  the  processes  which  cause 
the  loss.  Sometimes  the  dividing  line  appears  to  pass  through  the 
fixmg-point,  as  in  Fig.  74 ;  in  other  cases  it  diverges  to  the  temporal 
side  of  the  fixing-point,  so  as  to  leave  a  small  area  around  this  within 


150  C  It  AXIAL    NERVES. 

the  seeing  half.  The  difference  probably  depends  on  individual  varia- 
tions in  the  decussation  ;  in  some  persons  fibres  from  the  macular 
region  pass  in  both  divisions  of  the  nerve,  the  crossing  and  the  direct 
(see  "lateral  hemiauopia,"  p.  152).  In  most  cases  there  is  no 
peripheral  contraction  of  the  half-fields  that  remain.  When  such 
contraction  exists,  it  is  probably  due  to  damage,  by  inflammation,  to  the 
peripheral  layer  of  the  optic  nerves  in  front  of  the  chiasma.  The  loss 
of  sight  in  temporal  hemianopia  involves  all  forms  of  vision  ;  the 
colour-loss  has  the  same  limit  as  that  for  light. 

The  mode  in  which  temporal  hemianopia  comes  on  depends  on  the 
nature  of  the  morbid  processes  which  cause  it,  and  these  suggest  a 
division  into  three  causal  varieties  :  (1)  external  compression,  as  by  an 
advancing  growth,  or  interstitial  distension  of  the  third  ventricle ;  (2) 
interstitial  inflammation,  primary  in  character;  (3)  tabetic  atrophy  with 
secondary  processes  at  the  decussation.  The  distinction  of  the  first 
and  second  classes  is  often  difficult ;  because  both  may  be  attended  by 
headache,  and  only  the  course  of  the  affection  may  decide  its  nature. 
Permanent  arrest,  under  treatment  suggested  by  the  hypothesis  of 
inflammation,  justifies  the  diagnosis  of  this  morbid  process.  In  all 
forms  the  onset  is  usually  gradual,  occasionally  rapid,  and  very 
rarely  actually  sudden  ;  the  significance  of  these  variations  has  been 
already  mentioned. 

The  associations  of  temporal  hemianopia  vary  according  to  its  cause. 
Paralysis  of  some  of  the  adjacent  motor  nerves  to  the  eyeball- muscles 
is  frequent,  when  the  primary  disease  is  outside  the  chiasma.  Other 
structures  may  suffer  if  a  tumour  attaius  a  large  size.  Optic  neuritis 
does  not  often  result  from  the  cause  of  the  hemianopia,  certainly  less 
frequently  than  might  be  expected;  but  hemianopia  sometimes 
succeeds  optic  neuritis,  when  the  commissure  suffers  compression  from 
a  distended  third  ventricle,  and  the  cause  of  both  symptoms  is  a  sub- 
tentorial  tumour.  Thus  a  man  with  a  stationary  tumour,  probably 
syphilitic,  and  symptoms  of  internal  effusion,  had  considerable 
amblyopia  from  optic  neuritis  which  had  subsided  into  atrophy,  when 
he  gradually  developed  temporal  hemianopia,  and  then  became 
completely  and  permanently  blind  without  any  change  in  the  condition 
of  the  fundus  oculi. 

The  course  of  temporal  hemiauopia  necessarily  depends  on  that 
of  its  cause.  As  we  have  seen,  it  may  go  on  to  complete  blindness ; 
failure  of  the  remaining  half-field  of  one  eye  may  leave  the  patient 
only  the  nasal  half  of  the  other  field,  during  the  further  course  of  the 
intra-cranial  lesion  to  the  fatal  issue  which  progressive  disease  usually 
entails.  Sometimes  such  failure  precedes  arrest  in  cases  due  appa- 
rently to  a  primary  inflammation.  The  damage  may  be  increased  by 
the  cicatricial  contraction  of  inflammatory  tissue.  In  such  cases  the 
symptoms  are  not  permanently  progressive,  but  it  is  rare  to  obtain  conr 
siderable  improvement;  although  interstitial  inflammation  is  the  most 
probable  lesion,  we  are  necessarily  ignorant  of  its  jrreeise  nature  in  such 


OPTIO    NERVE. 


151 


cases.  It  is  conceivable  that  a  tumour,  arising  from  the  pituitary 
body,  uiay  sometimes  cease  to  increase. 

Tract  and  Hemisphere. — The  loss  of  sight  from  disease  of  the  visual 
path  behind  thechiasma,  "  homonymous  hemianopia,"  depends  on  the 
anatomical  arrangement  already  described.  There  is  an  arrest  of  the 
impressions  from  the  side  of  each  retina  corresponding  to  the  side  of 
the  lesion,  and  hence  there  is  a  loss  of  vision  in  the  opposite  half  of 
each  field. 

It  is  equally  common  for  the  loss  to  be  on  the  right  side  and  on 
the  left.  Of  cases  collected  by  Wilbrand,  eighty  were  on  the  left  side 
and  seventy-four  on  the  right.  The  half-loss  varies  in  its  extent.  In 
cases  of  complete  hemianopia  it  extends  up  to  the  vertical  middle  line 
(Fig.  77),  but  the  precise  character  of  the  dividing  line  varies  con- 


Fl<J.  77. — Right  hemianopia;  sudden  onset  with  right  hemiplegia  and 
heniiansesthesia,  which  passed  away  in  a  few  days,  leaving  the  hemi- 
anopia the  only  permanent  symptom. 


Fig-.  78. — Left  hemianopia  from  the  case  of  cerebral  tumour  shown  on 
p»  145,  but  probably  due,  not  to  the  pressure  on  the  tract,  but  to  the 
interruption  of  the  optic  radiation. 


siderably  in  its  minute  characteristics.  The  first  important  difference 
is  that  in  some  cases  the  line  seems  to  pass  through  the  fixation-point, 
while  more  frequently  (as  in  most  of  the  cases  figured)  the  fixation 
region*  is  included  in  the  seeing  half  .f  The  line  of  division  may  occupy 
the  vertical  meridian  above  and  below,  but  about  8°  or  10°  from  the 
fixation-point  it  divei'ges,  and  curves  round  this  point  at  about  the 

*  The  region  around  the  fixation-point  subserved  by  the  central  region  of  the 
retina  around  the  macula. 

t  Wilbrand  found  that  of  fifty  cases  in  which  the  point  was  specified  the  line 
seemed  to  pass  through  the  fixation-point  in  twenty-three  cases,  and  to  one  side  of  it 
in  thirty -three.     See,  however,  the  remarks  on  page  153. 


152  CRANIAL    NERVES. 

same  distance  from  it  to  regain  the  middle  line  below  (Fig.  77). 
Sometimes  the  divergence  occurs  some  distance  above  the  fixing-point 
(Fig.  78).  The  central  area  thus  enclosed  varies  from  3°  or  4°  to  10° 
or  even  15°  radius.  In  other  cases  again,  the  line  continues  in  the 
meridian,  and  seems  to  pass  through  the  fixing-point  itself.  Barely  it 
seems  to  pass  through  the  fixation-point  in  one  eye  and  beyond  it  in 
the  other.  In  a  third  group  the  line  diverges  from  the  meridian,  and 
when  near  the  level  of  the  fixing-point  turns  towards  it,  and  seems  to 
reach  it,  so  as  to  make  a  re-entrant  angle  in  the  outline  of  the  seeing 
half   (Fig.   79).      This  important   difference,  the  apparent  division 


A 


; 


Fi&.  79. — Left  liemianopia;  sudden  onset;  no  other  symptoms.  In  the 
right  eye  the  loss  appears  to  extend  to  the  fixing-point,  but  the  vertical 
line  in  the  small  figure  was  drawn  by  the  patient  as  the  limit  of  the 
blindness  when  the  central  spot  was  fixed. 

through  the  fixing-point  or  the  inclusion  of  the  fixing-point  in  the 
seeing  half,  does  not  depend  on  the  position  of  the  lesion ;  each  form 
occurs  in  cases  of  heinianopia  due  to  disease  of  the  tract,  thalamus,  or 
hemisphere,  and  we  have  already  seen  that  each  form  occurs  also  in 
cases  of  temporal  liemianopia  from  disease  of  the  chiasma.  The 
difference  can  only  be  explained  by  individual  variations  in  the 
decussation  of  the  nerves.  The  obvious  inclusion  of  the  central  region 
in  the  seeing  half,  occurs  equally  in  right-  and  left-sided  liemianopia. 
It  must  be  due,  therefore,  to  the  passage  of  fibres  from  the  maculai 
region  to  both  optic  tracts  and  both  hemispheres,  so  that  this  region 
is  not  blinded  by  disease  of  either  tract.* 

Since  the  distance  from  the  fixing-point  at  which  the  dividing  line 
passes  varies  in  different  individuals,  it  appears  that  there  is  a  corre- 
sponding variation  in  the  size  of  the  central  area,  from  which  fibres 
pass  to  both  tracts.  This  area  is  very  small  when  the  line  passes 
very  near  the  fixing-point,  and  if  it  passes  through  the  fixing-point 
itself  there  is  no  double  passage  of  thecenti-al  fibres,  but  a  division  of 
these  as  of  those  from  the  rest  of  the  retina.     Eecent  careful  obser- 

*  It  has  been  asserted  that  such  passage  has  been  proved  by  the  fact  that,  in 
cases  of  axial  neuritis  with  a  central  loss  of  sight,  degenerated  fibres  have  been 
traced  into  both  optic  tracts.  But  they  might  be  so  traced,  were  there  a  strict 
division  through  the  macula;  the  central  loss  always  extends  farther  from  the 
macula  than  the  area  of  preserved  vision  in  hemianopia.  The  passage  of  fibres  from 
each  side  of  the  macula  into  each  tract  could  not  possibly  be  followed. 


OPTIC    NERVE. 


153 


vations,  however,  lead  me  to  doubt  whether  the  dividing  line  ever 
passes  actually  through  the  fixing-point.  When  it  has  seemed  to  do 
so,  I  have  found,  on  testing  the  field  with  a  perimeter  and  making  a 
more  minute  examination,  that  the  line  passed  a  little  to  one  side  of 
the  actual  fixing-point,  and  did  not  go  through  this.  In  the  right  field 
shown  in  Fig.  79,  for  instance,  the  loss,  according  to  the  perimeter, 
seemed  to  extend  quite  up  to  the  fixing  object ;  but  when  the  patient 
fixed  a  small  dot,  the  area  of  vision  was  found  to  extend  beyond  it,  as 
shown  in  the  small  diagram.  If  so,  the  variations  in  different  indi- 
viduals will  depend  merely  on  differences  in  the  area  from  which  the 
central  fibres  pass  to  both  tracts,  and  the  apparent  difference  in  kind 
resolves  itself  into  one  of  degree. 

Other  differences  in  the  dividing  line  have  probably  the  same  origin. 
In  most  instances  it  is  somewhat  irregular,  and  in  some  cases  it  is 
oblique  above  and  below.  The  deviation  may  be  towards  one  side 
above  and  the  other  side  below,  so  that  the  general  direction  of  the 
division  is  the  same,  and  it  may  be  quite  similar  in  the  two  eyes.* 
Another  difference  in  the  dividing  line  is  also  probably  due  to  the 
anatomical  arrangement.  The  line  is  usually  sharp ;  good  vision 
suddenly  changes  to  blindness.  Sometimes,  however,  a  narrow  band 
of  indistinct  vision  limits  the  blind  half.  This  must  be  due  to  the 
passage  of  some  fibres  from  the  medial  zone  by  the  tract  on  the  same 
side  ;  they  are  not  numerous  enough  to  give  the  distinct  vision  of  the 
macular  region,  but  they  are  enough  to  maintain  some  vision  in  the 
middle  band.f  There  is  no  relation  between  the  existence  of  an 
amblyopic  zone  and  the  seat  of  the  lesion.  J  All  these  variations,  and 
also  slight  differences  sometimes  to  be  found  between  the  two  fields, 


Fig.  80. — Partial  left  heinianopia  involving  the  lower  quadrant.  The 
fields  were  taken  ten  years  after  the  onset.  The  hemianopia  was  at 
first  complete,  and  was  accompanied  hy  left  hemiansesthesia  (including 
the  special  senses),  slight  hemiplegia,  and  optic  neuritis.  The  lesion 
was  probably  a  syphilitic  gumma  near  the  hinder  part  of  the  right 
thalamus.  (A  chart  taken  ten  years  after  this  one  showed  precisely 
the  same  defect.) 


*  A  well-marked  instance  of  this  obliquity  is  shown  in  Fig.  15  of  my  'Diagnosis 
of  Diseases  of  the  Brain.' 

t  Hirschberg, '  Nagel's  Jahresber.,'  1876,  p.  79. 

J  Wilbrand,  '  Ueber  Hemianopsie,'  p.  160.     But  see  Delepine's  case,  p.  21. 


15-A  CRANIAL   NERVES. 

must  be  due  to  individual  differences  in  the  character  of  the  decussa- 
tion. When  the  hemianopia  is  incomplete  the  irregularity  of  outline 
must  be  referred  to  the  extent  of  the  lesion. 

Hemianopia  is  not  always  complete.  Only  part  of  a  half-field  may 
be  lost,  but  the  same  part  of  the  field  is  defective  in  each  eye.  Fig.  80 
shows  a  loss  of  the  lower  left  quadrant  in  each  eye.  The  lower  quad- 
rant seems  to  be  more  frequently  lost  than  the  upper.*  Sometimes 
the  loss  is  thus  partial  from  the  first ;  more  often,  as  in  this  case,  the 
hemianopia  is  at  first  complete,  and  vision  is  regained  in  some  part  of 
the  affected  half,  but  remains  absent  in  another  part.  The  loss  may 
extend  up  to  the  neighbourhood  of  the  fixing-point,  or  in  slight  cases 
may  be  confined  to  the  peripheral  part  of  the  field  (Fig.  81).  Such 
partial  loss  depends  on  the  partial  extent  of  the  disease  in  the  path  or 
centre.  It  is  very  rare  in  disease  of  the  tract,  in  which  all  the  fibres 
lie  very  near  together,  but  has  been  observed  in  a  case  of  partial 
softening  (Marchand).  In  the  case  shown  in  Fig.  80  it  probably 
resulted  from  disease  of  the  optic  thalamus  or  optic  radiation  near  the 
internal  capsule,  which  was  also  implicated.  Partial  hemianopia  is 
often  due  to  disease  of  the  occipital  lobe,  and  upper  or  lower  quad- 
rantic  defects  are  said  to  be  due  to  disease  of  the  upper  or  lower  parts 
of  the  cuneus. 


FiG.  81. — Right  hemianopia,  partial,  involving  only  the  periphery  of  the 
half-field. 

The  acuity  of  central  vision  is  often  lowered  in  hemianopia,  even 
when  the  fixation  region  is  included  in  remaining  half-field.  Indeed, 
as  Wilbrand  has  suggested,  there  should  always  be  some  central 
amblyopia ;  if  fibres  from  the  macular  region  pass  by  each  optic  tract, 
the  loss  of  those  which  pass  by  one  tract  should  lessen  vision.  Of 
ninety-three  cases  collected  by  him,  central  amblyopia  was  noted, 
however,  only  in  fifty-three,  and  in  some  of  these  ophthalmoscopic 

*  In  the  case  here  figured,  and  in  another  figured  in  '  Diagnosis  of  Diseases  of 
the  Brain,'  in  which  a  quadrant  was  defective,  this  was  the  lower  one,  and  the 
hemianopia  was  left-sided.  Wilbrand's  statistics  give — left  hemianopia,  lower 
quadrant  in  twenty-one  and  upper  in  five  cases ;  right  hemianopia,  lower  quadrant 
three  and  upper  five — a  curious  difference.  A  case  is  recorded  by  Hun  ('  Amer. 
Journ.  Med.  Sci.,'  Jan.,  1887)  in  which  there  was  defect  of  the  inferior  quadrant  of 
left  field  and  superior  quadrant  (peripheral  part)  also  of  left  field  on  both  sides. 
The  autopsy  revealed  atrophy  of  inferior  part  of  the  right  crureus. 


OPTIC    JSEliVE.  155 

changes  were  present.  The  cases  which  I  have  carefully  examined 
show  that  some  diminution  of  acuity  can  be  detected,  if  a  stringent 
test  is  used,  even  though  a  cursory  examination  may  reveal  no  defect.* 
The  number  of  fibres  supplying  the  macular  region  is,  however,  so 
large  that  a  loss  even  of  one  half  may  have  but  a  slight  effect. 

In  many  cases  of  hemianopia  the  unaffected  half-fields  have  their 
normal  peripheral  extent.  In  other  cases  there  is  some  peripheral 
reduction,  slight  or  considerable,  and  this  when  there  is  no  peripheral 
lesion,  such  as  optic  neuritis,  to  which  it  can  be  ascribed.  The  reduc- 
tion has  hardly  received  the  attention  it  deserves.  The  half-field  is 
usually  smallest  in  the  eye  on  the  side  towards  which  sight  is  lost, 
i.  e.  opposite  to  the  lesion  ;  but  as  this  is  always  the  nasal  half-field, 
the  peripheral  reduction  may  not  seem  so  great  as  in  the  larger  tem- 
poral half-field  of  the  other  eye.  The  reduction  has  been  supposed 
to  be  due  to  the  lesion  being  in  the  optic  radiation  near  the  thalamus 
(Wilbrand),  but  it  may  be  absent  even  in  disease  of  the  occipital 
cortex. t     Its  probable  significance  will  be  considered  presently. 

Subjective  visual  impressions  are  sometimes  described  in  the  blind 
halves  of  the  fields,  usually  a  faintly  luminous  fog,  but  occasionally 
elaborate,  and  so  definite  as  to  amount  to  visual  hallucinations. 


Fig.  82. — Left  hemianopia,  with  a  great  reduction  of  remaining  half- 
fields,  accompanied  by  left  hemiplegia  and  recurring  left-sided  con- 
vulsions. The  symptoms  have  now  persisted  for  more  than  twelve 
years. 

Colour  Hemianopia. — In  ordinary  hemianopia  the  loss  for  colours 
corresponds  to  that  for  white.  If,  however,  there  is  a  limitation  of 
the  half -fields  for  white,  the  colour-fields  are  also  proportionally 
reduced  in  size.  It  is  a  remarkable  fact  that  there  maybe  hemianopia 
for  colours  when  there  is  none  for  white — "  hemiachromatopia.'* 
There  is  no  change  in  the  field  for  objects,  but  as  soon  as  the 
vertical  line  is  passed,  all  colours  appear  grey.  Several  cases  of  this 
remarkable  defect  are  on  record, J  and  it  might  perhaps  be  found 

*  Of  course  the  possibility  that  the  acuity  of  vision  may  not  have  been  normal' 
hefore  the  onset  of  the  hemianopia  must  be  borne  in  mind. 

■j"  E.g.  case  of  Curschmann,  'Cent.  f.  Augenh./  1879,  p.  181. 

X  Bjerrum, '  Cent,  f .  Augenheilk.,'  1881,  p.  471 ;  Samelsohn, '  Cent.  f.  med.  Wiss.,' 
1881,  Nos.  47  and  50;  Eperon,  'Arch.  d'Ophth.,'  1884,  p.  356;  Charpentier,  "De  la 
Vision,    &c,"    '  These   de    Paris,'  1877 ;    Swanzy,    '  Trans.  Oph.  Soc.,'  vol.  iii,   p. 


156  CRANIAL    NEEVES. 

more  frequently  if  the  colour-fields  were  tested  at  the  bedside  in 
all  cases  of  cerebral  disease.  The  dividing  line  appears  generally  to 
pass  through  the  fixation-point.  The  symptom  probably  depends 
on  disease  of  one  part  of  the  occipital  lobe,  and  is  proof  of  a  separate 
centre  for  colour  vision,  but  the  position  of  this  centre  is  not  yet 
known;  Wilbrand  suggests  that  it  is  in  some  part  of  the  occipital 
cortex  in  front  of  the  apical  region,  and  that  impressions  pass  through 
the  latter  to  reach  the  colour  centre,  since  disease  of  the  apex  causes 
complete  hemianopia. 

With  the  two  exceptions  just  mentioned — the  limitation  of  the 
remaining  half-fields,  and  the  isolated  loss  for  colours — there  are  no 
known  differences  in  the  character  of  hemianopia  that  are  due  to 
differences  in  the  seat  of  the  disease  in  the  optic  path  behind  the 
chiasma. 

Double  lateral  hemianopia,  if  complete,  necessarily  involves  total 
loss  of  sight.  It  has  been  known  to  result  from  successive  lesions  in 
the  two  occipital  lobes,  the  hemianopia  left  by  the  first  attack  chang- 
ing to  complete  amaurosis  when  the  second  occurred.*  A  remark- 
able case  of  complete  colour-blindness  with  apoplectiform  onset  is  on 
record.  The  acuity  and  fields  of  vision  were  normal.  Some  colour 
vision  was  regained,  but  there  was  persistent  blindness  to  red  and  green,  f 

Lateral  hemianopia  is  attended  by  no  resulting  ophthalmoscopic 
changes  in  the  early  stage.  Alterations  in  the  fundus  may  co-exist,  in 
consequence  either  of  the  nature  of  the  cerebral  lesion  (as  papillitis 
in  cases  of  tumour)  or  of  associated  morbid  states  (as  albuminuric 
retinitis  in  cerebral  haemorrhage).  After  some  months  or  years,  slight 
atrophic  changes  may  be  visible.  Some  have  thought  that  pallor 
could  be  observed  in  the  corresponding  half  of  each  disc.  I  have 
not  myself  been  able  to  recognise  this,  but  have  seen  the  disc  on  the 
side  on  which  the  temporal  half-field  was  lost  become  slightly  paler 
than  the  other.  This  is  explained  by  the  fact  that  the  area  of  field 
lost  is  greater  in  this  eye  than  in  the  other,  and  a  correspondingly 
larger  number  of  fibres  have  their  function  arrested. 

Lateral  hemianopia  which  has  lasted  for  some  weeks  in  complete 
degree  seldom  passes  away  altogether,  and  may  remain  permanent 
with  little  diminution.  Its  persistence  for  twenty-three  years  has  been 
observed  by  Seguin.J     When  a  complete  hemianopia  lessens,  it  may 

185.  Swanzy's  case  is  especially  important  because  there  was  a  reduction  of  the  upper 
part  of  the  field  for  white,  on  the  side  on  which  colour  vision  was  lost,  which 
suggests  that  the  centre  for  colours  is  adjacent  to  that  part  of  the  half-vision  centre 
in  which  the  upper  quadrant  is  represented.  The  remaining  half-fields  for  colours 
were  much  lessened,  and  it  appears  from  the  chart  that  there  was  a  slight  limitation 
in  that  for  white.  , 

*  Cases  recorded  by  Nothnagel  ('Topische  Diag.  des  Gehirukr.,'  p.  389);  Calmeil 
('  Mai.  de  Cerv.,'  vol.  ii,  p.  411) ;  N.  Moore  ('  St.  Barth.  Hosp.  Rep.,'  vol.  xv,  1879); 
Chvostek  ('Oest.  Zeitschril't '  and  '  Virchow's  Jahresb.,'  1872,  vol.  ii,  p.  49). 

f  Steffen,  'Arch.  f.  Ophth.,'  xxvii,  1881. 

J  '  Journal  of  Nervous  and  Meutal  Diseases,'  Jan.,  1886 


OPTIC    NERVE.  157 

do  so  from  the  medial  region  towards  the  periphery,  so  as  to  leave  a 
symmetrical  peripheral  loss,  as  in  Fig.  81,  or  else  from  above  or  below, 
so  as  to  leave  a  quadrantic  defect.  Rarely,  however,  it  clears  from 
the  periphery,  so  as  to  leave  symmetrical  scotomata,  having  one 
extremity  in  the  central  region.* 

Hemianopia  may  remain  for  a  long  time  unnoticed  by  the  patient, 
or  if  he  detects  a  change  in  vision  he  is  apt  to  think  that  there  is  a 
loss  of  sight  of  one  eye.  The  loss  is  especially  apt  to  escape  notice 
when  a  considerable  area  around  the  fixing-point  is  spared,  and  central 
vision  is  thus  but  little  affected.  In  one  case  the  loss  was  only  dis- 
covered when  it  was  noticed  by  the  nurse  that  the  patient  at  dinner 
never  ate  his  potatoes,  which  were  always  placed  on  one  side  of  the 
plate.  Hemianopic  patients,  in  circumstances  which  require  a  wide 
range  of  vision,  often  carry  the  head  turned  a  little  towards  the  blind 
side,  so  as  to  bring  objects  opposite  them  nearer  the  centre  of  the 
remaining  portion  of  the  field.  The  loss  sometimes  leads  to  accidents, 
especially  in  those  who  are  unaware  of  their  defect. 

Lateral  hemianopia  is  frequently  associated  with  other  symptoms. 
of  an  organic  lesion  of  the  brain.  Of  these,  hemiplegia,  transient  or 
permanent,  is  the  most  common,  and  is  present  in  at  least  half  the 
cases. f  The  loss  of  power  is  always  on  the  side  of  the  blindness 
when  the  two  are  the  result  of  a  single  lesion ;  the  patient  is  unable 
to  see  towards  the  side  that  he  is  unable  to  move.  Hemianaesthesia 
is  also  an  occasional  complication,  and  speech-defects  are  sometimes 
met  with  in  right-sided  cases.  The  significance  of  these  associations- 
will  be  described  in  the  chapter  on  "  Cerebral  Localisation." 

As  a  transient  symptom,  present  only  during  the  early  stage  of 
the  disease,  hemianopia  often  occurs  in  severe  lesions  of  one  cerebral 
hemisphere,  especially  in  cerebral  haemorrhage.  If  the  observer's 
finger  is  suddenly  brought  near  the  eye  of  the  patient,  first  from 
one  side  and  then  from  the  other,  it  will  be  found  that  there  is  a 
reflex  contraction  of  the  orbicularis  when  the  finger  approaches  from 
the  sound  side,  and  none  when  it  is  on  the  side  of  the  hemiplegia. 
This  seems  to  show  a  hemianopic  defect,  as  part  of  the  initial  general 
interference  with  the  functions  of  the  affected  hemisphere,  although 
when  the  patient  has  so  far  recovered  as  to  permit  an  examination  of 
the  field,  no  defect  can  be  discovered,  and  the  difference  in  reflex 
action  no  longer  exists. 

Transient  functional  hemianopia  is  common  as  a  part  of  the  pheno- 
mena of  migraine  ;  and,  like  other  manifestations  of  that  disease, 
sometimes  occurs  as  an  isolated  symptom,  apart  from  headache.     It 

*  See  a  case  recorded  by  Lang  arid  Fitzgerald,  'Trans.  Oph.  Soc.,'  vol.  ii,  p.  231, 
where  references  to  other  cases  will  be  found. 

f  The  proportion  of  published  cases  is  one  third  (59  of  154  cases  collected  by 
Wilbrand),  but  this  certainly  under-represents  the  proportion.  The  more  thorough 
examination  of  cases  now  made  reveals  hemianopia  in  so  many  cases  of  hemiplegia 
that  its  presence  does  not  lead  to  the  publication  of  the  case  unless  this  is  completed 
by  an  autopsy,  and  it  is  still  probably  undiscovered  in  many  cases  in  which  it  exists. 


158 


CRANIAL    NERVES. 


is  remarkable  that  hetnianopia  very  seldom  occurs  as  part  of  the 
functional  disturbance  of  hysteria,  in  which  another  form  of  sight- 
defect,  pi-esently  to  be  mentioned,  is  so  common.  Cases  of  hysterical 
hemianopia  are  on  record,*  but  of  a  large  uumber  of  cases  of  heini- 
anopia  that  have  come  under  my  observation,  one  only  may  have  been 
of  hysterical  origin. 

Oblique  or  horizontal  hemianopia  is  seldom  met  with,  and  needs 
further  study.  It  has  been  mentioned  that  the  dividing  line  in  lateral 
hemianopia  may  have  an  inclination  to  one  side  above  and  to  the 
opposite  side  below,  apparently  in  consequeuce  of  an  individual  pecu- 
liarity in  the  decussation.  It  is  conceivable  that  a  similar  deviation 
may  sometimes  give  rise  to  a  hemianopia  which  may  fairly  be  termed 
oblique.  Hemianopia  in  which  the  dividing  line  is  horizontal,  and 
an  upper  or  lower  half  is  blind,  is  very  rare.f  It  may  be  simulated 
by  a  symmetrical  lesion  of  the  optic  nerves,  or  maybe  a  compound  of 
double  partial  hemianopia,  in  which  the  two  lower  quadrants  are  lost. 
In  the  same  way  a  loss  of  the  lower  quadrant  on  the  one  side,  and 
the  upper  quadrant  on  the  other  side,  may  conceivably  be  produced 
(Wilbrand). 

Importance  has  been  attached  to  the  difference,  already  alluded 
to,  between  cases  in  which  the  blind  half-fields  appear  to  the  sufferer 
merely  vacant,  or  distinctly  black,  i.  e.  whether  there  is  or  is  not  a 
sense  of  entire  absence  of  light  in  them.  It  probably  depends  on  the 
state  of  the  visual  centres  in  the  cerebral  cortex,  especially  on  the 
higher  centre.  In  the  case  of  temporal  hemianopia,  shown  in  Fig.  73, 
the  patient,  a  medical  practitioner,  described  the  blind  halves  as 
appearing,  not  black,  but  like  a  fog;  nevertheless  he  could  not  even 
discern  a  light  in  them. 

A  third  form  of  si£,rht-defect  from  brain  disease  is  what  is  termed 


Fig.  83. — Concentric  reduction  of  fields  of  vision,  greater  (with  consider- 
able amblyopia)  in  the  left  eye,  accompanied  by  left  hemianesthesia 
and  slight  hemiplegia;  sudden  onset.  The  patient  was  a  woman 
sixty  years  of  age. 

*  Bonnefoy  ("Troubl.  de  la  Vision  de  l'hysterie,"  'These  de  Paris/  1874)  records 
some  cases  observed  at  the  Salpetriere.  Dr.  James  Anderson  (c  Ophth.  Rev.,'  Aug., 
18S5)  has  recorded  a  case  in  which,  along  with  undoubted  symptoms  of  hysteria, 
there  was  complete  blindness  of  the  lower  halves  of  the  fields,  with  contraction 
above  and  to  the  inner  side. 

f  A  case  of  loss  of  the  lower  half  of  each  field  is  recorded  by  Anderson,  '  Med. 
Times  and  Gazette,'  1885,  No.  1842. 


OPTIC    NEEVE.  159 

crossed  amblyopia  (see  p.  22).  There  is  dimness  of  sight  of  the 
eye  opposite  to  the  cerebral  lesion,  and  examination  of  the  field 
shows  this  to  be  concentrically  reduced  in  size,  in  varying  degree  in 
different  cases.  Sometimes  it  is  reduced  to  a  small  area,  extending 
only  just  beyond  the  blind  spot,  about  20°  around  the  fixing-point. 
The  colour-fields  are  also  reduced,  and  disappear  altogether  when  the 
diminution  for  white  is  considerable.  The  patient  does  not  complain 
of  the  sight  of  the  other  eye,  but  if 
it  is  tested  there  is  found  to  be  a 
reduction  in  this  field  also,  similar, 
but  much  slighter  in  degree,  and 
never  involving  entire  loss  of  the 
colour-fields,  even  of  that  for  red. 

This  form  of  sight -defect  is  similar 
to  that  which  often  occurs  in  hysteria 
in  association   with  hemianesthesia. 

Pathological  evidence  of  the  seat  of    . 

°  .  ■     .  Fig.   84. — Concentric  restriction  or 

morbid  process  is  meagre,  but  is  suffi-  the  field  of  the  left  eye  (acconi- 
cient  to  make  it  highly  probable  that  panied  by  amblyopia)  in  a  woman 
the  symptom  depends  on  disease  of       age 

the  cortex  of  the  lower  and  hinder  part  of  the  parietal  lobe,  the  supra- 
marginal  and  angular  convolutions.  In  the  few  fatal  cases  with  this 
loss,  the  disease  has  involved  this  region  (see  p.  22)  ;  while  the  sym- 
ptom is  not  caused  by  disease  of  the  occipital  lobe,  or  of  the  temporal 
lobe,  or  of  the  superior  parietal  lobule,  or  of  the  ascending  parietal. 
The  facts  of  disease  make  it  probable,  moreover,  (1)  that  the  eye  of  the 
same  side  must  be  represented  in  slight  degree  in  this  centre  as  well  as 
the  opposite  eye  in  chief  degree;  (2)  that  partial  disease  lowers  the  func- 
tion of  the  centre  as  a  whole,  and  does  not  cause  a  partial  loss  of  one 
part  of  the  field ;  and  (3)  that  the  centre  in  the  opposite  hemisphere 
can  supplement,  to  a  considerable  degree,  that  which  is  destroyed, 
since  the  affection  of  vision  usually  lessens  after  a  time.  Complete 
destruction  of  this  centre  does  not  cause  complete  loss  of  sight  of 
the  opposite  eye ;  some  vision  and  a  small  field  remain,  and  these 
must  be  due  to  the  representation  of  this  eye  in  the  other  hemisphere, 
i.  e.  in  the  hemisphere  on  the  same  side  as  the  eye  concerned.  But 
disease  of  this  region  seldom  is  complete,  because  the  blood-supply  to 
it  is  usually  shared  by  both  the  middle  cerebral  and  the  posterior 
cerebral.  Thus  each  higher  visual  centre  must  be  connected  with  both 
occipital  lobes  ;  the  connection  with  that  of  the  opposite  hemisphere 
must  be  by  the  fibres  of  the  corpus  callosum. 

*  The  right  eye  had  been  removed  many  years  before;  the  affection  of  vision  was 
attended  by  left  hemiansesthesia,  dulness  of  all  the  other  special  senses  on  the  left 
side,  and  severe  headache.  There  was  no  sjmptom  suggestive  of  hysteria.  Syphilis 
was  probable.  The  symptoms  developed  gradually,  and  increased  until  iodide  of 
potassium  was  given,  when  they  became  arrested,  and  they  had  distinctly  lessened 
when  the  patient  ceased  to  attend  the  hospital. 


160  CRANIAL    XEBVES. 

In  the  theory  here  advanced  to  account  for  crossed  amblyopia  we 
may  find  an  explanation  of  the  concentric  restriction  of  the  remaining 
half-fields,  often  met  with  in  hemianopia.  If  disease  of  the  occipital 
lobe,    causing   half -blindness,  extends  forward  to  the  higher  visual 


Fig-.  85. — Concentric  reduction  of  fields,  greater  in  the  right,  accom- 
panying right  hemiplegia  and  hemianesthesia  (complete).  The  onset 
was  preceded  by  headache  and  accompanied  by  convulsion.  The 
patient  was  a  young  woman,  probably  the  subject  of  syphilitic  vascular 
disease.  The  condition  of  the  paralysed  limbs  was  characteristic  of 
an  organic  lesion.     The  fields  were  taken  six  weeks  after  the  onset. 

centre,  in  proportion  to  the  damage  to  the  latter  the  remaining  half- 
fields  will  be  concentrically  reduced,  while  if  the  higher  centre  is  com- 
pletely destroyed,  the  half -field  of  the  opposite  eye  will  be  reduced  to 
very  narrow  dimensions,  vision  being  subserved  only  by  the  other 
hemisphere.  It  is  possible  that  a  lesion  of  the  white  substance 
beneath  this  region  may  have  a  similar  effect.  "We  need  more  facts 
before  any  confident  opinion  can  be  expressed  regarding  the  cause  or 
causes  of  this  concentric  contraction,  but  the  hypothesis  here  advanced 
is  supported  by  the  fact  that  the  reduction  of  the  half-field  is  often 
much  less  in  the  eye  on  the  side  of  the  lesion  than  in  the  other  eye, 
just  as  is  the  contraction  of  the  whole  field  when  the  higher  visual 
centre  is  alone  diseased.  In  the  cases  of  hemianopia  that  I  have  seen, 
in  which  the  fields  were  narrowed  without  peripheral  disease  of  the 
nerve,  and  in  which  there  were  other  localising  symptoms,  these 
pointed  to  disease  of  the  cortex.  Thus,  in  the  case  shown  in  Fig. 
82,  hemiplegia  was  associated  with  the  hemianopia,  and  was  accom- 
panied by  convulsions  in  the  paralysed  limbs,  commencing  locally,  and 
recurring  during  many  years — a  sure  sign  of  a  cortical  lesion.  There- 
are  few  recorded  pathological  observations  bearing  on  the  point,  but 
those  that  exist  confirm  the  view  here  expressed.* 

*  Thus,  in  a  case  of  right  hemianopia  recorded  by  Forster  (Graefe  u.  Saemisch's 
'Handbuch/  Bd.  vii,  p.  118),  in  which  the  peripheral  limitation  was  moderate  in 
degree,  the  lesion  involved  the  caudate  and  lenticular  nuclei,  and  also  the  cortex  in  a 
small  region  in  the  anterior  part  of  the  occipital  lobe  and  posterior  part  of  the 
angular  gyrus.  In  another  case  recorded  by  Hosch  ('  Klin.  Monatsbl.  f .  Augenkr.,' 
1878,  p.  281),  in  which  the  limitation  was  considerable,  a  lesion  in  the  occipital  lobe 
extended  from  the  neighbourhood  of  the  internal  capsule  up  to  the  grey  substance. 


omc   NERVE.  161 

Mind-blindness. — The  last  form  of  visual  defect  is  the  singulav 
condition  called  ''  mind-blindness,"  which  has  been  already  briefly 
mentioned.  The  term  was  given  by  Munk  to  a  condition  which  he 
produced  in  dogs  by  extirpating  parts  of  the  occipital  lobes.  The 
animals,  while  apparently  able  to  see,  failed  to  recognise  the  nature  of 
objects,  such  as  food  placed  before  them,  or  to  know  persons  with 
whom  they  had  previously  been  familiar.  A  similar  condition  has 
been  observed  in  a  few  cases  of  brain  disease.  Without  other  mental 
defect  there  has  seemed  to  be  an  entire  loss  of  visual  memory  ;  familiar 
places  and  faces  seemed  strange  and  unfamiliar,  and  even  the  nature 
of  familiar  objects  was  not  recoguised.*  The  loss  necessarily  includes 
that  of  visual  word-symbols. 

The  structures  that  subserve  the  functions  lost  in  mind-blindness 
are  certainly  separate  from  those  of  the  half-vision  centres,  since 
hemianopia  from  disease  of  the  cortex  does  not  necessarily  involve 
this  special  loss.  The  centres  concerned  are  probably  in  front  of  the 
half- vision  region,  either  in  the  anterior  part  of  the  occipital  lobes  or 
in  the  posterior  part  of  the  parietal  lobes.  The  latter  is  more  pro- 
bable (see  p.  22).  The  recognition  of  visual  word-symbols  is  sub- 
served by  structures  in  this  region  in  the  left  hemisphere,  and  the  loss 
of  this  function  may,  as  we  have  seen,  be  regarded  as  partial  mind- 
blindness.  We  do  not  know  whether  complete  mind-blindness  can 
be  produced  by  a  lesion  in  one  hemisphere,  or  whether  disease  of  both 
hemispheres  is  necessary  for  the  production  of  the  symptom.  Its 
extreme  rarity  is  in  favour  of  a  bilateral  cause,  and  experiments  on 
animals  suggest  the  same  conclusion.  When  the  condition  results  from 
disease  of  one  hemisphere  (as  in  the  case  figured  on  p.  23)  it  is  probably 
transient.  If,  however,  there  is  a  congenital  defect  or  a  previous 
lesion  in  the  higher  visual  region  of  one  hemisphere,  disease  limited  to 
the  other  hemisphere  might  give  rise  to  permanent  mind-blindness. 

Although  hemianopia  does  not  involve  mind-blindness,  the  two 
symptoms  have  been  associated.  In  one  case  described  by  Wilbrand, 
incomplete  left  hemianopia  was  associated  with  a  slight  defect  in  the 
lower  parts  of  the  right  half-fields,  suggestive  of  a  lesion  in  each 
hemisphere.  Another  case  is  recorded  by  Bernheim,  and  is  remark- 
able since  considerable  and  persistent  mind-blindness  (including 
word-blindness)  accompanied  left  hemianopia  in  a  left-handed  man.f 

In  this  case,  however,  there  were  retinal  changes.  In  a  case  recorded  by  Wernicke 
of  right  hemianopia  and  peripheral  limitation  of  the  fields,  the  lesion  of  the 
occipital  cortex  extended  to  the  posterior  part  of  the  angular  gyrus  ('  Gehirnkr.,' 
Bd.  ii,  p.  190).  On  the  other  hand,  in  a  case  of  disease  of  the  white  substance 
recorded  by  Westphal  ('  Charite-Annalen,'  Bd.  vi)  without  contraction  of  the  field 
the  cortex  appeared  normal.  A  cortical  lesion  did  not  extend  beyond  the  limits  of 
the  occipital  lobe  in  casps  without  concentric  limitation  recorded  by  Curschmann 
('  Cent,  f .  Augenh.,'  1879,  p.  181). 

*  Wilbrand  ('  Die  Seelenbliudheit,'  1S87)  has  analysed  at  great  length  the  rela- 
tions of  this  symptom  to  other  mental  processes. 

f  Berr.helm,  '  Revue  de  Med./  18S5,  p.  625.     This  case  is  consistent  with  the 

VOL.  II.  11 


162  CRANIAL    NERVES. 

In  connection  with  the  interference  with  the  higher  visual  func- 
tions of  the  brain,  it  may  be  noted  that  the  area  of  the  cortex,  which 
is  apparently  related  to  these  functions,  is  very  extensive.  In  no 
part  of  the  brain  is  the  difference  greater  between  the  brain  of  the 
monkey  and  that  of  man  than  in  the  region  of  the  angular  gyrus  (in 
its  wider,  sense,  see  p.  5).  This  region  in  man  exceeds  in  size  the 
whole  brain  of  the  monkey. 

Diagnosis. — Impairment  of  sight  in  one  eye  without  auy  affection 
of  the  other,  and  with  loss  of  action  of  the  pupil,  means  disease  of 
one  optic  nerve.  A  central  scotoma  generally  means  disease  of  the 
fibres  of  the  nerve  which,  at  the  back  of  the  orbit,  occupy  the  middle 
of  the  trunk.  Peripheral  limitation  of  the  field  may  be  due  to  damage 
to  the  peripheral  layer  of  the  nerve;  it  may  probably  also  be  the 
result  of  a  slight  degree  of  damage  to  all  the  fibres  of  the  nerve,  which 
produces  most  impairment  in  the  periphery  of  the  retina,  where  vision 
is  normally  dull,  and  is  extinguished  first  by  a  general  reduction  of 
function.  A  sectorial  defect  in  one  eye  only  means  damage  to  the 
nerve,  considerable  in  degree,  but  partial  in  extent.  Amblyopia  with 
concentric  reduction  of  the  field,  considerable  in  one  eye  and  slight  in 
the  other,  may  be  due  to  atrophy  or  to  disease  of  the  higher  visual 
centre  in  one  hemisphere.  In  the  first  the  ophthalmoscope  reveals 
the  signs  of  atrophy,  and  the  action  of  the  pupil  is  lessened;  in  the 
second  the  aspect  of  the  nerve  is  normal,  the  pupil  contracts  perfectly 
uuder  the  influence  of  light,  and  the  onset  is  either  sudden  or 
attended  with  other  indications  of  an  organic  cerebral  lesion.  In 
functional  (hysterical)  amblyopia  the  symptoms  are  the  same  as  in 
disease  of  the  higher  visual  centre,  and  the  diagnosis  depends  on 
other  indications  of  organic  or  functional  disease  respectively.  In  the 
rare  cases  of  functional  disease  in  which  sight  is  affected  in  one  eye 
only,  the  perfect  action  of  the  pupil  effectually  distinguishes  the  con- 
dition from  organic  disease  of  the  nerve.  Total  loss  of  sight  of  both 
eyes  may  be  due  to  chronic  atrophy,  to  damage  to  the  chiasma,  or  to 
disease  of  both  tracts  or  both  hemispheres.  In  all  cases  the  mode  of 
development  of  the  symptoms  aids  the  diagnosis,  the  symptoms  being 
at  first  partial  ;  and  their  character  indicates  clearly  the  position 
of  their  cause.  It  is  unnecessary  to  describe  in  detail  the  significance 
of  the  various  combinations  of  symptoms  which  sometimes  occur  in 
the  progress  from  partial  loss  to  total  blindness,  since  the  diagnosis 
involves  ouly  an  application  of  the  facts  already  given  in  the  account 
of  the  symptoms. 

Temporal  hemianopia  indicates  disease  of  the  chiasma.  The  combi- 
nation of  complete  blindness  in  one"  eye,  and  a  loss  of  the  temporal 
half-field  in  the  other,  generally  means  disease  of  the  chiasma  ex- 

sugsrestion  given  in  the  text  that  unilateral  disease  only  causes  persistent  mind- 
blindness  when  there  is  a  defect  in  the  opposite  hemisphere,  tor  left-handedness  is 
often  the  result  of  an  early  lesion  or  congenital  defect  of  the  left  hemisphere. 


OPTIC    NERVE.  163 

tending  to  the  outer  fibres  or  nerve,  and  often  to  the  optic  tract,  on 
tlie  side  on  which  the  blindness  is  complete. 

The  diagnosis  of  the  seat  and  nature  of  the  cause  of  lateral  heini- 
anopia  depends  on  the  mode  of  onset  and  the  associations  of  the  sym- 
ptom ;  it  is  a  question  of  cerebral  diagnosis,  and  will  be  considered  in 
the  chapter  on  "Localisation."  Besides  the  characters  already 
described,  a  distinction  between  disease  of  the  tract,  and  of  the  intra- 
cerebral path  and  centres,  has  been  found  in  the  action  of  the  pupil 
when  light  falls  some  distance  to  one  side  of  the  macula,  called  by 
Wernicke  the  "  hemiopic  pupil-reaction."*  When  the  light  is  thrown 
on  to  the  blind  half  of  the  retina  the  pnpil  contracts,  as  much  as  if 
the  light  is  thrown  on  the  seeing  half,  if  the  disease  is  in  the  hemi- 
sphere, but  does  not  contract  if  the  disease  is  in  the  tract,  because 
the  path  to  the  corpora  quadrigemina  is  then  interrupted.  The  test 
is  of  value,  although  much  care  is  required  in  its  employment,  and, 
with  small  pupils,  the  effect  may  be  difficult  to  discern,  and  a  negative 
result  is  ofteu  misleading. 

Prognosis. — The  prognosis  depends  on  the  nature  of  the  lesion 
causing  the  symptoms.  As  a  general  rule  it  is  not  good.  Consider- 
able defect  of  sight,  due  to  a  lesion  of  the  path  or  centres,  seldom 
passes  away  entirely.  Hemianopia  is  especially  persistent,  and  often 
presents  very  slight  improvement  even  when  the  lesion  has  been 
stationary  for  years. 

Treatment. — The  treatment  depends  on  the  nature  of  the  morbid 
process  causing  the  symptoms,  and  this  is  described  in  detail  in  the 
account  of  the  several  diseases. 

Functional  Amblyopia  and  Amaurosis. — Toxic  Amaurosis. — 
Bilateral  loss  of  sight,  usually  complete  in  degree  and  extent,  but  brief 
in  duration,  is  an  occasional  result  of  certain  toxic  blood- states.  It  is 
especially  common  as  a  consequence  of  uraemia.  The  loss  of  sight 
comes  on  suddenly  ;  sometimes  the  patient  wakes  up  blind.  The 
pupils  are  commonly  dilated  ;  they  may  or  may  not  act  to  light.  Other 
ursemic  symptoms,  such  as  convulsions,  usually  accompany  the  amau- 
rosis. Sight  returns  when  the  state  of  the  blood  is  improved  bv  treat- 
ment. There  are  no  ophthalmoscopic  changes  related  to  the  amau- 
rosis, but  albuminuric  retinitis  often  coincides  with  it.  A  similar 
amaurosis  has  been  met  with  in  cases  of  lead-poisoning.  In  poisoning 
by  quinine,  and  in  the  acute  anaemia  that  results  from  loss  of  blood, 
sight  is  sometimes  lost,  but  changes  in  the  retina  are  commonly  met 
with,  although  it  is  not  certain  that  these  changes  are  the  cause  of  the 
affection    of    vision.     The   variations  in  the  action   of   the  pupil  in 

*  Indicated  by  v.  Graefe,  and  described  by  Wilbrand,  •  Ueber  Hemianopsie,'  Ber- 
lin, 1881,  p.  89 ;  Wernicke,  '  Fortsch.  der  Med.,'  1883  ;  and  Seguin,  '  Journ.  Xerv. 
and  Mental  Diseases,'  1SS7,  who  observes  the  pupil  by  light  reflected  very  obliquely 
from  a  plane  mirror,  while  throwing  in  the  bright  light  with  an  ophthalmoscope 
mirror. 


164  CRANIAL    NERVES. 

different  eases  of  uraeraic  anmurosis  seem  to  show  that  the  nerve- 
elenients,  on  ■which  the  blood-state  acts,  are  not  always  the  same. 
Xerve-cells  are  more  susceptible  to  arrest  of  function  than  nerve- 
fibres,  and  therefore  we  must  assume  that  when  the  action  of  the 
pupil  is  preserved,  the  poison  acts  on  the  cerebral  visual  centres ;  and 
that  when  the  action  of  the  pupil  is  lost,  the  retina  itself  is  rendered 
insensitive,  either  alone  or  together  with  the  cerebral  centres.  If  the 
amaurosis  is  sometimes  of  retinal  origin  it  must  be  due  to  a  direct 
action  on  the  nerve-elements,  because  the  absence  of  any  change  in  the 
retinal  vessels  during  the  loss  of  sight  is  well  established. 

Migrainous  Hemianopia  has  been  already  mentioned,  and  will  be 
described  more  fully  in  the  account  of  migraine. 

Reflex  Ambhjojjia. — Vision  is  sometimes  impaired  in  one  eye  or  both 
by  irritation  of  other  nerves,  especially  by  that  of  the  fifth.  There  is 
often  a  concentric  contraction  of  the  field  of  vision,  but  seldom  com- 
plete loss  of  sight.  Vision  is  most  affected  on  the  side  of  the  fifth 
nerve  irritated,  and  the  interference  is  sometimes  confined  to  this 
eve.  The  stimulus  may  be  the  pain  of  neuralgia  or  an  irritation 
of  the  nerve  by  organic  disease  or  injury  ;  frequently  it  is  due  to  a 
carious  tooth.  The  tooih  is  generally  a  molar,  although  it  has  been 
fancied  that  a  recognition  of  th's  pathological  connection  underlies 
the  popular  name  of  "  eye-teeth  "  for  tie  canines.  The  branch 
irritated  has  been  generally  in  the  second  or  first  division  of  the  fifth 
nerve ;  sometimes  it  has  been  a  branch  of  the  eyeball  itself,  as  when 
amblyopia  accompanies  the  photophobia  of  corneal  or  conjunctival 
inflammation.  The  affection  of  sight  generally  subsides  when  the 
irritation  of  the  nerve  is  removed.  It  does  not  depend  on  any  visible 
change  in  the  retina,  although  vascular  dilatation  has  been  seen  in 
some  cases.  Its  mechanism  is  uncertain,  but  the  most  probable 
explanation  is  that  an  inhibitory  influence  is  exerted  on  the  nerve- 
cells  of  the  retina  or  on  the  visual  centres  in  the  brain.*  At  the 
same  time  it  must  be  remembered  that  a  similar  irritation  has  been 
known  to  set  up  an  actual  inflammation  in  the  eyeball.  Cases  have 
been  recorded  in  which  amaurosis  was  supposed  to  be  due  to  the 
irritation  of  intestinal  worms,  but  more  cannot  be  said  than  that  this 
is  a  possible  but  certainly  very  rare  cause. 

Hysterical  Amblyopia. — The  characters  of  the  loss  of  sight  that 
occurs  in  hysterical  hemiansesthesia  have  been  already  mentioned,  and 
will  be  again  considered  in  connection  with  the  other  symptoms  of 
this  disease.  The  loss  of  sight  is  scarcely  ever  complete,  and  when  it 
is  considerable  in  the  eye  on  the  anaesthetic  side,  it  is  usually  distinct, 
in  slighter  degree,  in  the  other  eye.  In  rare  cases  the  loss  does  not 
conform  to  this  type.  Thus  I  have  met  with  absolute  loss  of  sight 
in  one  eye  without  any  affection  of  the  other,  and  a  curious  case  of 

*  Compare  the  case  mentioned  on  p.  1G7,  iu  which  pain  in  one  eye  accompanied 
visual  disturbance  as  the  aura  of  fits  due  to  a  tumour  of  the  opposite  cerebral 
hemisphere. 


OPTIC    NELiVE.  165 

paroxysmal  complete  blindness,  associated  with  abductor  palsy  of 
the  larynx — both  certainly  "  functional  " — is  mentioned  in  the  chapter 
on  Hysteria. 

Amblyopia,  such  as  is  met  with  in  hysteria,  sometimes  occurs  as  an 
isolated  symptom.  Although  usually  transient,  it  is  sometimes  of 
very  long  duration,  and  may  perhaps  be  permanent — perpetuated 
by  changes  in  nutrition  which  increase  to  changes  in  structure. 
A  middle-aged  lady  who  had  suffered  from  various  symptoms  of 
functional  derangement  of  the  nervous  system,  cardiac  irregularity, 
vaso-motor  "swelling  of  the  hands,  &c,  complained  of  dimness  of 
sight  of  the  right  eye.  Acuity  of  vision  was  greatly  reduced,  and  the 
field  was  contracted  to  a  small  area  around  the  fixing-point.  The 
fundus  and  the  action  of  the  pupil  were  perfectly  normal.  At  no  time 
was  there  any  other  sensory  loss,  or  any  other  symptom  to  suggest 
an  organic  cerebral  lesion.  The  patient  was  seen  occasionally  during 
two  years,  and  in  that  time  the  condition  of  vision  and  of  the  eye 
remained  unchanged.  Sometimes  amaurosis,  coming  on  under  condi- 
tions suggestive  of  functional  disturbance,  goes  on  to  optic  nerve 
atrophy.  A  lady  was  always  peculiarly  sensitive  to  thunderstorms, 
although  not  specially  alarmed  at  them  ;  and  she  could  always  fore- 
tell a  coming  storm  with  remarkable  accuracy.  During  one  severe 
storm  she  became  suddenly  blind.  There  was  no  suspicion  of  a 
lightning-stroke.  Vision  never  returned.  I  only  saw  her  years  after 
the  onset,  and  there  was  then  simple  but  complete  atrophy  of  the 
optic  nerves.  Such  a  case  may  remind  us  of  Charcot's  patient  with 
hysterical  paraplegia,  who  recovered,  but  relapsed  under  a  mental 
shock,  and  the  paraplegia  became  perpetuated  as  lateral  sclerosis  of 
the  spinal  cord,  found  after  death. 

It  is  probable  that  the  seat  of  the  morbid  process  in  functional 
amblyopia  and  amaurosis  is  the  cortex  of  the  brain.*  The  hypothesis 
of  a  higher  visual  centre  in  each  hemisphere  enables  us  to  understand 
its  seat  more  readily  than  does  the  theory  that  the  half-vision  region 
constitutes  the  highest  visual  centre.  Crossed  amblyopia,  on  the 
latter  theory,  involves  the  assumption  that  there  is  a  combined 
partial  disturbance  of  both  hemispheres,  while  all  the  associated 
symptoms  point  to  the  disturbance  of  one  hemisphere  only.  The 
nature  of  the  change  is  a  matter  of  speculation.  Arrest  of  function 
in  the  nerve-cells  is  indicated  by  the  symptoms,  and  it  seems  more 
reasonable  to  regard  this  arrest  as  a  primary  inhibition  than,  by 
assuming  vaso-motor  spasm,  to  invoke  a  derangement  of  other 
nerve-cells  in  the  vaso-motor  centres.  Such  a  theory  only  explains 
the  condition  by  throwing  the  difficulty  further  back  into  the  obscurity 

*  Priestley  Smith  ('  Oplith.  Rev.,'  iii,  139)  urges  that  it  is  retinal.  Certainly 
either  hypothesis  explains  it.  When  slighter  contraction  of  the  other  field  co- 
exists, the  central  theory  best  explains  it.  Possibly  both  cortex  and  retina  have 
some  pathological  susceptibilities  in  common,  as  have  other  central  and  peripheral 
structures.     But  the  pupil-action  should  decide.     He  does  not  mention  this. 


166  CRANIAL    NERVES. 

of  the  sympathetic.  The  addition  to  this  theory,  favoured  in  France, 
that  the  vaso-rnotor  spasm  is  the  result  of  uterine  irritation,  need  ouly 
be  mentioned.  The  treatment  of  these  functional  conditions  is  that  ox 
the  general  nervous  states  of  which  they  commonly  form  part. 

Irritation  Symptoms  in  the  functions  of  the  optic  nerves  are  very 
rare  in  organic  disease,  although  common  in  certain  functional 
maladies,  especially  in  migraine  and  epilepsy.  In  migraine,  the  com- 
mon form  is  the  zigzag  appearance,  often  coloured,  and  known  as  the 
"  fortification  spectrum."  Similar  appearances  are  occasionally  seen 
without  other;  symptoms  of  migraine,  both  by  those  who  are  subject 
to  headaches  and  by  others.  One  patient  under  my  care  was  troubled 
with  these  appearances  for  years  as  an  isolated  symptom.  Often  the 
zigzag  was  arranged  in  definite  relation  to  some  actual  visual  image, 
as,  for  instance,  around  a  piata  which  was  before  him.  At  other 
times  the  spectrum  was  unilateral,  and  appeared  to  start  from  one 
edge  of  the  field  of  vision.  These  phenomena  are  described  more  fully 
in  the  chapter  on  Migraine. 

In  epilepsy  visual  impressions  are  very  common  as  the  aura  of  an 
attack,  or  as  constituting  a  minor  seizure.  They  are  exceedingly 
varied  in  charactei",  and  are  of  every  degree  of  elaboration,  from  a 
complex  visual  idea  (such  as  an  appearance  of  an  old  woman  in  a  red 
cloak)  to  a  simple  flash  of  light.  Stars,  or  a  luminous  ball  coming- 
nearer  or  receding,  are  other  forms.  Various  colours  are  sometimes 
seen,  especially  red  or  blue  ;  the  most  common  colour  is  a  yellowish 
red,  resembling  that  of  a  fire.  Simple  coloured  vision,  in  which  all 
objects  appear  coloured,  is  scarcely  ever  met  with.  An  apparent  in- 
crease or  reduction  in  the  size  of  objects  seen  by  the  patient  is  a  rare 
aura,  described  in  the  chapter  on  Epilepsy.*  I  have  known  micro  psy 
to  precede  migrainous  headaches.  Simple  coloured  vision,  red  or  blue, 
lasting  for  a  few  minutes,  may  occur  as  an  isolated  symptom  in  appa- 
rently healthy  individuals.  The  cause  of  the  coloured  vision  occasion- 
ally met  with  in  jaundice,  and  from  the  administration  of  santonin, 
is  not  known. 

Visual  hallucinations  are  common  in  delirium  and  insanity,  and 
similar  illusions  occasionally  occur  as  isolated  symptoms  in  various 
states  of  nervous  weakness.  They  are  especially  common  in  persons 
of  unstable  nervous  organisation,  in  whose  families  insanity  exists. 
Such  patients  are  often  persistently  annoyed  by  spectral  visions  of 
various  kinds,  grinning  faces,  horrible  sights,  and  the  like,  when  they 
close  their  eyes  and  try  to  sleep. f  Occasionally  similar  visions  disturb 
such  persons  in  their  waking  state.     Thus  one  young  lady  frequently 

*  In  the  author's  '  Epilepsy  and  other  Convulsive  Diseases '  a  full  analysis  of 
these  symptoms  will  be  found. 

f  Hemiopic  hallucinations  may  also  occur,  i.e.  the  images  of  objects  more  or  less 
familiar  in  the  halves  of  the  visual  fields.  Hemianopia  may  or  may  uot  be  present 
('  Laucet,'  1891,  i,  617).     See  also  p.  155. 


OPTIC    NERVE.  16? 

has  a  distinct  vision  of  a  rat  or  a  dog  running  across  the  room  in 
which,  she  is  sitting.  A  curious  relation  has  been  noted,  in  a  few 
cases,  between  such  illusions  and  functional  excitation  of  the  optic 
nerves.  We  have  just  seen  that  a  zigzag  spectrum  may  be  determined 
in  its  position  by  an  actual  sense  impression ;  in  the  cases  now  under 
consideration  a  distinct  false  vision  has  existed  only  when  the  eyes 
were  open,  and  has  disappeared  when  they  were  closed.  lb  would 
seem  that  the  nerve-cells  are  only  excited  to  morbid  action  by  func- 
tional stimulation.  In  a  curious  case,  recorded  by  Hammond,*  a 
woman,  dnring  many  months,  frequently  saw  before  her  the  image  of 
a  man  and  a  woman  whenever  her  eyes  were  opened,  and  could  at  any 
time  produce  the  vision  by  hanging  her  bead  down.  It  disappeared 
when  the  eyes  were  closed,  and  when  the  right  eye  was  closed  one  of 
the  figures  always  disappeared,  and  the  other  when  the  left  eye  was 
closed,  f 

As  a  result  of  organic  brain  disease,  a  visual  aura  has  preceded 
convulsions  in  several  cases  of  disease  of  the  occipital  lobe.  In  one 
case  of  a  tumour  of  the  occipital  cortex  extending  as  far  as  the 
angular  gyrus,  the  aura  was  a  flash  of  light  referred  to  the  left  eye 
and  an  apparent  diminution  in  the  size  of  objects  seen,  and  sometimes 
pain  in  the  eyeball. £  In  another  case,  with  visual  aura,  recorded  bv 
Traube,  the  disease  was  a  cyst  in  the  white  substance  of  the  occipital 
lobe.§ 

Ocular  Hyioerassthesia. — A  simple  increased  sensitiveness  of  the  optic 
nerve,  involving  merely  an  ability  to  perceive  a  slighter  amount  of 
light  or  smaller  objects  thau  can  be  perceived  by  individuals  with 
normal  vision,  scarcely  occurs  as  an  effect  of  disease.  The  power  of 
seeing  with  the  naked  eye  the  satellites  of  Jupiter  may  be  relegated  to 
the  category  of  physiological  curiosities.  The  term  "  hyperaesthesia  " 
is  commonly  used  in  connection  with  sight  to  denote  the  condition  in 
which  distress  or  pain  is  produced  by  an  amount  of  light  which  causes 
no  inconvenience  in  health.  Such  intolerance  is  common  in  many 
ocular  inflammations  or  irritation,  especially  in  iritis  and  keratitis, 
and  is  then  termed  "photophobia."  Apart  from  ocular  disease  it 
occurs  in  weak  states  of  the  nervous  system,  especially  in  women,  and 
sometimes  in  association  with  symptoms  of  hysteria.  In  these  cases 
it  is  termed  "retinal  hypersesthesia,"  but  it  is  not  certain  that  the 
morbid  state  is  retinal.  The  symptom  was  once  thought  to  indicate 
inflammation  of  the  retina,  but  in  most  of  these  cases  the  deeper  parts* 
of  the  eye  are  normal,  and  actual  retinitis,  strange  to  say,  may  cause 

*  '  Journal  of  Nervous  and  ifental  Disease,'  1885,  p.  467. 

t  A  relation  which  we  can  understand  on  the  theory  that  in  the  higher  visual 
centre  the  opposite  eye  is  chiefly  represented,  but  not  on  the  current  hypothesis 
that  the  half-vision  relation  obtains  in  the  higher  as  in  the  lower  visual  regions. 

X  'Lancet,'  1879,  vol.  i,  p.  363. 

§  '  Gesnmmt.  Beitrage,'  Bd.  ii,  p.  1083.  Another  case  is  recorded  by  Westphal, 
'  Charite-Annalen,'  Bd.  vi. 


]63  CBANIAL    NE  LIVES. 

no  intolerance,  nor  does  this  ever  result  from  simple  neuritis.  Even 
in  health  an  excessive  amount  of  light  is  distressing,  and  in  albinoes 
may  act  painfully  on  the  retina  when  that  which  falls  on  the  eye  is 
not  more  than  can  be  borne  by  a  normal  individual.  Optic- hyper- 
esthesia is  sometimes  accompanied  by  lessened  power  of  sight,  or 
rather  bv  extreme  readiness  of  exhaustion,  so  that  the  field  of  vision 
quickly  contracts  under  examination,  and  use  of  the  eyes  rapidly  dims 
the  sight.  Intolerance  of  light  is  always  associated  with  a  tendency 
to  protect  the  eye  by  closing  the  lids — "  blepharospasm."  This  may 
exist,  however,  without  real  intolerance  of  light. 

It  is  remarkable  that  the  diseases  that  most  readily  produce  photo- 
phobia are  those  of  structures  that  are  supplied  by  the  fifth  nerve. 
The  reflex  consequence,  closure  of  the  eyelids,  is  related  to  both  the 
fifth  and  the  optic  nerves,  which  guard  the  eye  from  mechanical  injury 
and  from  an  excess  of  light.  It  is  probahle  that  there  is  a  relation 
between  the  centres  for  the  two  centripetal  nerves  concerned,  so  that 
increased  action  of  the  centres  of  the  fifth  alters  the  sensibility  of  those 
for  vision.  At  the  same  time  the  possibility  that  light  may  influence 
the  fifth  nerve  in  the  eye  cannot  be  altogether  excluded.  A  curious 
case  has  been  recorded  by  Hutchinson  in  which  photophobia  was  pro- 
duced by  corneal  inflammation  in  a  blind  eye. 

The  treatment  of  intolerance  of  light  is,  first,  the  removal  of  its 
cause,  whether  this  is  disease  in  the  region  of  the  fifth  nerve  or  defec- 
tive nutrition  of  the  nervous  system;  and  secondly,  the  diminution  of 
the  surface  sensitiveness  of  the  eye,  especially  by  the  instillation  of 
cocain,  and  by  cold  douches. 


MOTOR  NERVES   OF   THE   EYEBALL. 
(third,  fourth,  and  sixth  nerves.) 

The  motor  nerves  of  the  eyeball  are  the  third,  fourth,  sixth,  and 
sympathetic.  Tbe  external  muscles  are  supplied  by  the  three  former, 
the  internal  muscles  by  the  third  nerve  and  the  sympathetic.  It  will 
Jbe  convenient  to  reserve  for  special  description  the  affections  of  the 
internal  muscles,  and  to  consider  first  the  general  symptoms  of  para- 
lysis of  the  external  muscles,  the  special  symptoms  of  disease  of  each 
nerve,  and  the  causes  and  treatment  of  such  disease. 

When  there  is  no  muscular  contraction  the  eyeball  is  in  the  position 
of  rest,  and  in  this  position,  under  normal  circumstances,  the  line  of 
vision  is  at  right  angles  to  the  plane  of  the  face.  This  is  termed  its 
"  primary  position."  Any  deviation  from  the  primary  position  is  due 
to  muscular  action.     Many  movements  are  produced  by  more  than 


OCULAK,    KEEVKS. 


169 


one  muscle.  Each  of  the  straight  muscles  turns  the  eyeball  in  the 
direction  indicated  by  its  special  name,  but  the  superior  and  inferior 
recti,  in  consequence  of  their  origin  being  nearer  the  middle  line  of 
the  body  than  is  their  attachment  to  the  eyeball,  tend  to  turn  the 
eyeball  inwards  and  to  rotate  it,  so  as  to  incline  the  vertical  axis  of 
the  globe.  The  upper  end  of  this  vertical  axis  (which  it  is  convenient 
to  indicate  by  S.)  is  inclined  inwards  by  the  superior  rectus,  outwards 
by  the  inferior  rectus.  This  tendency  to  rotation  is  counteracted  by 
the  simultaneous  contraction  of  the  oblique  muscles  ;  the  inferior, 
which  rotates  S.  outwards,  acts  with  the  superior  rectus  ;  the  superior 
oblique,  which  rotates  S.  inwards,  acts  with  the  inferior  rectus.  The 
oblique  muscles  also  counteract  the  inward  movement  of  the  globe 
on  its  vertical  axis,  caused  by  the  superior  and  inferior  recti,  and 


SUP.    REXTU-0  INF.  OBLIQUE 


INF.  RECTUS  5UP.  OBLIQUC 


->*  <■ 


Fig.  86. 


Fig.  87. 


Fig.  86.  —  Action  of  eWators  of  right  eye;  the  arrow-heads  indicate  the 
direction  of  movement  produced  by  the  muscles  named.  The  curved  lines 
represent  the  rotation  on  the  anteroposterior  axis,  the  vertical  lines  that 
on  the  transverse  axis,  and  the  horizontal  lines  that  on  the  vertical  axis  of 
the  eyeball. 

Fig.  87. — Action  of  depressors  of  right  eye.    See  last  fig.  and  description. 

they  also  assist  the  recti  in  moving  the  eyeball  upwards  and  down- 
wards, having  a  slight  elevating  and  depressing  action  (see  diagrams, 
Figs.  86  and  87).  When  the  eyeball  is  moved  diagonally  the  lateral 
rectus  acquires  a  rotating  influence,  but  this  is  counteracted  by  the 
opposite  tendency  of  the  associated  superior  or  inferior  rectus.  In 
the  case  of  slight  inward  diagonal  movements  the  rotating  tendency 
of  the  superior  and  inferior  recti  corresponds  with  that  of  the  lateral 
muscle  concerned,  and  must  therefore  be  counteracted  by  an  oblique 
muscle. 

The  origin  of  the  eyeball  nerves  has  been  already  described  (p.  52). 
The  tract  of  grey  matter  beneath  the  aqueduct  of  Sylvius,  which  gives 
origin  to  the  third  nerves,  is  continuous  behind  (i.  e.  below)  with  that 
of  the  nuclei  of  the  fourth  nerves,  and  is  connected  with  the  apparently 
separate  nucleus  of  the  sixth  by  the  posterior  horizontal  fibres;  We 
have  as  yet  no  complete  evidence  of  the  precise  distribution  of  func- 
tion in  the  nucleus  of  the  third  nerve  in  man.      The  conclusion  of 


Ciliary  muscle. 
Sphincter  iridis. 
Lev.  palp. 

Rect.  Int.     Eect.  sup. 
Rect.  infer.     Obliq.  inf. 
(Obliq.  sup.,  4th  n.) 


170  CRANIAL    SERVES. 

Hensen  and  Voelcker,*  from  tbeir  experi- 
ments on  dogs,  has  been  stated  at  p.  53.     A  Mid-Line, 
case    investigated    by   Kabler    and    Pickf 
suggests  that  the  arrangement  of  centres  is 
not  simply  from  before  back,  but  that  there 
is   also   a   lateral    difference    of    function. 
They  suggest  the  accompanying  modifica- 
tion of  the  plan  of  Hensen  and  Yoelcker. 
The  evidence  is  strong  that  the  anterior  part  of  the  nucleus  controls 
accommodation,  and  the  next  the  action  of  the  iris  to  light,  and  that 
these  functions  are  subserved  by  the  anterior  fasciculi  of  the  roots  of 
the  nerve, J  while  a  small  haemorrhage  behiud  these  centres  has  para-/ 
lysed  the  two  internal  recti. § 

The  relation  between  the  internal  rectus  and  the  opposite  external 
rectus,  and  the  anatomical  arrangement  concerned  in  the  lateral 
movement  of  the  eyes,  will  be  described  in  the  account  of  their 
conjoint  palsy. 

G-eneeax  Symptoms  of  Paealtsis. — Loss  of  power  in  the  ocular 
muscles  is  indicated  by  five  kinds  of  symptoms :  limitation  of  move- 
ment, non-correspondence  of  visual  axes  (i.  e.  strabismus),  secondary 
deviation  of  the  sound  eye,  erroneous  projection  of  the  field  of  vision, 
and  diplopia.  Strabismus  and  diplopia  may  result  from  spasm,  but 
persistent  spasm  is  rare  except  as  the  common  form  of  "  squint,"  and 
in  this  diplopia  is  absent,  for  a  reason  that  will  be  presently 
meutioned.  An  abnormal  state  of  the  eyeball  muscles  must  not  be 
assumed  from  the  posture  during  comatose  states.  In  sleep  stupor, 
as  in  common  sleep,  the  globes  may  diverge  and  be  directed  upwards; 
one  may  be  higher  than  the  other,  and  on  the  patient  being  roused 
they  may  at  once  assume  a  normal  position.  Moreover,  a  congenital 
difference  of  position  is  far  from  rare,  and  may  readily  mislead ;  it 
may  also  result  from  old  and  forgotten  injury. 

Limitation  of  Movement. — If  a  muscle  is  paralysed,  the  eyeball 
cannot  be  moved  so  far  as  normal  in  the  direction  of  action  of  that 
muscle.  In  complete  yjalsy  the  defect  is  absolute  ;  the  eyeball  cannot 
be  moved  beyond  mid-position  unless  slight  movement  by  other 
muscles  is  possible.  After  a  time  the  globe  is  fixed  in  the  opposite 
position  by  contraction  of  the  unopposed  antagonist  of  the  paralysed 

*  '  Arch,  f .  Ophth.,'  Bd.  xxiv,  1878,  p.  1.     See  also  p.  53. 

f  '  Prag.  Zeitsch.  f.  Heilk.,'  1881,  p.  301,  and  '  Cent.  f.  Augenh./  1883.  The 
chief  evidence  is  that  in  two  cases  of  nuclear  disease  and  palsy  of  some  muscles 
there  was  a  marked  difference  in  the  affection  of  the  medial  and  literal  fibres  of 
some  fasciculi.     The  observed  grouping  of  palsy  in  disease  is  seldom  significant. 

+  It  is  not  probable  that  the  position  of  these  centres  in  nun  is  as  far  forwards 
Ueneath  the  floor  of  the  third  ventricle  as  it  is  in  dogs,  and  as  it  has  been  assumed 
to  be  in  man  by  some  writers.  The  nuclei  of  the  third  nerves  cannot  be  traced 
farther  forwards  th:in  the  position  of  the  posterior  commissure. 

§   Bouchard,  '  Rev.  de  Med./  1891. 


OUULAR    NEEVES.  171 

muscle.  Thus  in  paralysis  of  the  external  rectus  the  eyeball  cannot 
be  moved  outwards,  and  after  a  time  is  turned  inwards  by  the  con- 
tracture of  the  internal  rectus.  If  the  paralysis  is  incomplete,  move- 
ment is  deficient  in  proportion  to  the  amount  of  palsy,  and  towards 
the  limit  of  movement  the  motion  is  often  jerky  ("  paralytic  nystag- 
mus") from  remissions  in  the  contraction,  analogous  to  tremor  in  a 
weak  limb.  When  both  eyes  are  open,  and  acting  together,  the  extent 
of  movement  is  usually  less  than  when  the  other  eye  is  closed  and  the 
patient  uses  the  affected  eye  only,  and  is  compelled  to  strive  to  "  fix  " 
the  object  with  it. 

Strabismus  and  Secondary  Deviation. — In  consequence  of  the  defect 
in  movement,  the  axes  of  the  two  eyes  do  not  correspond  in  positions 
that  necessitate  the  action  of  the  paralysed  muscle.  If  a  lateral  rectus 
is  affected,  the  axes  converge  or  diverge,  producing  convergent  or 
divergent  "  strabismus,"  which  increases,  the  greater  the  degree  of 
movement  of  the  sound  eye  in  the  direction  of  action  of  the  paralysed 
muscle.  Paralysis  of  the  external  rectus  causes  convergent  strabismus, 
that  of  the  internal  rectus  divergent  strabismus.  The  deviation  of 
the  axis  of  the  paralysed  eye  from  parallelism  with  that  of  the  sound 
eye  is  termed  the  "  primary  deviation."  If  the  sound  eye  is  pre- 
vented from  seeing  the  object,  and  the  patient  looks  at  this  (is  made 
to  "fix"  it)  only  with  the  affected  eye,  the  sound  eye  is  moved  still 
farther  in  that  direction,  and  hence  the  deviation  of  the  visual  axes  is 
increased.  This  is  called  the  "secondary  deviation."  Its  existence 
and  amount  may  be  best  ascertained  by  subsequently  covering  the 
paralysed  eye,  and  making  the  patient  "  fix  "  with  the  unaffected  eve, 
which  has  then  to  move  back  to  its  former  position.  The  hand,  or  a 
piece  of  paper,  may  be  so  placed  as  to  intercept  the  vision  of  the  one 
eye,  while  leaving  it  exposed  to  observation.  A  piece  of  ground  glass 
placed  over  the  eye  answers  the  same  purpose,  and  permits  observa- 
tion. The  occurrence  of  secondary  deviation  depends  on  the  fact  that 
normally  two  muscles  which  act  together  are  equally  innervated  for  a 
given  movement.  If  one  is  weak,  and  an  effort  is  made  to  contract  it 
(as  in  fixing  with  that  eye),  the  increased  innervation  influences  also 
the  other  muscle,  and  causes  an  undue  contraction.  It  is  as  if  a  rein 
acted  equally  on  a  hard-mouthed  and  a  tender-mouthed  horse  yoked 
together ;  the  effort  to  make  the  former  deviate  would  cause  an 
excessive  deviation  of  the  latter.  The  secondary  deviation  is  a 
delicate  test  for  weakness  of  an  ocular  muscle,  and  may  reveal  its 
existence  when  the  primary  deviation  is  too  slight  to  be  observed. 
Moreover  these  deviations  afford  a  distinction  from  strabismus  due 
to  muscular  spasm,  such  as  ordinary  squint.  In  the  latter  the  devia- 
tion exists  in  all  movements ;  in  paralytic  strabismus,  only  in  those 
movements  that  call  into  action  the  paralysed  muscle.  In  ordinary 
strabismus,  the  deviation  is  the  same  whether  the  patient  fixes  with 
one  eye  or  with  the  other;  in  paralytic  strabismus  fixation  with  the 
normal  eye  evokes  the  primary,  and  that  with  the  affected  eye  the 


3  72  OBANIAL    NERVES. 

secondary  deviation:  these  two  are  similar  in  direction,  but  opposite 
in  character,  the  primary  being  a  defect,  and  the  secondary  an  excess 
of  movement. 

Erroneous  Projection. — An  interesting  and  important  effect  of  the 
increased  innervation  that  causes  tbe  secondary  deviation,  is  erroneous 
projection  of  the  visual  field.  We  judge  of  the  relation  of  external 
objects  to  each  other  by  the  relation  of  tlie'r  imagos  on  tbe  retina; 
but  we  judge  of  their  relation  to  our  own  body  by  the  position  of  the 
eyeball  as  indicated  to  us  by  the  innervation  we  give  to  the  ocular 
muscles.  When  there  is  no  muscular  effort,  and  the  eyes  are  at  rest 
in  mid-position,  we  know,  to  use  popular  language,  that  an  object  at 
which  we  are  looking  is  opposite  our  face;  that  is,  that  a  line  from 
the  centre  of  the  field  of  vision  to  the  macula  lutea  is  perpen- 
dicular to  the  facial  plane.  If  we  turn  the  eyes  towards  one  side,  we 
know  that  an  object  in  the  middle  of  the  field  is  to  the  side  of  its 
former  position ;  how  far  to  that  side  we  estimate  by  the  degree  of 
movement  of  the  eyes  indicated  by  the  amount  of  innervation  ;  and  if 
we  want  to  touch  the  object,  the  knowledge  thus  gained  enables  us 
to  so  contract  the  muscles  of  the  arm  as  to  effect  tbe  desired  move- 
ment with  precision.  But  the  increased  innervation  needed  by  a  weak 
ocular  muscle  gives  the  impression  of  a  greater  movement  of  the  eye 
than  has  really  taken  place,  and  suggests  that  the  objects  seen  are 
further  from  the  middle  line  than  they  really  are.  If  the  patient 
then  attempts  to  touch  an  object,  the  finger  goes  beyond  it.  The 
erroneous  projection  exists,  of  course,  only  in  those  movements  of  the 
eyes  for  which  the  weak  muscle  is  necessary.  It  is  greatest  when  the 
affected  eye  is  used  alone ;  it  disappears  altogether  when  this  is  closed. 
The  erroneous  projection  is  always  in  the  direction  of  action  of  the 
affected  muscle.  The  knowledge  of  the  relation  of  external  objects 
to  the  body,  gained  from  the  contraction  (i.  e.  innervation)  of  the 
eyeball  muscles,  is  one  of  the  most  important  sources  of  guidance  to 
the  centres  that  regulate  the  muscular  contractions  for  maintaining  the 
equilibrium  of  the  body.  The  erroneous  projection  of  the  field  destroys 
the  harmony  between  the  visual  impressions  and  the  others  that  are 
correct;  the  resulting  discord  and  its  consequences  may  affect  con- 
sciousness as  the  sensation  of  "  giddiness."  This  giddiness  depend- 
ing on  paralysis  of  an  ocular  muscle,  is  termed  "  ocular  vertigo." 

Double  Vision. — We  have  seen  that  the  field  of  vision  of  the  para- 
lysed eye  is  erroneously  projected.  Each  object  in  the  field  is  referred 
to  a  position  other  than  that  which  it  actually  occupies,  and  corre- 
sponding to  the  degree  of  ineffectual  innervation.  But  if  the  patient 
looks  with  both  eyes,  the  field  of  the  unaffected  eye,  being  normally 
projected,  does  not  correspond  with  the  field  of  the  affected  eve ;  the 
images  formed  in  the  two  eyes  are  mentally  referred  to  different  posi- 
tions; objects  are  seen  double.  The  patient  is  conscious  of  the 
doubling  only  of  that  object  the  image  of  which  is  formed  at  the 
macula  lutea  of  one  eye  or  the  other,  that  is  of  tbe  object  which  is 


OCULAR    NERVES. 


173 


fixed  by  one  eye,  for  which  the  eye  is  accommodated,  ami  to  which  the 
attention  is  directed.  The  image  formed  in  the  unaffected  eye,  being 
referred  to  its  correct  position,  is  termed  the  "  true  image,"  the  other 
is  termed  the  "  false  image."  The  distance  between  the  two  images 
depends  on  the  amount  of  the  error  of  projection,  and  corresponds  to 
the  degree  of  deviation  of  the  eyeball  from  the  position  wLich  it 
should  occupy  with  that  amount  of 
innervation.  In  consequence  of 
this  deviation  of  the  two  visual 
axes,  the  retinal  image  is  formed 
at  the  macula  lutea  only  in  one 
eye  (the  fixing  eye).  In  the  other 
eye  it  falls  upon  a  part  of  the 
retina  away  from  the  macula,  at  a 
distance  from  it  which  corresponds 
with  the  degree  of  deviation,  and 
therefore  with  the  amount  of  erro- 
neous projection.  It  was  formerly 
thought  that  the  circumstance  that 
the  two  images  are  formed  upon 
non-corresponding  parts  of  the  two 
retina?  affords  an  adequate  expla- 
nation of  the  diplopia.  But  the 
diplopia  which  occurs  in  secondary 

contracture  of  a  muscle  cannot  be    Fl(?'  88.— Diagram  to  illustrate  the  pro- 
duction or  diplopia  by  the  eironeous 


explained  by  the  simple  theory  of 
non-correspondence  of  retinal  areas, 
muscle — the  right  external  rectus, 
for  instance  —  is  paralysed,  and 
when  all  the  muscles  are  at  rest  and 
each  eye  should  be  directed  straight 
forwards,  the  right  eye  is  turned  in- 
wards by  the  permanent  shortening 
of  the  unopposed  internal  rectus. 
The  image  of  an  object  opposite 


projection.  In  consequence  of  weak- 
ness of  the  right  external  rectus  the 
image  of  A  formed  at  the  macula,  M, 
of  the  left  eye,  falls  within  the  macula 
of  the  right  eye  at  a.  But  the  effort 
corresponds  to  that  necessary  to  bring 
the  macula  to  m  (in  the  broken  arc). 
Hence  B,  whose  image  is  at  m,  seems 
to  occupy  the  position  of  A,  and  the 
image  formed  at  a  to  the  left  of  m 
is  projected  to  the  other  side  of  A, 
and  seems  to  occupy  the  position  C, 
as  if  it  were  formed  at  c  to  the  left 
of  m. 


the  eye  is  formed  on  the  macula 
lutea  of  the  left  eye,  but  to  the  inner  side  of  the  macula  lutea  of 
the  right.  That  this  is  no  reason  why  there  should  he  diplopia  will 
be  evident  if  we  suppose  for  a  moment  that  the  patient  has  only  the 
right  eye,  that  this  is  normal  and  voluntarily  turned  to  the  left;  It  is 
clear  that  the  object  in  the  position  supposed  will  be  seen  (not 
distinctly,  because  its  image  falls  on  an  excentric  part  of  the  retina) 
in  its  actual  place.  So,  too,  if  we  suppose  the  patient  to  have 
only  the  left  eye,  and  that  this  is  directed  towards  the  object; 
this  will  also  be  seen  in  its  normal  place.  Thus  there  is  no  reason 
in  the  mere  deviation  of  the  eyes,  and  the  non-correspondence  in 
position  of  the  retinal  images,  why  the  object  should  be  seen  in  this 


174  CEAN1AL    NERVES. 

eye  in  an  erroneous  position,— why  there  should  be  double  vision. 
The  explanation  is  that  in  the  case  supposed — of  a  normal  eye 
being  turned  to  the  left — the  field  is  mentally  projected  to  the 
left,  in  correspondence  with  the  degree  of  active  muscular  inner- 
vation ;  the  centre  of  the  field  lies  thus  to  the  left,  and  the  object 
straight  in  front  is  referred  to  its  proper  excentric  position  in  the 
field.  But  in  the  case  of  the  contractured,  eye  all  the  muscles  are 
at  rest ;  the  field  is  referred  to  the  position  normally  corresponding 
to  rest,  the  centre  of  the  field  is  projected  directly  in  front,  the 
excentric  image  of  the  object  is  referred  to  an  excentric  position  in 
the  field,  and  the  patient  sees  the  object  in  a  false  position  with  this 
eye,  in  the  real  one  with  the  other.  Thus  the  non-correspondence 
of  the  retinal  images  does  not  explain  the  diplopia,  except  with 
the  help  of  the  erroneous  projection.  The  latter  does  explain  it 
without  the  former.  Nevertheless,  if  there  is  no  contracture,  and  the 
paralysed  eye,  when  at  rest,  is  in  mid-position  (as  in  recent  paralysis), 
the  facts  of  diplopia  may  be  explained,  and  its  laws  formulated,  on 
either  hypothesis. 

Diplopia  exists  equally  whether  the  patient  fixes  with  the  normal  or 
with  the  paralysed  eye,  but  in  the  former  case  the  true,  in  the  latter 
the  false  object  is  the  more  distinct,  that  image  being  always  the  more 
distinct  which  is  formed  at  the  macula.  The  distance  between  the 
double  images  is  greater  when  fixation  is  by  the  paralysed  eye,  because 
the  greater  muscular  effort  results  in  a  wider  error  of  projection ;  of 
this  greater  effort  the  secondary  deviation  of  the  non-paralysed  eye 
is  evidence.  As  G-raefe  has  pointed  out,  if  the  patient  moves  his 
finger  from  the  fixing  (paralysed)  eye  to  the  apparent  image,  in  trying 
to  touch  it,  the  line  taken  by  the  finger  coiTesponcls  in  direction  with 
the  visual  line  of  the  other  (secondary  deviating)  eye  ;  each  repre- 
sents the  excessive  amount  of  muscular  innervation,  and  the  degree  of 
excess  is  a  measure  of  the  erroneous  projection  of  the  field  of  the 
paralysed  eye. 

In  recent  paralysis,  diplopia  exists  only  when  the  eyeball  is  in  a 
position  that  needs  the  action  of  the  paralysed  muscle.  In  old  cases 
with  secondary  contracture  and  permanent  deviation,  diplopia  may 
occur  during  rest,  or  even  during  other  movements.  The  distance 
between  the  double  images  increases,  the  farther  the  object  is  moved 
in  the  line  of  action  of  the  affected  muscle.  As  a  rule  it  is  the  false 
image  which  appears  to  move  from  the  other,  and  the  direction  of  its 
movement  is  that  of  the  action  of  the  muscle. 

The  false  image  may  be  on  the  same  side  of  the  other  as,  the  eye  by 
which  it  is  seen  (homonym,ous  or  simple  diplopia),  or  it  may  be  on  the 
other  side  (crossed  diplopia?).  When  the  muscle  which  is  paralysed  is 
an  abductor,  and  the  eyes  therefore  converge,  the  diplopia  is  simple  ; 
when  the  muscle  is  an  adductor,  and  the  eyes  diverge  in  paralysis,  the 
diplopia  is  crossed.  This  depends  on  the  fact  that,  in  the  former  case 
(of  convergent  strabismus  frorn  loss  of  abduction),  the  false  image  is 


OCULAR    NERVES.  175 

formed  on  the  side  of  the  retina  towards  the  sound  eye,  and  is  therefore 
projected  on  the  other  side  of  the  real  object.  In  the  case  of  divergent 
strabismus  from  paralysis  of  an  adductor  the  false  image  is  formed 
on  the  side  of  the  retina  farthest  from  the  sound  eye,  and  is  therefore 
projected  on  the  side  of  the  real  object  towards  the  sound  eye.  The 
student  may  remember  the  relation  by  the  rule  that  when  the  visual 
lines  (prolonged  ocular  axes)  cross,  the  diplopia  is  not  crossed. 

In  diagonal  positions  of  the  eyeballs  the  two  images  are  not  parallel ; 
the  false  one  appears  inclined.  On  the  theory  that  the  diplopia  is  due 
to  the  non-correspondence  of  the  parts  of  the  retinae  on  which  the 
images  are  formed,  the  obliquity  is  explained  by  the  fact  that  an 
abuormal  rotation  occurs  in  these  diagonal  positions.  This  rotation  is 
due  to  the  action  of  the  oblique  muscle,  which  should  prevent  rotation 
by  opposing  this  tendency  of  the  paralysed  muscle.  The  obliquity  is 
explicable  also  on  the  theory  that  the  diplopia  is  due  to  erroneous 
projection:  as  v.  G-raefe  has  shown,  the  same  principles  apply  to  an 
abnormal  rotation  as  to  a  defect  in  lateral  movement. 

The  total  field  of  vision  which  is  brought"  into  view  by  various 
movements  of  the  eyes,  the  head  being  still,  may  be  represented  as  a 
circle,  the  centre  of  which  is  at  the  fixing-point  when  the  eyes  are  at 
rest,  while  the  radii  represent  the  various  movements,  horizontal, 
vertical,  and  diagonal.  The  circle  is  termed  the  "  motor  field."  In 
paralysis  of  one  muscle  without  secondary  contracture  there  is 
diplopia  only  in  one  part  of  this  field,  that  corresponding  to  the  move- 
ment of  the  muscle.  Thus  in  paralysis  of  the  right  external  rectus 
there  is  diplopia  in  the  right  half  of  the  field.  The  line  which  sepa- 
rates the  area  of  single  or  double  vision  varies  in  direction  with  each 
muscle,  and  corresponds  with  the  position  of  the  axis  of  the  eveball 
around  which  the  globe  moves  when  the  muscle  is  in  action;  but  the 
correspondence  is  seldom  exact,  on  account  of  the  co-operation  of 
other  muscles  in  certain  positions.  To  lessen  the  double  vision  the 
patient  often  holds  his  head  in  such  a  position  as  to  call  the  paralysed 
muscle  into  action  as  little  as  possible.  The  movement  of  the  head  is 
on  an  axis  which  corresponds  to  the  line  of  separation  of  single  from 
double  vision,  and  thus  to  the  axis  on  which  the  eyeball  is  moved  by 
the  affected  muscle. 

Patients  are  not  always  conscious  of  double  vision.  If  the  mus- 
cular weakness  is  slight  the  two  images  may  nearly  correspond, 
and  the  result  may  be  an  indistinct  outline  to  the  apparently 
single  image.  Agaiu,  if  the  images  are  far  apart  the  less  distinct 
excentric  image  may  be  neglected,  and  the  patient  may  be  conscious 
only  of  that  which  is  seen  by  the  normal  eye.  This  is  geuerally  the 
case  in  old  palsies.  The  detection  of  diplopia  is  facilitated  by  placing 
a  red  glass  before  one  eye,  preferably  the  sound  eye,  because  the  more 
distinct  image  seen  with  this  eye  is  thus  rendered  less  preponderant. 
A  strip  of  white  paper  is  then  held  up  in  various  parts  of  the  motor 
field  ;  the  patient  looks  at  it  without  moving  his  head  :  one  image  is 


176  CRANIAL    NERVES. 

seen  red,  the  other  white.     The  two  are  thus  more  easily  distinguished, 

and  their  relative  position  can  be  ascertained.     If  the  red  glass  alone 

does  not  at  first  suffice,  the  view  from  each  eye  may  be  alternately 

obstructed  (as  by  the  hand  held  before  the  eye)  ;  and  if  there  is  double 

vision  the  position  of  the  object  will  seem  to  alter  as  it  changes  from  red 

to  white.     Such  obstruction  will,  alone,  often  elicit  unnoticed  diplopia. 

In  employing  diplopia  iu  diagnosis  we  must  first  prove  that  it  is 

not  monocular,  by  ascertaining  that  it  ceases  when  one  eye  only  is 

used.*     We  then  learn  by  the  coloured  glass  whether  the  double  vision 

is  simple  or  crossed,  whether  the  two  images  are  on  the  same  level  or 

not,  whether  parallel,  and  the  direction  in  which  movement  of  the 

ohject  increases  the  distance  between  them.    When  the  images  are  side 

by  side,  and  the  diplopia  is  simple,  the  paralysed  muscle  is  of  the  eye 

on  the  side  towards  which  movement  increases  the  distance  between 

the  images.     If  the  diplopia  is  crossed,  it  is  a  muscle  of  the  other  eve. 

If  the  images  are  one  above  the  other,  the  paralysed  eye  is  that  of 

which  the  image  ascends  from  the  other  in  looking  up,  descends  in 

looking  down.     If  there  is  secondary  contracture  of  the  antagonist  of 

the  paralysed  muscle,  diplopia  exists  through  the  whole  range  of 

movement  in  the  plane  of  action  of  the  muscles,  i.  e.  during  the  action 

not  only  of  the  paralysed  muscle,  but  also  of  its  antagonist ;  but  the 

distance  between  the  images  during  movement  remains  the  same  on 

the  side  of  the  contractured  antagonist,  while  it  alters  on  the  side 

of  the  paralysed  muscle.     It  must  be  remembered  that  the  vertical 

action  of  the  superior  and  inferior  recti  is  greatest  in  abduction  of 

the  eye,  and  that  during  adduction  the  oblique  muscles  also  elevate 

and  depress.     Vertical  movements  are  therefore  in  the  line  of  action 

of  two  sets  of  muscles,  and  to  discriminate  between   them  we  must 

move  the  object  up  and  down  both  during  adduction  and  abduction. 

Vertical  diplopia  in  abduction  is  due  to  the  superior  or  inferior  rectus  ; 

if  in  adduction  only,  it  may  be  due  to  paralysis  of  an  oblique  muscle. 

Aid  in  diagnosis  is  also  to  be  obtained  by  prisms,  on  the  principle 

that  a  prism  so  placed  that  its  base  corresponds  with  the  direction  of 

action  of  the  paralysed  muscle,  increases  the  distance  between  the 

double  images;  one  in  the  opposite  position  tends  to  blend  them. 

They  may  also  be  brought  together  by  a  prism  placed  before  the 

unaffected  eye  in  the  position  in  which  before  the  affected  eye  the 

diplopia  is  increased.      Fusion  by  a  prism  before  the  affected  eye 

removes  the  erroneous  projection  ;    fusion  by  a   prism  before  the 

normal  eye  brings  the  projection  of  this  field  into  the  same  error  as 

the  other. 

Paralysis  of  Individual  Muscles. — We  may  now  consider  the 
symptoms  of  paralysis  of  each  muscle.     It  must  be  remembered  that 

*  The  cause  of  monocular  diplopia  is  still  unknown.  It  is  sometimes  well 
marked  when  there  is  no  discoverable  abnoimality  in  the  refraction  or  in  the  lundus 
ot  the  eye. 


OCULAR    NERVES. 


177 


more  than  one  muscle  is  often  affected,  and  the  symptoms  are  corre- 
spondingly combined  ;  and  that  in  diseases  of  the  central  nervous 
system,  palsy  and  spasm,  are  sometimes  so  associated  as  to  render  an 
exact  diagnosis  difficult  and  occasionally  impossible.  This  difficulty 
is  often  due  to  the  circumstance  that  a  given  palsy  was  pi*eceded  by- 
some  other  derangement  of  movement,  as  another  slight  paralysis  and 
secondary  contracture. 

The  paralyses  described  and  figured  are  of  the  muscles  of  the  right 
eye,  except  that  of  the 
external  rectus,  which  is 
of  the  left  eye  for  com- 
parison with  the  paraly- 
sis of  the  opposite  in- 
ternal rectus.* 

External  Rectus,  Left 
(Fig.  89).— Tb.e  defect  of 
movement  is  outwards, 
with  convergent  strabis- 
mus ;  secondary  deviation 
is  by  the  opposite  internal 
rectus.  The  diplopia  is 
simple,  in  the  left  half  of 
the  motor  field ;  the  two 
images  are  on  the  same 
level  in  the  horizontal 
movement,  and  tbe  dis- 
tance between  them  in- 
creases as  the  object  is 
moved  to  the  left.  In  dia- 
gonal positions  the  false 
image  is  inclined,  the 
images  diverging  from  the 
horizontal  plane.  Towards 
the  limit  of  movement 
there  are  often  slight  spas- 
modic rotatory  movements 
by  the  unopposed  oblique 
muscle.  The  head  is  in- 
clined to  the  left. 

Internal  Rechis,  Right 
-(Fig.  90). — The  defect  of  movement  is  inwards  ;  the  secondary  devi- 
ation is  by  the  opposite  external  rectus  ;  the  strabismus  is  divergent. 
Diplopia  is  crossed,  and  exists  in  the  left  half  of  the  motor  field. 

*  The  diagrams  of  double  vision  are  after  those  of  "Woinow  ('Das  Verh.  der 
Doppelbilder,'  Wien,  1870),  modified  a  little  by  actual  observation.     The  objects  are 
figured  as    described    by   a    patient   when    they   are   held   between    him  and   the 
observer.     If  figured  as  seen  by  the  patient,  the  position  of  the  object  is  reversed. 
VOL.   II.  12 


SEcr. 


Fig.  89. — Paralysis  of  the  left  external  rectus; 
coloured  glass  over  right  eye  ;  primary  deviation 
on  looking  towards  an  object  (o)  on  the  left; 
position  of  double  images;  secondary  deviation 
of  the  right  eye  when  the  screen,  s,  obstructing 
the  fixation  of  *  by  this,  eye,  compels  fixation  by 
the  weak  muscle.  When  the  screens  are  removed, 
the  right  eye,  in  fixing,  moves  back  to  the  position 
of  the  dotted  outline  of  the  cornea.  (In  the 
diagram  of  diplopia  the  highest  white  [false] 
image  should  have  been  represented  a  little 
lower  than  the  true  image.) 


178 


CRANIAL    SERVES. 


In  diagonal  movements   the  images  diverge  towards   the  horizontal 
plane.     The  head  is  inclined  towards  the  left. 

Superior  Rectus  (Fig.  91). — Movement  is  defective  upwards,  espe- 
cially upwards  and  outwards,  and  in  attempting  the  movement  the  eye- 
ball is  rotated,  the  upper  end  of  the  vertical  meridian  outwards,  by 

the  inferior  oblique.  Se- 
condary deviation  is  by  the 
opposite  superior  rectus. 
The  diplopia  is  crossed  and 
exists  in  tbe  upper  half  of 
the  motor  field ;  the  images 
are  one  above  the  other, 
the  upper  image  being  the 
false  one,  and  receding 
from  the  other  as  the  ob- 
ject is  moved  upwards. 
Tbe  false  image  is  inclined. 
The  difference  in  height  is 
greatest  in  abduction, 
while  the  inclination  is 
greatest  in  adduction. 
These  differences  are  due 
to  tbe  influence  of  the  in- 
ferior oblique,  which  ro- 
tates as  well  as  elevates. 
The  head  is  held  back- 
wards and  inclined  to- 
wards the  sound  side. 

Inferior     Rectus     (Fig. 
92). — Movement  is  defec- 
tive downwards,  especially  downwards  and  outwards,  because  in  the 


SEX*    D£V" 


FlG.  90. — Paralysis  of  right  internal  rectus ;  pri- 
mary deviation;  double  vision  (red  glass  over 
right  eye)  j  secondary  deviation.  (Compare 
Pig.  89  and  description.) 


Fig,  91.  Pig.  92. 

Fig.  91.— Diplopia  in  paralysis  of  right  superior  rectus.  (The  black 
image  is  that  of  affected  eye.) 

Fig.  92.— Diplopia  in  paralysis  of  the  right  inferior  rectus.  (Right 
image  black.) 


OOULAE  NEiiVJfliS.  179 

downward  and  inward  movement  the  superior  oblique  is  best  able  to 
supplement  the  paralysed  rectus.  The  upper  end  of  the  vertical 
meridian  is  inclined  inwards  by  the  oblique,  from  the  loss  of  the 
rotating  action  of  the  inferior  rectus.  Diplopia  exists  in  the  lower  half 
of  the  field,  especially  in  the  outer  portion ;  it  is  crossed,  the  images 
being  near  together  laterally,  but  the  false  image  is  below  the  other, 
and  recedes  with  the  downward  movement.  The  two  images  (if  the 
object  is  held  vertically)  diverge  from  the  horizontal  plane.  The 
difference  of  height  is  greatest  on  looking  inwards ;  that  of  obliquity 
on  looking  outwards.  Secondary  deviation  is  produced  by  the  opposite 
inferior  rectus.  The  head  is  inclined  downwards  and  towards  the 
affected  side.  In  an  attempt  to  look  down,  the  upper  lid  does  not 
descend,  but  remains  raised  in  correspondence  with  the  position  of 
the  eye  (see  Fig.  94,  and  "  Facial  Paralysis"). 

Superior  Oblique  (Fig.  93). — Defect  of  movement  chiefly  downwards 
and  inwards,  since  in  this  posi- 
tion the  muscle  exerts  most  de- 
pression, but  it  is  often  scarcely 
recognisable.  Strabismus  exists 
only  below  the  horizontal  plane, 
and  is  convergent  by  the  un- 
opposed inferior  rectus,  causing 
deviation  inwards.  Secondary 
deviation  is  chiefly  by  the  oppo- 
site superior  oblique  and  inferior 
rectus,  &c,  turning  the  eye  down 
and   in.     Diplopia  exists  in  the 

inner  lower  part  of  the  motor  Fig.  93— Diplopia  in  paralysis  of  right 
„,,.,.       .        ,       ,,      „,      .  superior  oblique.  (Right  image  black.) 

field;  it  is  simple;  the  false  image 

is  the  lower,  and  the  images  diverge  towards  the  horizontal  plane. 

The  difference  in  height  is  greatest  in  adduction,   the  obliquity  of 

the  false  image   is    greatest  in  abduction.      The  lateral  distance  is 

greatest  in  the  middle  line,  and  lessens  when  the  object  is  moved 

either  inwards   or  outwards.      The  head  is  inclined  forwards  and 

towards  the  sound  side.     The  diplopia  is  chiefly  noticed  when  the 

patient  has  to  look  down,  as   in   descending   stairs,  which   appear 

double.     The  detection  of  this  palsy  is  difficult,  and  the  diplopia  is 

the  most  important  indication ;  if  the  other  eye   cannot  be  moved 

downwards  the  detection  of  the  palsy  may  be  impossible. 

Inferior  Oblique. — Defect  of  movement  inwards  and  upwards,  the 

effect  being  the  converse  of  that  of  paralysis  of  the  superior  oblique. 

The    secondary   deviation    is    inwards  and  upwards  by  the  inferior 

oblique  and  superior  rectus,  &c,  of  the  sound  eye.     Diplopia  exists 

in  the  upper  inner  part  of  the  field ;    it  is   simple,  the  false  image 

above  the  other,  especially  in   adduction,  and  oblique  (the  images 

converging   towards   the  horizontal  plane),  especially  in  abduction. 

The  head  is  inclined  backwards  and  towards  the  affected  side. 


180 


CRANIAL    NEEVES. 


Of  isolated  palsies,  that  of  the  external  rectus  is  incom  parably  the  most 

frequent,  and  the  order  or 
frequency  of  145  cases 
was  found  by  A.  Grraefe 
to  be — external  reel  us 
105,  superior  oblique  52,. 
inferior  rectus  10,  superior 
rectus  9,  internal  rectus 
4,  inferior  oblique  2.  The 
frequency  of  isolated 
palsies  of  the  first  two 
muscles  is  due  to  their 
separate  innervation.  In 
the  estimate,  the  frequency 
of  loss  of  some  of  tbe 
associated  palsies  is  pro- 
bably not  included.  They 
were  not  then  adequately 
recognised. 

Affections  of   Special. 
Nerves. 

Sixth  Nerve,  Ab&ucens- 
Oculi. — Only  one  muscler 
the  external  rectus,  being 
supplied  by  the  sixth- 
nerve,  tbe  disease  of  the 
nerve  causes  only  paralysis 
of  this  muscle.  As  the 
figures  given  above  show, 
it  is  a  frequent  ocular 
palsy,  perhaps  because  the 
nerves  have  so  long  and 
exposed  a  course. 

Third  Nerve* — When 
the  whole  of  the  third 
nerve  is  affected,  all  the 
external  muscles  of  the  eye  are  paralysed,  with  the  exception  of  the 
superior  oblique  and  external  rectus  ;  the  levator  palpebrse,  sphincter 
iridis,  and  ciliary  muscle  are  also  affected.  Tbe  upper  eyelid  droops 
and  cannot  be  raised ;  the  eye  can  be  moved  only  outwards,  and  a 
little  downwards  and  inwards  by  the  superior  oblique.  The  pupil  is 
of  medium  size,  and  does  not  contract ;  power  of  accommodation  is  lost. 

*  The  third  nerve  is  commonly  termed  in  Germany  the  "  oculo-motorius,"  a  name 
which  has  the  grave  practical  inconvenience  of  preventing  the  use  of  the  term 
"  oculo-motor  "  in  its  exact  and  much-needed  general  significance. 


Fig.  94. — Partial  paralysis  of  left  third  nerve. 
Defective  movement  upwards,  from  weakness  of 
the  superior  rectus,  and  downwards,  from  weak- 
ness of  inferior  rectus. 


OCULAR  NERVES. 


181 


In  an  attempt  to  raise  the  eyelid  the  frontal  muscle  contracts  strongly 
(see  next  page).  After  a  time  the  deviation  outwards  of  the  eye 
increases,  in  consequence  of  con- 
tracture in  the  external  rectus,  and 
the  pupil  becomes  larger  than  it  was 
at  first  by  a  similar  contracture  in 
the  radiating  fibres. 

Paralysis  of  the  third  nerve  is 
often  partial ;  the  various  muscles 
supplied  by  it  are  affected  in  differ- 
ent degrees,  and  some  may  escape 
altogether.  The  muscles  to  the  eye- 
ball may  be  involved,  and  the  levator 
may  escape,  but  the  paralysis  of  the 
former  is  then  seldom  complete.  The 
levator  and  superior  rectus  may 
suffer  apart  or  together ;  in  bilateral 
nuclear  disease  they  are  generally 
paralysed  together.  The  external 
muscles  may  suffer,  and  those  within 
the  globe  may  be  unaffected  ;  the 
converse  relation  is  only  seen  in 
central  cases. 

Both  third  nerves  may  be  affected, 
but  it  is  rare  for  both  to  be  paralysed 
completely,  as  in  the  case  shown  in 
Fig.  95.  There  is  then  complete 
double  ptosis,  and  if  the  lids  are 
raised  the  eyeballs  are  seen  to  be 
turned  outwards,  and  to  be  almost 
immovable.  In  most  cases  of  bi- 
lateral disease  of  these  nerves  the 
paralysis  is  partial.  In  some  cases 
the  distribution  of  the  palsy  is  deter- 
mined by  functional  association ; 
thus  each  internal  rectus  may  be 
affected  and  no  other  muscles  :  such 

cases  are  central  and  nuclear  in  nature,  involving  this  nerve  merely 
because  its  functions  are  so  extensive ;  they  will  be  separately  con- 
sidered. 

Ptosis.— The  drooping  of  the  eyelid  may  be  complete,  so  that  it 
cannot  be  raised,  or  incomplete,  being  raised  to  a  certain  point  but  not 
higher.  There  is  usually  a  conspicuous  over-action  in  the  corre- 
sponding half  of  the  frontalis,  so  that  the  eyebrow  is  always  higher 
than  it  should  be.  The  frontalis  normally  acts  with  the  levator  when 
the  eyes  are  directed  much  above  the  horizontal  plane.     This  is  an 


Fig.  95. — Paralysis  of  both  third  nerves 
in  a  child  two  years  old.  Complete 
double  ptosis,  and  divergence  of  both 
eyes  by  the  external  recti  when  the 
eyelids  are  raised.  The  child  was  of 
a  tubercular  family,  and  presented 
also  double  optic  neuritis  and  weak- 
ness of  the  limbs  of  both  sides.  No 
other  cranial  nerves  were  affected. 
The  probable  cause  of  the  symptoms 
was  a  tubercular  tumour  in  the 
interpeduncular  space.  Under  tonic 
treatment  all  the  symptoms  passed 
away,  and  a  year  later  the  child 
appeared  quite  well. 


182 


CRANIAL    XliKVES. 


instance  of  secondary  over- action  in  an  associated  muscle,  analogous 
to  the  secondary  deviation  in  an  ocular  muscle  (p.  171).  The  frontalis 
responds  to  the  increased  innervation,  which  has  no  influence  on  the 
paralysed  levator.  It  appears  as  if  the  patient  were  trying  to  raise  the 
lid  by  the  frontal  muscle,  hut  this  appearance  is,  at  least  chiefly, 
fallacious,  and  the  real  explanation  is  that  just  given.  But  in  some 
persons  the  frontalis  can  produce  a  slight  elevation  of  the  lid  ;  hence 
to  ascertain  whether  a  slight  voluntary  elevation  of  the  lid  is  due  to 
the  levator  or  frontalis,  it  is  necessary  to  fix 
the  eyebrow  by  pressing  it  against  the  bone. 

Fourth  Nerve. — The  symptom  of  paralysis 
of  the  fourth  nerve  is  paralysis  of  the  su- 
perior oblique,  which  has  heen  already  de- 
scribed. It  is  seldom  met  with  alone,  except 
in  cases  of  nuclear  disease.* 

Sympathetic. — Disease  of  the  sympathetic 
causes  paralysis  of  the  radiating  fibres  of  the 
iris,  with  consequent  loss  of  the  dilatation  of 
the  pupil.     There  are  also  slight  prominence  of 

Fig.  96.— Paralysis  of  the   the  eye  and  slight  ptosis,  supposed  to  be  due 
left  third  nerve;  ptosis;    ,  c   ,,       .         ,  ,.,  c  -.r..,, 

over-action  of  I rontalis.       to   atony   of  the  ^voluntary  fibres  of  Muller 
in  the  fascia  of  the  orbit. 


Internal  Ocular  Palsy. — Ciliary  Muscle:  Cycloplegia ;  Loss  of 
Accommodation. — The  evidence  of  this  in  normal  and  hypermetropic 
eyes  is  that  near  vision  fails  and  distant  vision  remains  good,  while 
near  vision  can  be  restored  by  a  convex  glass.  Usually,  though  not 
invariably,  the  contraction  of  the  iris  which  normally  occurs  on  ac- 
commodation is  absent  also.  In  myopia  and  presbyopia  the  absence 
of  the  power  of  accommodation  makes  little  difference  to  sight,  and 
the  diagnosis  of  the  condition  is  difficult.  Accommodation  depends 
on  the  third  nerve,  and  is  lost  in  complete,  and  often  in  partial,  dam- 
age to  the  trunk  of  the  nerve,  and  in  disease  of  the  anterior  fibres  by 
which  it  ai'ises,  or  of  the  anterior  part  of  its  nucleus.  The  path  from 
the  lenticular  nerve  is  through  the  ganglion  and  ciliary  nerves.  Loss 
of  accommodation  in  one  eye  only,  without  the  affection  of  other 
branches  of  the  third  nerve,  is  possibly  due  to  disease  of  this  ganglion 
or  of  the  nervous  ganglia  within  the  eye,  but  we  have  no  evidence  at 
present  of  the  effect  of  disease  of  these  structures.f  Bilateral  cyclo- 
plegia, occurring  alone,  usually  depends  on  disease  of  the  centres  in 
the  nuclei  of  the  third  nerves.  It  occurs  in  dipththeritic  paralysis, 
of  which  it  is  one  of  the  earliest  and  most  constant  symptoms.  It 
occurs  also  as  an  associated  symptom  in  degenerative  disease  of  the 
spinal  cord,  especially  in  taues.  Its  relation  to  such  disease  is  similar 
to  that  of  the  loss  of  the  reflex  action,  immediately  to  be  described. 

*  See  Reinak,  '  Neur.  Cent.,'  1888.  p.  5. 

t  See  Hosch,  'Near.  Cent./  1SS9,  p.  592. 


OCULAR    NERVES.  IBS 

Iris  :  Iridoplegia. — The  pupil  maybe  unduly  large  (mydriasis),  from 
palsy  of  the  sphincter  (third  nerve)  or  spasm  of  the  radiating  fibres 
(sympathetic),  or  it  may  be  unduly  small  (inyosis)  from  the  opposite 
conditions.     The  iris  has  three  actions,  two  reflex  and  one  associated : 

(1)  Reflex  contraction  of  the  sphincter  on  exposure  of  the  eye  to  light. 

(2)  Reflex  dilatation  by  the  radiating  fibres  on  stimulation  of  some 
cutaneous  nerve.  (3)  Contx-action  on  accommodation,  usually,  but 
not  necessarily,  associated  with  convergence. 

(1)  Loss  of  the  Associated  Action  :  Accommodation  Iridoplegia. — The 
pupil  does  not  lessen  in  size  when  an  effort  to  accommodate  is  made. 
To  examine  this  action  it  is  only  necessary  to  make  the  patient  look 
first  at  a  distant  and  then  at  a  near  object ;  the  two  should  be  in  the 
same  hue  of  vision,  so  as  to  avoid  any  change  in  the  amount  of 
light  that  enters  the  eye.  There  is  usually  paralysis  of  accommoda- 
tion, but  the  ciliary  muscle  may  be  competent,  and  yet  the  asso- 
ciated action  of  the  iris  may  be  lost,  and  vice  versa.  This  loss  is  less 
common  than  is  that  of  reflex  action  ;  it  is  due  to  the  same  causes  as 
cycloplegia. 

(2)  Loss  of  the  Light  Reflex:  Reflex  Iridoplegia. — In  examining  the 
action  of  the  iris  to  light,  care  must  be  taken  to  test  each  eye  separately, 
keeping  the  other  eye  covered.  Light  entering  one  eye  acts  on  both 
pupils,  and  the  contraction  of  each  is  the  result  of  the  total  amount 
of  light  that  enters  both  eyes.  If  one  eye  be  covered  and  the  action 
of  the  other  pupil  noted,  it  will  be  found  to  contract  still  more  when 
the  first  eye  is  uncovered.  A  good  light  is  important ;  a  slight  action, 
distinct  on  a  bright  day,  is  often  imperceptible  in  a  dull  light.  If 
artificial  light  is  used,  it  is  best  to  make  the  patient  look  at  an  object 
in  a  distant  dark  part  of  the  room,  and  then  bring  a  light  suddenly 
in  front  of  the  eye.  If  the  patient  looks  at  a  near  light,  he  will  ac- 
commodate for  it,  and  the  pupil  may  then  contract  when  there  is  no 
action  to  light.  Hence,  if  the  light  is  looked  at,  it  must  be  at  least 
four  feet  from  the  patient,  and  should  be  bright.  To  avoid  the  accom- 
modation it  is  desirable,  if  a  light  is  brought  in  front  of  the  eye,  that 
the  other  eye  should  be  shielded  from  the  light  but  not  closed,  so  that, 
by  continuing  to  fix  a  distant  object,  accommodation  may  be  kept 
relaxed.  Reflection  of  light  into  the  eye  by  an  ophthalmoscopic  mirror 
is  not  a  good  test,  because  the  light  falls  only  on  a  very  small  area, 
and  may  miss  the  macula,  the  most  sensitive  part.  Reflex  iridoplegia 
is  usually  double  ;  when  one-sided,  as  in  a  case  recorded  by  Eales,* 
its  cause  is  usually  exceptional.  But  I  have  observed  the  loss  to  be 
unilateral  in  tabes,  although  this  is  very  rare. 

The  path  through  which  this  reflex  action  is  produced  is  the  optic 
nerve,  both  optic  tracts,  probably  the  corpora  cpuadrigemina,  the 
anterior  part  of  the  nucleus  of  the  third  nerve  behind  the  centre  for 
accommodation,  probably  the  second  fasciculus  of  origin  of  the  third 
nerve,  its  trunk,  the  ciliary  ganglion,  and  the  ciliary  nerves. 
*  '  Ophth.  Rev.,'  ii,  p.  225. 


184  CRANIAL    NERVES. 

(3)  Loss  of  the  Shin  Reflex:  Cutaneous  Iridoplegia. — The  dilatation 
on  cutaneous  stimulation  occurs  in  most  persons  under  normal  cir- 
cumstances. The  skin  of  the  neck  is  a  convenient  place  for  the  stimu- 
lation. The  faradic  current  applied  with  a  wire  brush,  so  as  to  pro- 
duce a  sharp  painful  sensation,  has  been  usually  employed,  but  in 
most  persons  the  prick  of  a  needle  or  pin,  of  a  quill  point,  and  even 
a  pinch,  is  sufficient.*  The  motor  path  for  this  action  lies  in  the 
cervical  sympathetic,  and  the  fibres  connecting  this  with  the  cord  at 
the  lowest  part  of  the  cervical  region.  The  centre  on  which  it  depends 
is  said  to  be  beneath  the  corpora  quadrigemina,  to  the  outer  side  of 
that  for  the  light  reflex.  If  so,  both  motor  and  sensory  paths  tnust 
traverse  the  cervical  region  of  the  spinal  cord. 

Each  reaction  is  lost  when  disease  interrupts  its  path  or  damages 
the  centre  on  which  it  depends.  Thus  the  light  reflex  is  impaired  or 
lost  in  disease  of  either  the  optic  nerve  (including  the  retina)  or  in 
disease  of  the  trunk  of  the  third  nerve.  Disease  of  one  optic  tract 
does  not  lessen  the  action,  unless  the  light  falls  only  on  the  blind 
half  of  the  retina  (see  p.  163),  no  doubt  because  the  fibres  from  the 
most  sensitive  (central)  region  of  each  retina  pass  by  both  optic 
tracts,  and  so  disease  of  one  does  not  abolish  the  reflex.  So,  too,  the 
skin  reflex  is  lost  in  disease  of  the  cervical  sympathetic,  and  in  some 
affections  of  the  cervical  spinal  cord,  especially  in  those  that  impair 
sensibility.  In  any  case  we  infer  the  seat  of  the  disease  from  the 
other  symptoms  that  are  associated  with  the  loss. 

When  the  loss  of  reflex  action  occurs  without  such  accompanying 
symptoms,  and  is  thus  isolated,  so  far  as  immediate  associations  are 
concerned,  it  is  generally  due  to  disease  of  the  centres,  degenerative  in 
character.!  It  occurs  in  association  with  disease  of  the  spinal  cord, 
chiefly  with  locomotor  ataxy,  in  which  it  is  a  common  and  early 
symptom.  The  loss  is  frequent  also  in  general  paralysis  of  the 
insane,  and  is  occasionally  met  with  in  other  degenerative  diseases  of 
less  definite  type.  It  may  occur  also  without  other  nerve  symptoms. 
In  most  of  the  cases  I  have  seen,  in  which  it  existed  alone,  the  patients 
have  had  constitutional  syphilis  many  years  before,  and  the  same 
statement  is  true  of  at  least  one  disease  (locomotor  ataxy)  with  which 
the  symptom  is  often  associated. 

*  In  some  persons  in  whom  the  reflex  action  is  readily  produced,  it  occurs  on 
slighter  cutaneous  impressions.  It  may  occur,  for  instance,  when  the  palm  of  the 
hand  is  tickled,  as  schoolboys  know  who  pretend  to  dilate  the  pupil  by  an  act  of  the 
will. 

t  This  has  not  yet  been  demonstrated,  but  hardly  admits  of  doubt  because  the 
loss  of  reflex  action  occnrs  under  the  same  conditions  as  another  affection  to  be 
presently  described,  progressive  paralysis  of  the  external  muscles,  the  central  and 
degenerative  nature  of  which  has  been  proved. 

The  frequency  of  loss  of  the  light  reflex  without  loss  of  the  associated  action  of 
the  iris  was  first  pointed  out  by  Argyll- Robertson.  The  fact  that  loss  of  reflex 
dilatation  is  usually  associated  with  that  of  reflex  contraction  was  discovered  by 
Erb. 


OCULAR    NERVES.  185 

The  two  palsies  are  often,  but  not  always,  conjoined.  There  may 
he  loss  of  reflex  action  to  light,  when  the  pupil  still  dilates  on  stimula- 
tion of  the  skin.  The  pupils  are  often  small,  reduced  to  two,  one  and 
a  half,  or  one  millimetre  in  diameter.  The  association  of  these  small 
pupils  "with  spinal  disease  was  noticed  before  the  more  significant  loss 
of  the  light  reflex  was  discovered,  and  the  condition  was  called  "spinal 
myosis."  But  the  pupils  are  not  always  small ;  they  may  he  three, 
four,  or  five  millimetres  in  diameter,  although  there  is  no  trace  of  re- 
action to  light.  I  think  that  it  will  generally  he  found  that  when  the 
pupils  are  not  small  the  skin  reflex  persists,  and  when  they  are  small 
it  is  lost.  The  small  pupils  may  he  the  result  of  the  loss  of  tone  in 
the  radiating  fibres  accompanying  the  loss  of  the  skin-reflex,  and  pre- 
served when  the  pupils  are  large.  In  cases  of  disease  of  the  third 
nerve  the  ciliary  muscle  is  paralysed  as  well  as  the  iris.  When  the 
reflex  loss  is  due  to  central  degeneration  the  ciliary  muscle  is  usually 
unaffected,  and  the  pupils  contract  during  accommodation.  In  some 
•cases,  however,  there  is  also  cycloplegia.  All  the  internal  muscles  of 
the  eyeball  are  then  paralysed,  a  condition  which  we  shall  again 
consider. 

Compound  Ocular  Palsies. — Loss  of  Convergence  and  of  Accommo- 
dation.— The  power  of  accommodation  may  be  lost  although  the  eyes 
can  still  be  converged,  but  in  many  cases  the  two  actions,  habituallv 
associated,  are  lost  together.  The  internal  recti  may  contract  in  a 
normal  manner  in  lateral  movements  of  the  eyes,  but  cannot  be  made 
to  contract  together.  Doubtless  there  is  a  separate  centre  for  the  con- 
verging action,  as  we  shall  presently  see  there  is  for  the  action  of  one 
with  the  opposite  external  rectus  in  lateral  movements.  The  former 
must  be  closely  connected  with  the  accommodation  centre,  since  we 
only  converge  when  we  accommodate.  A  remarkable  example  of  this 
loss  in  a  child  has  been  published  by  Eales.*  There  was  absolute 
loss  of  convergence,  of  accommodation,  and  of  the  associated  action 
of  the  iris,  while  all  other  movements  of  the  eyes,  and  the  reflex 
action  of  the  pupil,  were  perfect.  The  loss  developed  gradually 
without  recognisable  cause,  and,  after  lasting  for  about  a  year,  passed 
away. 

Paralysis  of  the  upward  movement  of  the  eyes  has  often  been  observed 
in  cases  of  central  disease,  associated  with  paralysis  of  the  levators.  It 
may  result  from  disease  of  the  posterior  part  of  the  third  nerve  nuclei 
{Kahler  and  Pick).  When  due  to  such  a  focal  lesion  it  is  usually 
unilateral.  It  is  possible  that  there  js  also  a  higher  centre,  disease  of 
which  may  paralyse  the  upward  movement  without  the  lid,  since  this 
isolated  symptom  may  be  met  with.  I  have  recorded  one  such  case  in 
which  the  symptom  was  well  marked. f 

*  '  Trans.  Ophth.  Soc.,'  iv,  1884,  p.  300,  and  oral  communication. 
t  'Trans.  Ophth.  Soc./  i,  81,  p.  117.     The  patient  has  died   since  the  account 
of  her  case  was  published.     A  very  small  tumour  was  found  in  the  middle  line 


186  CRANIAL    NERVES. 

Paralysis  of  both  upward  and  downward  movements  of  the  eyes, 
without  impairment  of  the  lateral  movements,  has  also  "been  observed, 
and  is  probably  also  due  to  a  lesion  in  the  same  position.  The  para- 
lysis has  been  bilateral  and  accompanied  with  ptosis.  But  it  has  also 
been  caused  by  disease  of  the  cerebral  hemisphere,  situated  in  the 
corpus  striatum  and  optic  thalamus.* 

Paralysis  of  Lateral  Movement:  Conjugate  Deviation  oftheEyes. — The 
conjugate  deviation  of  the  eyes,  towai'ds  the  side  of  a  lesion  in  the 
cerebral  hemisphere,  the  result  of  a  loss  of  the  power  of  moving  them 
to  the  other  side,  has  been  already  described  (p.  78).  The  deviation 
is  occasionally  due  to  spasm,  and  is  then  from  the  side  of  the  cerebral 
lesion.  We  infer  to  which  of  these  two  mechanisms  it  is  due,  by  the 
associated  symptoms  in  the  limbs,  which  are  paralysed  and  flaccid 
when  the  eyes  deviate  from  them,  rigid  with  spasm  when  the  devia- 
tion is  towards  them,  and  from  the  side  of  the  lesion.  These  are  merely 
an  exteusion  to  the  eyes  of  the  effects  of  the  disease  manifest  in  the 
limbs.  Their  occurrence  and  degree  seem  to  be  related  to  the  seat  of 
the  cerebral  lesion.  But  in  disease  of  the  pons  the  condition  is 
reversed.  A  paralysing  lesion  on  one  side  causes  a  loss  of  the  move- 
ment of  both  eyes  towards  that  side.f  The  seat  of  the  disease  that 
has  this  effect  is  the  tegmental  region  of  the  pons,  at  or  above  the 
nucleus  of  the  sixth, J  and  the  facts  show  that  the  path  for  this  com- 
bined movement  descends  in  the  same  side  of  the  pons  as  that  to- 
wards which  the  eyes  are  moved,  and  that  the  movement  is  effected 
through  the  nucleus  of  the  sixth.  The  sixth  nucleus  must  therefore 
act  on  the  the  opposite  third  nucleus  and  internal  rectus,  and  the  path 
by  which  the  influence  is  exerted  is  almost  certainly  the  posterior 
horizontal  fibres.  It  has  even  been  thought  that  through  these  fibres, 
those  of  the  third  nerve  for  the  internal  rectus  actually  arise  from 

behind  the  posterior  quadrigerninal  bodies,  damaging  these  slightly,  the  velum,  and 
the  adjacent  part  of  the  inferior  vermiform  process  of  the  cerebellum. 

It  must  be  remembered  that  disease  of  the  nerves  or  their  roots  may  chance  to 
affect  only  the  fibres  for  the  superior  recti.  This  was  apparently  the  case  in  a 
patient  with  an  interpeduncular  syphiloma  (Thomsen,  '  Berlin.  Gesellsch.  f.  Psych./ 
June  7th,  1886).  One  superior  rectus  was  more  affected  than  the  other,  a  character 
that  is  probably  of  diagnostic  importance. 

*  Wernicke,  '  Berlin,  kl.  Wochenschr./  1876,  p.  394,  and  1S7S,  p.  154.  A  similar 
loss,  associated  with  hemianopia,  was  present  in  a  case  recorded  by  Lang  and  Fitz- 
gerald, '  Trans.  Ophth.  Soc./  vol.  ii,  p.  230. 

f  Much  attention  has  been  lately  given  to  this  palsy.  The  most  important 
writings  on  the  subject  are  those  of  Broadbent,  '  Med.  Times  and  Gaz./  1872,  vol.  i; 
Duval  and  Laborde,  '  Journ.  de  l'Anat.  et  Phvs.,'  1879;  Bernhardt,  '  Gehirn- 
geschwulste /  Wernicke,  '  Gehirnkrankhjeiten,'  Bd.  i ;  Mierzejewski  and  Rosenbach, 
'Neurolog.  Centralbl./  1885,  p.  363;  and  Bleuler,  '  Deut.  Arch.  f.  kl.  Med.,'  1886, 
Bde.  xxxvii  and  xxxviii,  in  whose  paper  abstracts  of  most  writings  on  the  subject 
will  be  found,  and  an  important  case  by  Hughes  Bennet  ('  Brain/  1889),  in  which 
there  was  permanent  conjugate  deviation  of  head  and  eyes,  the  result  of  a  patch 
of  softening  limited  to  the  sixth  nucleus.     Power  of  convergence  was  retained. 

J  Very  seldom  below,  and  then  reaching  up  to  the  nucleus.  See  note  on  next 
page. 


OCULAR    NERVES. 


187 


tbe  sixth  nucleus  ;  this  assumption  is  opposed  by  many  facts,  and  it 
seems  that  the  horizontal  fibres  merely  connect  the  two  nuclei.* 
Other  signs  of  disease  of  the  pons  are  often  present,  paralysis  either 
of  the  facial  or  of  the  fifth  nerve.  Nystagmus  is  often  associated 
(see  p.  207). f 

Since  the  movement  is  excited  from  the  opposite  cerebral  hemi- 
sphere, the  path  must  cross  the  middle  line  above  the  middle  of  the 
pons,  and  it  probably  does  so  at  the  corpora  quadrigemina.  If  so  the 
arrangement  must  be  that  shown  in  Fig.  97.  We  do  not  know,  how- 
ever, whether  the  pons  contains  merely  the  path  to  the  sixth  nucleus,  or 
whether  there  is  a  special  centre  for  the  movement  distinct  from  this 
nucleus.  The  latter  is  probable  on  account  of  the  relation  of  the 
movement  to  sensory  impressions,  especially  to  those  of  the  auditory 


Fig.  97. 


Fig.  98. 


R.  EYE 


L.  EYE 


Fig.  97. — Diagram  of  the  mechanism  for  the  associated  lateral  move- 
ment. 

Fig.  98. — Diagram  of  probable  relation  of  the  superior  olivary  body  to 
the  associated  lateral  movement.  The  asterisk  in  each  figure  indicates 
the  downward  path. 

nerve,  combined  with  the  fact  that  a  movement  of  the  head  is  often 
associated  with  that  of  the  eyes,  so  that  a  connection  of  the  auditory 
nerve  with  the  sixth  nucleus  would  scarcely  suffice.  The  connections 
of  the  superior  olivary  body,  according  to  Bechterew,  are  precisely 


*  The  evidence  is  that  the  internal  rectus  is  not  always  totally  paralysed;  it  has 
been  known  to  act  in  convergence  although  not  in  tbe  lateral  movement,  and  also 
inwards,  in  a  normal  manner,  if  the  other,  eye  was  covered,  although  there  was  no 
movement  when  the  eye  with  the  paralysed  external  rectus  was  uncovered.  Moreover, 
when  the  sixth  nucleus  has  been  totally  destroyed,  no  degenerated  fibres  could  be 
found  in  the  opposite  third  nerve. 

t  Experiments  suggest  that  deviation  towards  the  side  of  a  lesion  of  the  pons 
means  irritation  and  imperfect  destruction.  The  opposite  deviation  follows  sub- 
sidence of  the  irritation,  each  being  attended  by  nystagmus  (Laborde,  '  Gaz.  med. 
de  Paris,'  1878). 


138 


CBANIAL    NERVES. 


those  that  such  a  centre  would  have.  By  some  fibres  of  the  fillet, 
which  degenerate  downwards,  this  body  is  connected  with  the  corpora 
•quadrigernina,  and  fibres  pass  between  it  and  the  sixth  nucleus,  the 
auditory  nuclei,  the  cerebellum,  and  the  lateral  column  of  the  spinal 
cord;  the  last  may  subserve  the  movement  of  the  head.*  If  this  hy- 
pothesis is  correct,  the  mechanism  must  be  such  as  is  shown,  m  side 
view,  in  the  diagram  Fig.  98.  The  arrow-heads  indicate  the  direction 
of  conduction;  and  the  thicker  lines  indicate  the  path  by  which  the 
movement  is  excited  by  the  will. 

According  as  the  disease  does  or  does  not  involve  the  nucleus  of  the 
sixth  nerve,  the  symptoms  present  some  variation.  If  the  disease  is 
above  the  nucleus,  there  is  a  loss  of  the  power  of  moving  both  eyes 
beyond  the  middle  line  towards  the  side  of  the  lesion.  If  they  are 
moved  towards  the  other  side,  they  can  be  moved  back  as  far  as  the 
middle  line,  but  no  further.  In  most  cases  the  other  eye  cannot  be 
moved  inwards  in  convergence  or  alone,  but  in  a  few  instances  these 
movements  have  been  preserved,  although  the  inward  movement 
associated  with  the  outward  movement  of  the  other  eye  has  been  lost. 
We  do  not  know  the  cause  of  this  difference.  If,  however,  the  disease 
involves  the  nucleus  of  the  sixth  nerve,  there  is  total  palsy  of  the  ex- 
ternal rectus,  so  that  the  eye  deviates  inwards  and  cannot  be  moved 
outwards,  even  up  to  the  middle  line.     The  condition  of  the  other  eye 

is  the  same  as  in  the  first  case. 

In  this  condition  the  facial  nerve 
is  usually  paralysed  as  well  as  the 
sixth,  its  fibres  being  damaged  as 
they  course  round  and  through  the 
sixth  nucleus.  An  instance  of  this 
palsy  is  represented  by  Fig.  99.  The 
onset  was  sudden,  and  slight  hemi- 
plegia was  present  at  first.  The  left 
sixth  and  facial  nerves  were  com- 
pletely paralysed ;  the  left  eye  de- 
viated inwards,  and  no  outward 
movement  was  possible  ;  the  right 
eye  could  not  be  moved  inwards ; 
the  facial  muscles  presented  the  re- 
action of  degeneration.     If  a  lesion 

in  the  pons  damages  the  fibres  of 

Fig.  99. — Complete  paralysis   of  the  ,,  .    ,,  n  ,,     . 

left  sixth  and  facial  ner4s  (with  in.  the  sixth   nerve    away  from    their 

ability  to  move  the  right  eve  towards  nucleus,  the  paralysis  of  the  external 
the  left)  from  an  acute  lesion  on  the  t        {     complete  but  exists  alone  ; 

left  side  or  the  pons,     (i  roro  a  pho-  r     . 

tograph.)  there  is  no  deficiency  of  movement 

*  In  one  recorded  case  the  lesion  was  below  the  level  of  the  sixth  nucleus,  the 
lower  end  of  this  nucleus  being  near  the  highest  part  of  the  lesion.  It  is  probable 
that  the  superior  olivary  body  was  involved  (Senator,  '  Berl.  Psych.  Gesellsch./ 
July  9th,  1883). 


OCULAR  NERVES.  189' 

of  the  opposite  internal  rectus.  The  lesion  that  causes  these  sym- 
ptoms may  be  either  a  chronic  process,  such  as  a  small  tumour,  or  art 
acute  lesion,  haemorrhage,  or,  more  frequently,  softening.  Other 
symptoms  of  disease  on  one  side  of  the  pons  are  often  present, 
especially  in  the  region  of  the  fifth  nerve  on  the  side  of  the  lesion, 
sometimes  in  the  limbs  on  the  opposite  side. 

Total  Ophthalmoplegia. — Paralysis  of  all  the  muscles  of  both  eyes, 
internal  and  external,  is  a  very  rare  consequence  of  disease  at  the 
neighbourhood  of  the  orbital  fissure  and  optic  foramen  on  each  side,, 
either  in  the  orbit  or  within  the  skull,  such  as  thrombosis  in  each 
cavernous  sinus.*  But  it  is  met  with  chiefly  in  cases  of  nuclear 
disease,  and  will  be  described  in  the  account  of  this  variety. 

Causes  and  Causal  "Varieties. — Paralysis  of  the  ocular  muscles 
may  be  due  to  disease  of  the  nerves  in  the  orbit  or  at  the  base  of  the 
brain,  to  lesions  of  the  fibres  of  origin  between  the  surface  of  the  brain 
and  the  nerve-nuclei,  and  to  disease  of  the  nuclei  themselves.  A 
defect  in  certain  ocular  movements  may  also  be  produced  by  disease 
of  the  cortex  of  the  brain  and  of  the  path  from  the  cortex  to  the  nuclei,, 
but  the  loss  that  is  usually  so  produced  is  that  of  the  conjugate  lateral 
movement  of  both  eyes,  already  described  in  the  account  of  hemi- 
plegia, with  slight  ptosis  on  the  side  opposite  to  the  lesion.  It  is- 
possible,  however,  that  a  defect  of  associated  movements  (e.g.  of  the 
upward  or  downward  movement)  is  also  sometimes  due  to  disease  of 
the  hemisphere,  but  our  knowledge  of  this  cause  is  imperfect.  Of 
the  remaining  lesions  those  of  the  nuclei  (constituting  the  important 
group  of  nuclear  palsies)  will  be  separately  described. 

Injury  is  a  common  cause,  and  may  damage  the  nerves  in  any  part 
of  their  course,  especially  at  the  orbital  fissure  or  in  the  orbit,  but 
sometimes  at  their  origin.  Some  of  the  roots  of  one  third  nerve  have 
been  found  torn.f  One  eye  is  usually  alone  affected.  The  injury  is 
usually  a  blow  on  the  side  of  the  head,  which  causes  an  extravasation 
and  immediate  paralysis,  or  excites  an  inflammation  and  palsy  after  a. 
few  days.  All  or  only  some  of  the  nerves  may  suffer.  Recovery  is 
slow  and  often  imperfect.  Sometimes,  indeed,  there  is  a  late  exten- 
sion, perhaps  by  processes  outside  "the  nerves,  or  cicatricial  contraction 
of  adjacent  tissue.  Thus  a  blow  on  the  right  temple  was  followed  at 
once  by  palsy  of  all  parts  of  this  third  nerve.  Slow  improvement  was 
followed  by  a  relapse,  with  palsy  of  the  external  rectus. 

Neuritis  in  the  orbit  or  at  the  base  of  the  brain,  involving  the  trunks 
or  branches,  is  not  rare.  It  may  be  syphilitic  in  either  situation.  In 
the  orbit  it  is  sometimes  primary  and  "  rheumatic,"  but  it  is  occa- 
sionally secondary  to  adjacent  cellulitis.  Within  the  skull  it  is  gene- 
rally secondary  to  meningitis.  The  nerves  in  the  orbit  are  damaged 
by  slow  pressure  only  in  rare  cases  of  orbital  growths,  but  within  the- 

*  Coupland,  'Trans.  Oph.  Soc.,'  vol.  v. 

t  Hutchiuson,  Astlcy  Cooper  Prize,  May  1st,  ISfio. 


190  CRANIAL    NERVES. 

skull  they  often  suffer  compression  by  growths  or  aneurisms.  All 
the  nerves  to  one  eye  may  be  compressed  in  the  wall  of  the  cavernous 
sinus  by  thrombosis  in  it,  by  an  aneurism  of  the  internal  carotid,  or 
bj  an  adjacent  growth,*  and  both  third  nerves  maybe  damaged  by  a 
growth  between  the  cerebral  peduncles,  or  by  an  aneurism  of  the  pos- 
terior cerebral  artery.  Tumours  of  the  nerves  themselves  are  rare; 
neuromata  are  almost  unknown,  but  nodular  syphilitic  growths  some- 
times occur,  and  may  be  symmetrical — situated,  for  instance,  on  the 
two  sixth  nerves  near  their  origin  (Barlow).  The  root-fibres  suffer, 
in  their  deep  course,  from  various  lesions  of  the  brain, — haemorrhage, 
softening,  tumours,  and  islets  of  disseminated  sclerosis.  Such  lesions, 
involving  the  sixth  or  third  nerve-fibres,  often  also  implicate  the  motor 
tract,  and  there  results  hemiplegia  associated  with  palsy  of  one  of 
these  nerves.  In  consequence  of  the  decussation  of  the  motor  tract 
below  the  origin  of  the  nerve,  the  two  symptoms  are  always  on  the 
opposite  sides,  "  alternate  hemiplegia ;"  if  on  the  same  side  there 
must  he  two  lesions.  Very  rarely  a  small  focus  of  softening  in  the 
crus  may  damage  only  some  of  the  roots  of  the  third  nerve,  f  Paralysis 
of  all  the  ocular  muscles  has  heen  caused  by  the  fumes  of  charcoal,  by 
lead,  and  that  of  the  third  nerve  has  been  met  with  in  Graves' 
disease. J  Other  toxemic  states,  as  that  from  alcohol,  may  have  a 
similar  effect.  In  some,  the  mechanism  is  a  peripheral  neuritis,  but 
an  action  on  the  centre  is  more  frequent. 

Diphtheritic  Paralysis. — A  rare  cause  of  palsy  of  the  external 
muscles  is  diphtheria.  The  external  rectus  has  been  occasionally 
affected,  and  both  internal  recti  have  been  weakened  in  association 
with  the  loss  of  accommodation  so  common  in  this  disease.  In  one 
case  all  the  muscles  supplied  by  one  third  nerve  were  affected 
(Vadelot),  and  in  two  others  there  was  paralysis  of  all  the  external 
muscles  of  both  eyes.§ 

Tabetic  Paralysis. — In  locomotor  ataxy  it  is  very  common  for  some 
of  the  ocular  muscles  to  be  weakened.  The  loss  of  power  is  often 
transient,  and  then  may  recur;  sometimes  it  is  permanent.  Each  form 
may  occur  at  any  stage  of  the  disease,  and  is  sometimes  an  early 
symptom,  even  preceding  those  in  the  limbs.  The  external  rectus,  or 
the  levator  and  superior  rectus,  are  the  muscles  most  frequently 
affected ;  occasionally  all  the  muscles  supplied  by  the  third  nerve 
suffer.  Loss  of  the  light-reflex  is  extremely  common,  and  other  in- 
ternal palsies  are  not  infrequent.  External  palsy  is  generally  on 
one  side  only,  hut  sometimes  both  eyes  are  affected  (see  Figure, 
vol.  i,  p.  408).     We  have  scarcely  any  evidence  at  present  of  the 

*  Many  instances  of  such  palsy  are  on  record.  A  typical  one  is  recorded  by 
Nettleship,  '  Trans.  Ophth.  Soc.,'  vol.  i,  p.  186. 

t  Kahler  and  Pick,  'Arch.  f.  Psych.,'  x,  334.  It  has  been  termed  "fascicular 
palsy."     "  Root  palsy,"  internal  or  external,  would  be  a  better  name. 

J  Knapp,  Buzzard,  Finlayson. 

§•  Uhthoff, '  Neur.  Centralbl.,'  1S85,  p.  125;  and  Mendel,  ib.,  p.  128. 


OCULAR    NKEVES.  191 

cause  of  these  palsies,  but  the  fact  that  total  nuclear  palsy  is  some- 
times met  with  makes  it  probable  that  these  also  are  often  of 
nuclear  origin.  The  peripheral  nerve  degeneration  of  tabes  has  not 
been  found  in  the  ocular  nerves,  and  its  limitation  elsewhere  to  the 
sensory  fibres  renders  its  occurrence  in  these  nerves  improbable.  It 
must  be  remembered  that  many  subjects  of  tabes  have  had  constitu- 
tional syphilis,  and  that  a  true  syphilitic  ocnlar  palsy  may  co  exist 
with  locomotor  ataxy. 

Rheumatic  Paralysis. — Affections  of  the  ocular  muscles  due  to  expo- 
sure to  cold  are  regarded  as  due  to  rheumatic  neuritis.  They  are 
always  one-sided,  and  commonly  involve  a  single  nerve,  or  a  single 
branch,  or  two  contiguous  branches,  such  as  those  to  the  levator  pal- 
pebrse  and  superior  rectus.  Rarely  all  the  nerves  of  one  orbit  are 
involved,  including  the  optic  nerve  (see  p.  144).  The  onset  of  the 
disease  is  often  attended  with  pain  about  the  orbit.  The  occurrence 
of  a  rheumatic  neuritis  does  not  rest  on  pathological  evidence,  but 
is  nevertheless  highly  probable.  In  two  of  the  cases  in  which  all 
the  nerves  of  the  orbit  were  affected  the  patient  had  previously 
suffered  from  facial  neuritis  due  to  cold.  In  one  recorded  case,  in 
which  swelling  of  the  lids  seemed  to  prove  that  the  disease  was  orbital, 
the  internal  muscles  escaped,  on  account,  it  is  supposed,  of  the  more 
central  position  of  their  nerves.* 

Hsemorrhage. — Paralysis  of  an  ocular  nerve  may  be  apparently  the 
result  of  hsemorrhage  into  the  sheath,  compressing  the  fibres.  In  a 
case  of  paralysis  of  one  fourth  nerve,  the  onset  was  quite  sudden 
during  an  attack  of  vomiting.  No  other  cause  could  be  traced. 
Hsemorrhage  into  the  sheath  of  the  third  nerve,  near  its  origin,  has 
preceded,  by  a  few  days,  meningeal  hsemorrhage. f  Other  cranial 
nerves  may  be  suddenly  paralysed  in  like  manner.  This  mechanism 
is  probably  not  uncommon  and  may  depend  on  a  special  arrangement 
of  the  blood-vessels.  The  cases  come  within  the  general  law  that  an 
organic  lesion  of  actually  sudden  onset  is  always  vascular,  due  to  the 
rupture  or  occlusion  of  a  vessel.  An  onset  during  strain  renders 
rupture  scarcely  questionable. 

Syphilitic  Paralysis. — From  the  list  of  causes  already  given  it  is  evi- 
dent that  syphilis  may  produce  palsy  of  ocular  muscles  in  several  ways. 
The  nerves  may  be  the  seat  of  isolated  syphilitic  inflammation  or  of  a 
gumma ;  they  may  be  involved  in  syphilitic  meningitis  or  compressed 
by  a  syphilitic  growth  outside  them.  They  may  also  be  damaged  by 
an  aneurism  of  syphilitic  origin.  A  young  man,  a  few  years  after 
primary  syphilis,  became  affected  with  palsy  of  one  third  nerve,  which 
did  not  yield  to  antisyphilitic  (or  any)  treatment.  After  some 
months  he  was  seized  with  apoplexy  and  died,  probably  from  the 
rupture  of  an  aneurism  of  the  posterior  cerebral  artery.  Lastly, 
syphilis  seems  to  predispose   to   degeneration  of  the   nuclei   of  the 

*  Mobius,  '  Cent,  f .  Nervenh.,'  1886,  p.  516.  The  symptoms  followed  exposure 
to  cold.  f  Goldscheider  '  Charite-Aun.,5  1892. 


192 


CEANIAL    NERVES. 


nerves.     Thus  the  mere  fact  that  paralysis  is  due  to  syphilis  is  only- 
the  first  step  in  the  din  gnostic  problem  of  the  nature  of  the  disease. 

Relapsing  Palsy. — One  form  of  paralysis  of  the  third  nerves^ 
■which  occurs  chiefly  in  the  subjects  of  syphilis,  presents  a  peculiar 
tendency  to  relapse  and  persist.  One  third  nerve  becomes  para- 
lysed, improves  under  treatment,  and  then,  perhaps  while  the  treatment 
is  being  continued,  the  other  third  nerve  suffers,  and  afterwards  the 
affection  of  the  first  returns.  An  instance  of  the  palsy  is  shown  in  Fig. 
100.  Syphilis  was  contracted  four  years  previously,  but  the  suddeu 
onset  of  the  palsy  of  the  left  nerve  occurred  during  a  severe  cold. 

The  patient  was  treated  with  iodide 
and  mercury,  but  the  course  of  the 
paralysis  was  that  described  above,, 
and  the  permanent  condition  was  that 
the  left  eye  could  only  be  moved  out- 
wards and  a  little  upwards.  There 
was  extreme  ptosis  of  the  left  eye  and 
slight  ptosis  of  the  right.  The  in- 
ternal muscles  were  also  paralysed. 
In  another  case,  similar  in  course  but 
less  complete,  the  interval  after  the 
syphilis  was  thirty  years,  so  that  its 
influence  is  doubtful.  The  nature  of 
the  lesion  in  these  cases  is  uncertain. 
The  course  and  limitation  of  the  sym- 
ptoms seems  inconsistent  with  nuclear 

disease. 

Fig.  100. — Double  ptosis  from  para-         „  .  _      .      .     7 

lysis  of  the  third  nerves,  complete  Recurring  or  Periodical  Palsy.— 
on  the  left  side,  partial  on  the  The  last  variety  to  be  described  is  a 
right.  Over-action  of  frontales,  rare  form  of  transient  palsy,  usually 
greater  on  the  side  or  the  com-  .  -  J 

plete  palsy.  on   one   sic*e  only,    which    comes   on 

at  intervals  during  many  years.*  It 
has  been  miscalled  "  relapsing  palsy,"  but  typical  attacks  are  recur- 
rences, not  relapses,  and,  in  most  instances,  have  been  periodical.  Both 
sexes  suffer,  but  women  are  more  subject  to  the  disease  than  men. 
It  often  dates  from  early  childhood,  and  has  been  known  to  begin  at 
eleven  months, f  at  fifteen  months, J  at  five  years  of  age,  and  later  ;§ 
it  continues  up  to  at  least  middle  life.  An  attack  may  occur  at  the 
same  time  each  year,  or  at  intervals  of  about  six  months.  A  much 
longer  interval  usually  separates  the  early  attacks.  Sometimes  the 
intervals  have  been  long  and  irregular,  amounting  to  several  years, || 

*  Cases  have  been  recorded  in  this  country  by  Saundby,  '  Lancet,'  1882,  ii,  345, 
and  1885,  i,  57 ;  and  by  Snell,  *  Trans.  Ophth.  Soc./  v,  193. 
f  Mobius,  *  Neur.  Cent./  1884,  p.  307. 
%  Snell,  loc.  cit. 

§  Thomsen, '  Charite-Annalen,'  18S5,  p.  562. 
||  Five  to  nine  years  in  a  case  recorded  by  Camuset,  'L'Union  med.,'  1876,  p.  906. 


OCULAR    NERVES.  193 

while  in  other  cases  they  Lave  been  short,  and  attacks  have  even 
occurred  at  each  menstrual  period.*  As  a  rule  the  paroxysm  begins 
with  severe  pain  in  the  eye,  and  often  with  headache  and  vomitino-. 
These  symptoms  last  two  or  three  days ;  the  palsy  may  accompauy 
them  or  may  come  on  as  they  lessen.  In  many  cases  only  the  third 
nerve  has  been  affected,  but  in  some  the  external  rectus  was  also  in- 
volved. The  palsy  may  be  complete  or  incomplete;  the  internal 
muscles  are  often,  but  not  always,  affected  ;  there  is  usually  ptosis. 
The  loss  of  power  lasts  for  a  few  days  or  weeks,  and  then  gradually 
passes  away.  When  the  attacks  are  frequent  they  are  usually  brief. 
In  many  cases  a  slight  defect  of  power  has  persisted  during  the 
intervals.  In  one  case  there  was  concentric  contraction  of  both 
fields  of  vision,  greatest  in  the  paralysed  eve,  and  varying  in  degree 
in  proportion  to  the  motor  palsy  (Thomsen).  The  attacks  may  last 
for  several  weeks,  from  three  to  eight ;  and,  as  a  general  rule,  when 
the  intervals  are  long,  so  are  the  attacks.  When  the  paroxysms 
recur  frequently — as,  for  instance,  every  month — they  last  for  a  few 
clays  only.  A  child  of  three  and  a  half,  with  some  indications  of  con- 
genital syphilis,  had  ptosis  of  the  right  eye.  Four  months  later  it  had 
ptosis  of  the  left  eye,  and  a  second  attack  in  the  same  eye  ten  months 
afterwards.  Each  time  the  attack  lasted  a  few  days,  and  passed  off 
without  leaving  any  weakness.  In  several  cases  the  headache  was 
unilateral.  In  patients  subject  to  the  affection,  an  attack  has  been 
brought  on  by  mental  shock. 

The  nature  of  this  disease  is  mysterious.  It  has  been  compared  to 
migraine,  and  is  perhaps  more  closely  allied  to  this  than  to  any  other 
disease.  Charcot  has  termed  it  "  migraine  ophthalmique,"  and  in  one 
case  there  was  a  strong  family  history  of  migraine  (Snell).  But  the  long 
duration  of  the  attacks,  the  motor  character  of  the  chief  symptoms,  their 
long  duration,  and  the  occasional  persistence  of  slight  defect  of  move- 
ment, are  marked  differences  from  purely  migrainous  and  neuralgic 
affections. f  It  has  been  suggested  that  the  cause  is  organic  disease 
with  periods  of  activity,  but  this  theory  is  scarcely  tenable.  Vaso-motor 
disturbance  has,  of  course,  been  invoked  to  explain  it,  but  this  is  only 
putting  the  difficulty  farther  back.  The  few  post-mortem  examina- 
tions so  far  obtained  do  not  clear  up  the  mystery.     With  permanent 

*  Hasner, '  Prag.  med.  Wochenschr.,'  1883,  No.  10. 

t  A  case  recorded  by  Buzzard  (*  Clin.  Lect./  p.  164)  is  perhaps  a  connecting  link 
between  these  cases  and  pure  neuralgias.  A  woman  had  been  subject  for  many 
years  to  fortnightly  paroxysms  of  neuralgia  of  the  first  division  of  the  fifth  nerve, 
and  for  two  years  before  she  came  under  observation  each  attack  was  followed  by 
partial  palsy  of  the  third  nerve  lasting  for  a  few  days.  Complete  palsy  has  occurred 
during  each  attack  of  migraine  (Anderson,  '  Trans.  Oph.  Soc./  1892). 

In  a  case  recorded  by  Pfliiger  there  were  periodical  attacks  of  paralysis  of 
variable  seat ;  of  the  left  third  and  facial  nerves  at  eighteen,  of  the  nerves  on  the 
right  side  at  twenty,  of  the  left  third  nerve  again  at  twenty-two,  and  six  months 
later  of  the  left  sixth  and  facial.  Each  attack  lasted  from  one  to  two  months,  and 
was  preceded  by  pain,  which  before  the  last  was  about  the  left  mastoid  process, 
VOL.   II.  13 


194  OKANIAL    NERVES. 

weakness  there  have  been  changes  in  the  peripheral  nei'ves  and  not 
in  the  nuclei.  A  woman  died  of  phthisis  at  thirty  who  had  suf- 
fered, since  childhood,  from  periodical  attacks  of  palsy  of  the  left 
third  nerve.  This  appeared  grey,  and  its  roots  were  surrounded  by 
small  grey  granulations  which  contained  tubercular  bacilli,  which 
did  not  extend  into  the  crus.  Some  fatty  degeneration  was  found  in 
the  muscles  supplied  by  it,  the  other  muscles  being  normal.*  In  other 
three  examinations  the  lesion  was  peripheral  and  the  nuclei  intact.f 

Nuclear  Ocular  Palsy. — Disease  of  their  nuclei  is  a  frequent 
cause  of  paralysis  of  the  eye-muscles,  internal  and  external,  and 
certain  forms  may  be  due  to  disease  of  the  corpora  quadi igeniina 
which  does  not  penetrate  the  nuclei.  The. symptoms  vary  much  accord- 
ing to  the  position  and  character  of  the  lesion,  which  may  be  various, 
and  either  acute  or  chronic ;  but  they  are,  as  a  rule,  bilateral,  except 
when  there  is  the  isolated  affection  of  the- sixth  nucleus,  already  con- 
sidered  in  the  account  of  such  conjugate  palsy. J 

The  chief  forms  of  nuclear  palsy  may  be  classified  according  to  the 
character  of  the  symptoms  and  probable  nature  of  the  morbid  process. 
The  most  common  is  (1)  chronic  nuclear  palsy,  due  usually  to  degene- 
rative processes,  very  rarely  to  such  chronic  disease  as  a  tumour.  A 
rare  form  is  (2)  acute  nuclear  palsy,  in  which  the  symptoms  come  on 
in  a  few  days  or  a  few  weeks.  The  onset  suggests  inflammation, 
and  the  form  has  been  termed  (by  Wernicke)  "polio-encephalitis 
superior,"§  from  its  analogy  with  polio-myelitis,  and  to  distinguish  it 
from  a  similar  affection  of  the  lower  nuclei  in  the  medulla,  "  polio- 
encephalitis inferior."  But  it  may  apparently  also  be  excited  by  toxic 
influences.  (3)  In  sudden  nuclear  palsy  the  onset  occupies  a  few 
minutes,  or  at  most  an  hour  or  two.  These  cases  are  often  miscalled 
"  acute,"  but  this  term  is  needed  for  class  2.  Such  an  onset  always 
indicates  a  vascular  lesion,  which  probably  is  the  common  cause  of 
this  form. 

The  characteristic  feature  of  all  forms  is  the  paralysis  of  muscles 
of  both  eyes,  internal  or  external,  symmetrical  or  irregular.  Limita- 
tion to  one  eye  occurs  so  seldom  that  it  should  not  suggest  nuclear 
disease.     On  the  other  hand,  both  eyes  may  suffer  from  disease  of  the 

*  It  should  be  remembered  that  disturbance  of  function  may  cause  organic 
changes  or  determine  disease  of  the  nerve,  as  well  as  result  from  such  disease. 

t  '  Neur.  Cent./  1888,  p.  88. 

%  Nuclear  ocular  palsy  is  also  termed  ophthalmoplegia,  a  term  first  used  by 
Brunner  in  1850.  The  nature  of  the  cases  was  pointed  out  by  M.  Graefe  in  1856 
('  Arch,  f .  Oph.'),  and,  in  1868,  compared  with  labio-glossal  palsy.  Forster 
correctly  localised  the  lesion  in  1878  for  external  palsies ;  and  internal  ophthalmo- 
plegia was  well  described  by  Hutchinson  in  1878  ('  Med.-Chir.  Trans/),  and  the 
external  ophthalmoplegia,  with  post-mortem  proof  of  its  nature,  in  1879  (ibid.). 

§  A  name  open  to  many  objections,  both  theoretical  and  practical.  Nuclear 
palsy  of  all  the  external  muscles  has,  indeed,  been  associated  with  polio-myelitis  in 
a  man  of  forty,  but  the  cord  affection  was  acute,  and  that  of  the  eyes  was  chronic 
(Sachs,  '  American  Journ.  Med.  Science,'  1889). 


OCULAR   NERVES.  195 

nerves  (trunks,  branches,  or  endings),  but  such  bilateral  disease  is 
rare,  and,  without  other  evidence  of  a  nerve  lesion,  should  suggest 
nuclear  mischief. 

(1)  Chronic  nuclear  palsy,  chronic  ophthalmoplegia,  includes  the 
isolated  loss  of  the  reflex  action  of  the  iris,  isolated  palsy  of  the 
•ciliary  muscles,  palsy  of  all  the  internal  muscles,  of  all  or  many  of  the 
external  muscles,  and  lastly,  of  both  the  external  and  internal  muscles. 
It  also  includes  loss  of  the  upward  or  downward  movements  of  the 
eyes,  ptosis,  and  the  conjugate  lateral  palsy  already  described.  The 
combinations  met  with  are  extremely  numerous  and  varied. 

Later  observations  have  shown  that  we  cannot  separate  most  forms 
of  chronic  palsy.  They  occur  under  similar  conditions  ;  they  may  be 
variously  combined,  and  the  dependence  of  one  of  them  on  nuclear 
disease  has  been  conclusively  proved,  so  that  it  is  probably  true  of 
most.  Each  form  is  met  within  association  with  locomotor  ataxy ; 
the  simple  loss  of  reflex  action  is  indeed  present  in  the  majority  of 
cases  of  this  disease.  It  has  been  mentioned  that  when  this  loss  exists 
alone  the  subjects  of  it  have  frequently  suffered  from  constitutional 
syphilis,  and  the  same  fact  is  true  of  the  other  forms  of  ophthalmo- 
plegia.* They  sometimes  occur,  however,  without  this  antecedent, 
which  may  or  may  not  develop  later.  They  occasionally  affect  youno- 
persons,  and  are  met  with  more  frequently  in  males  than  in  females, 
resembling  in  this  their  congener,  tabes.  It  is  seldom  that  any 
immediate  cause  can  be  traced ;  in  one  instance  the  symptoms  are  said 
to  have  come  on  after  a  wetting.  I  have  seen  the  condition  as  a  late 
and  permanent  sequel  of  diphtheria. 

Some  other  features  deserve  mention.  The  first  muscles  to  suffer 
may  be  those  that  are  associated  in  action — the  superior  recti  and 
levators,  the  two  internal  recti,  or  the  internal  rectus  on  one  side  and 
the  external  rectus  on  the  other ;  or  it  may  be  quite  irregular.  The 
loss  of  power,  at  first  slight,  slowly  increases  ;  often  a  strong  effort 
shows  more  power  than  is  habitually  exerted,  and  the  weakness  may 
be  less  in  the  morning  than  in  the  evening.  The  disease  slowly 
extends,  until  at  last,  often  after  several  years,  only  one  or  two  of  the 
muscles  of  both  eyes  retain  power,  and  sometimes  every  muscle  is 
paralysed.  The  levators,  however,  seldom  become  completely  para- 
lysed, and  maybe  unaffected.  The  aspect  of  the  patients  is  peculiar ; 
when  there  is  partial  ptosis,  this  gives  them  a  sleepy  expression,  and 
in  total  palsy  without  ptosis  a  staring  look  results  from  the  immobility 
of  the  eyes,  which  are  fixed  in  mid-position.  Sometimes,  although 
rarely,  they  are  slightly  prominent.     Occasionally  one  eye  is  much 

*  As  in  so  many  of  these  degenerative  diseases,  the  facts  that  can  be  ascertained 
probably  under-represent  the  relation  to  syphilis.  The  case  of  Mr.  Hutchinson, 
examined  by  me  (see  p.  197),  is  an  illustration  of  this.  The  man  persistently  denied 
any  venereal  sore,  and  no  trace  or  history  of  syphilitic  disease  could  be  found.  But 
some  years  later  a  child  of  this  man  was  brought  to  Mr.  Hutchinson  with  charac- 
teristic notched  teeth  and  interstitial  keratitis. 


196  CRANIAL    NERVES. 

more  affected  than  the  other;  on  one  side  there  may  be  total  palsy,  on. 
the  other  only  ptosis,  or  loss  of  the  light-reflex.  The  internal  muscles 
are  often  unaffected;  when  this  is  tbe  case  the  diagnosis  of  nuclear 
palsy  can  be  made  with  confidence,  because  the  escape  of  the  internal 
muscles  in  bilateral  disease  of  the  nerve-trunks  is  scarcely  possible. 
This  feature  was  thought  to  be  a  characteristic  of  pi'ogressive  ophthal- 
moplegia by  von  Graefe,  but  it  is  not  so ;  the  affection  of  the  external 
muscles  may  be  combined  with  loss  of  reflex  action  of  the  iris,  with 
cycloplegia,  or  with  both  as  "  total  ophthalmoplegia."  In  the  case 
presently  to  be  mentioned,  in  which  the  nature  of  the  lesion  was 
ascertained,  the  internal  muscles  were  affected.  Double  vision  may 
trouble  the  patient  in  the  early  stage  of  the  affection,  but  it  generally 
passes  away  as  the  disease  progresses,  and  is  sometimes  absent  from 
the  first,  perhaps  when  tbe  early  loss  is  of  associated  movements.  The 
duration  of  the  malady  is  long.  In  one  of  Hutchinson's  cases  the 
symptoms  continued  for  seventeen  years.  In  one  of  Mauthner's  the 
affection  is  said  to  have  been  limited  to  one  eye  for  twenty  years.  It 
is  common  for  arrest  to  occur  when  a  certain  degree  of  palsy  has  been 
attained.  The  symptoms  may  exist  alone,  but  they  are  frequently 
associated  with  indications  of  other  diseases  of  the  nervous  system — 
with  optic  nerve  atrophy,  with  affection  of  the  bulbar  nerves*  (rarely 
amounting  to  typical  bulbar  palsy),  with  general  paralysis  of  the 
insane,  and  especially  with  locomotor  ataxy.  It  may  attain  a  consider- 
able degree  before  there  are  any  symptoms  of  tabes,  even  when  this 
is  ultimately  severe.  A  similar  condition  is  perhaps  sometimes  con- 
genital, and  even  hereditary.! 

The  nature  of  these  cases  is  not  a  matter  of  speculation.  In  a  case 
of  Mr.  Hutchinson's,  in  which  I  examined  the  brain  (1879),  the  state 
of  the  nuclei  of  the  ocular  nerves  was  nearly  the  same  as  that  of  the 
grey  matter  of  the  spinal  cord  in  progressive  muscular  atrophy.  The 
patient  was  a  man,  aged  fifty-five,  who  had  had  syphilis.  The  sym- 
ptoms began  gradually,  seven  years  before  death,  with  palsy  of  the 
internal  recti  and  ciliary  muscles.  Ultimately  all  the  ocular  muscles 
became  very  feeble,  the  optic  nerves  atrophied,  there  was  mental 
excitement,  and  some  palsy  developed  in  the  limbs,  the  condition 
resembling  that  of  some  forms  of  general  paralysis  of  the  insane. 
The  roots  of  the  ocular  nerves,  outside  and  inside  tbe  brain,  were 
grey,  small,  and  contained  scarcely  any  normal  fibres.  In  their 
nuclei  a  few  nerve-cells  of  normal  size  were  seen,  but  these  had,  for 
the  most  part,  lost  their  processes,  and  a  large  number  of  the  cells 
were  reduced  to  small  angular  bodies  or  had  disappeared  (Fig.  101). 

*  This  combination  existed  in  the  case  that  was  a  late  sequel  of  diphtheria. 

t  Thus  Hirschberg  ('  Berlin.  Gesellsch.  f.  Psych.,'  June  8th,  1885)  has  described 
the  case  of  a  man  with  congenital  double  ptosis  and  paralysis  of  all  the  ocular 
muscles,  incomplete  in  the  superior  oblique  and  the  internal  muscles,  whose  mother 
presented  a  similar  condition,  while  his  son  had  congenital  ptosis  and  paralysis  of 
the  superior  recti. 


OCULAE   NEEVES. 


197 


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In  the  intervening  tissue  there  were  many  connective-tissue  nuclei. 
The  change  involved  the  sixth,  fourth,   and  the  whole  of  the  third 
nuclei.     The  other  nerve-roots  and  nuclei  were  normal.     The  spinal 
cord  was  not  obtained.     Thus  the  lesion,  in  a  fairly  characteristic 
case,  was  a  degeneration,  limited  to  structures  having  a  common 
function.     The  internal  palsies  occur  under  similar  conditions,  and 
their  frequent  limitation  to 
a  single  function  in  the  two 
eyes  points  to  a  like  change 
of   more  restricted  seat.     It 
is    only    by    toxemic    influ- 
ences  or   degeneration   that 
structures  of  common  func- 
tion are  selected,  as  it  were, 
for   isolated  disease,    and  it 
is  probable  that  all  degene- 
rations  are  often  the   effect 
of  a  toxemia  (see  "  Tabes," 
vol.  i),  perhaps    a   chemical 
"toxine,"  produced  by  organ- 
isms.    In  other  and  younger 
subjects  they  seem  to  be  due 
to  deficient  vital   endurance 
of  the  structure,  varying  in 
degree  so  as  to  be  manifested   Fig.  101.— A,  part  of  sixth  nucleus  in  pro- 
at   birth    or    not   until   adult        gressive  ophthalmoplegia;    B,  cells  of  the 
-l-n  normal  nucleus,  for  comparison. 

But  in  all  degenerations  destruction  begins  as  slight  and  slow 
changes  in  nutrition,  doubtless  sometimes  capable  of  recovery,  as 
when  internal  palsy  passes  away  after  it  has  lasted  for  many  months, 
and  perhaps  for  more  than  a  year.  I  have  known  the  light-reflex  to 
return,  in  stationary  tabes,  after  it  had  been  lost  for  at  least  two 
years,  and  the  remarkable  case  of  internal  ophthalmoplegia  recorded 
byEales  (see  p.  185)  is  an  instance  of  the  way  in  which  such  a  palsy, 
limited  and  complete,  may  pass  away.  Such  recovery  is  especially 
intelligible  if  the  changes  are  due  to  a  toxaemia. 

Infantile  oculo -facial  palsy  is  a  rare  variety  of  the  chronic  form, 
which  may  be  congenital,  or  begin  at  some  period  of  childhood,  rarely 
in  early  adult  life.  Palsy  of  the  external  ocular  muscles,  all  or 
many,  is  very  commonly  accompanied  by  paralysis  of  the  face,  some- 
times chiefly  of  the  zygomatics.  Ptosis  is  common,  but  the  internal 
'  muscles  do  not  suffer.  It  usually  becomes  stationary,  and  remains  so 
through  life.  Nothing  definite  is  known  of  its  causation,  but  its 
history  suggests  defective  vital  endurance  in  the  nuclear  structures.* 

Sudden  Nuclear  Palsy. — The  vascular  lesion  which  causes  sudden 
palsy,  and  the  onset  of  which  is  survived,  is  usually  obstruction  of  the 

*  Mobius  (1892)  has  collected  forty-four  cases  ('Munch,  med.  Wochenschr.'). 


198  CRANIAL    NERVES. 

arterial  branches  which  the  basilar  gives  to  this  part.  The  obstruc- 
tion is  usually  bilateral,  because  disease  in  the  wall  of  the  basilar, 
whether  atheroma  or  syphilitic,  affects  the  branches  given  off  at  the 
spot  on  each  side.  Hence  small  foci  of  softening  are  often  found  in  each 
third  nucleus.  The  same  conditions  determine  the  bilateral  character 
of  the  lesion  and  symptoms  in  the  rare  cases  of  embolic  obstruction. 
But  the  lesions  are  irregular  in  distribution,  and  the  symptoms 
unsyminetrical  as  a  rule,  and  even  partial,  different  parts  of  the 
nuclei  being  supplied  by  different  branches,  according  to  Heubner. 
This  irregularity  is  a  difference  from  the  chronic  form,  while  other 
distinctions  are  furnished  not  only  by  the  onset,  but  by  the  tendency 
to  improvement  which  they,  and  all  similar  lesions,  pi'esent,  and  by  the 
occasional  association  of  hemiplegia,  usually  on  the  side  opposite  to 
the  greater  eye-palsy.  Haemorrhage,  when  it  occurs,  is  apt  to  spread, 
and  although  there  may  be  definite  ocular  palsy  at  the  onset,  the 
duration  of  life  is  seldom  more  than  a  few  hours.  Only  in  rare  cases 
has  recovery  followed  irritant  apoplexy,  that  has  made  haemorrhage 
probable.*  An  instructive  example  of  the  embolic  form  is  recorded 
by  Allen  Starr.f  A  man  with  heart  disease  had  sudden  giddiness 
and  double  vision,  followed  by  somnolence,  unequal  pupils,  paralysis 
of  the  right  inferior  and  internal  recti,  and  the  left  inferior  and 
superior  recti.  In  eight  days  the  pupils  were  equal,  and  the  internal 
rectus  normal;  the  other  muscles  remained  paralysed  at  the  end  of 
a  year. 

An  example  of  a  much  slighter  lesion,  probably  due  to  syphilitic 
vascular  disease,  and  characteristic  in  its  course  and  irregularity,  was 
that  of  a  man  who,  one  day,  suddenly  found  both  upper  lids  drooping, 
and  then  that  both  eyes  deviated  outwards,  and  could  not  be  moved. 
In  a  few  days  he  could  move  the  right  eye  fairly  well,  but  six  months 
later  he  presented  complete  internal  ophthalmoplegia  in  both  eyes, 
with,  in  the  left,  slight  ptosis  and  complete  palsy  of  the  other 
muscles  supplied  by  the  third  nerve,  but  not  of  the  external  rectus, 
and  the  superior  oblique  possessed  a  little  power. 

Acute  and  subacute  nuclear  palsy  includes  the  cases  which  reach 
their  height  in  a  few  days  or  a  few  weeks,  an  onset  that  suggests  one 
of  two  morbid  processes — inflammation,  or  the  action  on  the  centre  of 
some  poison  circulating  in  the  blood,  to  which,  indeed,  actual  inflam- 
mation may  sometimes  be  due.  But  such  a  poison  may  abolish 
function  without  causing  visible  changes ;  hence  the  name  proposed 
by  "Wernicke  J  and  widely  used,  "  polio-encephalitis  superior,"  is  not 
always  correct.  Even  the  less  objectionable  "acute  nuclear  palsy" 
may  prove  to  be  sometimes  inaccurate,  since  the  symptoms  may  be 

*  See  Sturge,  '  Trans.  Oph.  Soc.,'  vol.  i. 

f  *  Journ.  Nerv.  and  Mental  Dis.,J  1888. 

J  Who  first  accurately  distinguished  this  form  ('  Gehirnkrankheiten/  ii,  233). 
It  was  also  well  described  by  Thomsen  ('Arch.  f.  Psych.,'  1888).  Good  descrip- 
tions have  been  given  by  Mauthner  ('  Vortrage'). 


OCULAB   NERVES.  199 

due  to  peripheral  neuritis  and  not  to  nuclear  disease.  Hitherto, 
however,  most  post-mortem  examinations  have  shown  evidence  of 
inflammation  in  the  nuclei  beneath  the  corpora  quadrigemina,  soften- 
ing, minute  extravasations,  &c,  Thus  in  two  cases  of  external  palsv, 
complete  except  that  the  levator  escaped,  Thomsen  found  great 
hyperemia  of  the  nuclei,  third,  fourth,  and  sixth  (and  of  the  hypo- 
glossal), with  degenerative  changes  in  the  nerve-elements.  But  the 
malady  is  rare,  pathological  observations  are  very  few,  and  our 
knowledge  of  the  cause  of  this  form  is  therefore  meagre.  Of  three 
cases  described  by  Wernicke,  one  followed  poisoning  by  sulphuric 
acid,  and  the  other  two  in  the  subjects  of  chronic  alcoholism.  Injury 
has  been  supposed  to  be  an  occasional  cause. 

Eye-symptoms  usually  exist  alone,  the  combination  with  bulbar 
palsy  being  seldom  met  with  except  in  the  chronic  form.  In  a  few 
cases,  however,  acute  imperfect  bulbar  palsy  has  spread  to  the  upper 
part  of  the  face,  and  then  to  the  eye  muscles,  a  form  that  has  been 
termed  "  ascending  inferior  polio-encephalitis." 

In  the  usual  form  of  acute  nuclear  palsy  the  eye  muscles  suffer  in 
the  same  irregular  manner  as  in  the  sudden  variety.  It  is  common 
for  the  internal  muscles  to  escape  :  the  levator  may  or  may  not  be 
involved.  In  fatal  cases  the  motor  influence  spreads,  becomes  extensive, 
both  in  the  centres  of  other  nerves  and  in  the  cortex,  and  the  cere- 
bral functions  suffer  so  widely  as  to  cause  death  in  one  or  two  weeks. 
In  the  cases  that  survive  there  is  some  improvement  in  the  ocular 
palsy,  which  may  be  considerable,  so  that  there  is  only  slight  residual 
impairment,  or  considerable  palsy  is  limited  to  one  eye.  This  is 
explained  by  the  random  character  of  inflammatory  damage. 

In  the  rare  cases  in  which  a  lesion  is  limited  to  the  grey  matter  of 
the  corpora  quadrigemina,  the  chief  eye  symptom  appears  to  be  a  loss 
of  certain  conjugate  movements,  especially  of  that  upwards.  But 
acute  lesions  usually  produce  other  effects  which  mask  those  in  the 
ocular  muscles. 

Peripheral  Ophthalmoplegia. — Palsy  of  the  muscles  of  both  eyes, 
resembling  the  nuclear  form,  may  be  due  to  peripheral  neuritis.  How 
relatively  frequent  this  form  is  we  cannot  say,  since  the  chief  cause 
of  peripheral  neuritis,  alcoholism,  may  also  cause  inflammation  of  the 
nuclei.  Neuritis  may  be  suspected  when  many  other  nerves  suffer  at 
the  same  time,  or  alcoholic  multiple  neuritis  co-exists  in  the  limbs,* 
although  the  latter  cannot  be  regarded  as  proof,  since  alcohol  may 
affect  the  nuclei.  A  case  of  neuritic  ophthalmoplegia,  which  may  be 
regarded  as  typical,  is  that  of  a  man  of  sixty-two  in  whom  all  the  eye 
muscles  became  weak  as  well  as  the  levator  palpebrse.  The  fifth 
nerve  suffered,  swallowing  became  difficult,  and  death  followed. 
The  ocular  nuclei  were  normal,  but  there  was  wide- spread  peripheral 
neuritis  of  both  cranial  and  spinal  nerves. f 

*  Suckling,  '  Brit.  Med.  Journ.,'  1888. 
t  Meyer,  '  Neur.  Cent.,'  18S8. 


200  CK AXIAL    NERVES. 

Other  Forms  of  Ptosis. — Reflex  Ptosis. — In  very  rare  cases  irrita- 
tion of  the  fifth  nerve  bas  been  observed  to  cause  transient  drooping 
of  the  eyelid,  which  must  be  referred  to  inhibition  of  the  centre  for 
the  muscle.  A  physiological  connection  doubtless  underlies  this  effect ; 
spasmodic  closure  of  the  lids  frequently  results  from  irritation  of  the 
fifth  nerve ;  for  closure  of  the  lids  there  is  always  relaxation  of  the 
levator  (as  is  shown  by  the  slight  amount  of  orbicular  contraction 
which  will  suffice),  and  hence  irritation  of  the  fifth  nerve  has  a  tendency 
to  cause  relaxation  of  the  levator.  Reflex  ptosis  has  been  observed  to 
follow  division  of  the  fifth  nerve,  no  doubt  from  the  irritation  of  the 
fibres  by  the  section  (Longet).  It  may  result  from  the  extraction  of  a 
tooth,  as  the  following  case  shows.  An  upper  right  molar,  decayed  and 
causing  much  pain,  was  extracted  from  a  woman  aged  fifty-five.  The 
tooth  was  firm,  and  the  patient  had  no  anesthetic.  A  few  hours  after- 
wards right-sided  ptosis  existed,  varied  by  occasional  attacks  of  clonic 
spasm  in  the  levator,  each  lasting  a  few  seconds.  Both  symptoms 
continued,  in  slighter  degree,  on  the  following  day,  and  gradually 
improved,  so  that  the  condition  of  the  eyelid  by  the  fifth  day  was 
natural.  On  the  sixth  day  there  was  some  pain  referred  to  all  the 
branches  of  the  fifth  nerve,  but  this  soon  passed  off,  and  there  was  no 
recurrence  of  nervous  symptoms.* 

Ptosis  from  Paralysis  of  the  Sympathetic. — The  unstriated  muscular 
fibres  (fibres  of  Miiller),  which  exist  in  the  fascia  of  the  orbit,  and  are 
innervated  from  the  sympathetic,  act  indirectly  on  the  tarsal  cartilages 
by  the  connection  of  these  with  the  fascia.  They  probably  aid  to  a 
slight  extent  in  maintaining  the  upper  lid  in  its  normal  position. 
When  the  cervical  sympathetic  is  paralysed,  the  upper  lid  on  that 
side  is  a  little  lower  than  on  the  other.  Its  movements  are  unimpaired. 
Ptosis  from  this  cause  is  distinguished  by  the  presence  of  other 
symptoms  of  paralysis  of  the  sympathetic,  such  as  contraction  of 
the  pupil,  and  sometimes  dilatation  of  the  vessels  of  the  surface  or 
altered  secretion  of  sweat. 

Congenital  j)tosis,  not  due  to  malformation  of  the  lid,  is  usually 
bilateral  and  partial.  It  is  generally  associated  with  defective  power 
of  elevation  of  the  globes,  and  is  probably  due  to  a  congenital  central 
defect.  In  one  case  there  was  also  a  defect  in  the  outward  move- 
ment of  the  eye,  associated  with  an  inward  movement  of  the  other, 
but  absent  when  the  eye  was  moved  alone.  Congenital  ptosis  may  be 
hereditary,  and  is  probably  allied  to  the  more  extensive  infantile  nuclear 
palsy  already  described.  Slight  double  ptosis  sometimes  runs  in 
families,  and  may  (as  I  have  seen)  affect  chiefly  the  female  members, 
sometimes  coming  on  after  puberty,  and  occasionally  after  middle 
life.  The  characteristic  over-action  of  the  frontal  muscles  causes  the 
anxious  aspect  already  mentioned,  and  this  may  actually  be  more 
conspicuous  than  the  slight  drooping  of  the  lids  to  which  it  is  secon- 
dary. 

*  Communicated  to  me  by  Mr.  H.  E.  Gooding,  by  whom  the  ease  was  observed. 


OCULAR    NERVES. 


201 


Allied  to  this  is  a  form  which  may  "be  termed  morning  ptosis. 
During  sleep  tbe  levator  is  relaxed,  to  permit  closure  of  the  eyes  by 
a  gentle  contraction  of  the  palpebral  orbicularis.  Many  sound 
sleepers  find  a  difficulty  in  opening  the  eyes  on  being  first  roused. 
In  weakly  women  this  difficulty  is  sometimes  increased  ;  after  waking, 
it  may  be  impossible  for  them  to  raise  the 
eyelids  for  ten,  fifteen,  or  thirty  minutes. 
During  the  rest  of  the  day  they  have  no  dif- 
ficulty. This  condition  is  usually  recovered 
from. 

Hysterical  ptosis  is  occasionally  met  Avith, 
single  or  double.  It  is  generally  accompanied 
by  a  slight  spasm  in  the  orbicularis  ;  this  can 
readily  be  proved  by  making  the  patient  look 
upwards,  when  the  spasm  of  the  orbicularis 
becomes  much  gi*eater  to  prevent  the  lid  from 
moving  with  the  eyeball.  When  double*  (Fig. 
102)  both  eyelids  droop,  and  the  patient  puts 
her  head  back  when  she  is  told  to  look  up. 
If  the  head  is  held  in  the  attempt  to  look 
up,   both   orbiculares   contract,   and    prevent 

the  lids  rising.  This  contraction  of  the  orbiculares  proves  that  there 
is  no  true  paralysis  of  the  levators.  There  is  sometimes  over-action 
of  the  frontales  associated  with  the  ptosis,  as  if  from  a  struggle  to 
overcome  the  contraction  of  the  orbiculares. 


Fig.  ]02.  —  Hysterical 
ptosis,  bilateral.  Over- 
action  of  frontales. 


Treatment. — The  most  important  element  in  the  treatment  of 
paralysis  of  the  ocular  muscles  is  that  of  the  morbid  process  that 
•causes  them,  and  this  is  described  elsewhere.  It  is  only  necessary 
here  to  mention  those  measures  that  the  special  effect  of  the  disease 
renders  necessary.  Whenever  the  onset  is  acute  or  subacute,  or  if 
other  symptoms  suggest  inflammation,  counter- irritation  should  be 
employed.  A  blister  may  be  placed  behind  the  ear  or  at  the  occiput 
when  the  disease  is  probably  at  the  base  of  the  brain,  on  the  temple 
if  it  is  in  the  orbit.  The  blister  is  often  followed  by  a  striking 
increase  in  the  power  of  the  affected  muscle.  In  acute  rheumatic 
cases  hot  fomentations  should  be  applied  to  the  orbit,  forehead,  and 
temple,  frequently  repeated.  Leeches  may  be  applied  to  the  temple, 
at  the  onset  if  the  patient's  general  condition  does  not  contra-indicate 
their  use.  In  syphilitic  cases  appropriate  remedies  should  be  freely 
employed.  In  most  cases  of  local  neuritis,  indeed,  whether  syphilitic 
or  not,  mercury  is  probably  the  most  efficient  agent  we  possess.  De- 
fective general  health  must  be  corrected  by  tonics,  of  which  iron  and 
strychnia  are  the  most  useful. 

*  A  case  is  recorded  by  Debove  ('La  Semaine  medicale/  1890)  of  paralysis  of 
botb  third  nerves  with  double  divergent  strabismus,  said  to  be  hysterical.  The 
condition  came  on  after  an  accident. 


202  CRANIAL   NERVES. 

For  nuclear  palsy,  in  syphilitic  subjects,  mercury  and  iodide  have 
seemed  useful  only  when  the  onset  was  acute  or  subacute.  It  is  pro- 
bable that  in  some  instances  these  drugs  have  cured  the  patient,  but 
in  other  cases  it  is  doubtful  whether  the  improvement  has  been  more 
than  the  .tendency  to  recovery  which  usually  follows  an  acute  process 
that  has  spent  its  force.  In  cases  that  are  chronic  from  the  beginning 
this  treatment  is  as  powerless  as  it  commonly  is  in  locomotor  ataxy, 
and  the  most  effective  measures  are  those  suited  to  primary  nerve  de- 
generations elsewhere — arsenic,  quinine,  strychnine,  and  small  tonic 
doses  of  mercury  in  syphilitic  patients.  Strychnine  may  be  given 
with  advantage  by  hypodermic  injection,  as  in  progressive  muscular 
atrophy  (see  vol.  i,  p.  497).  Such  treatment  as  is  here  suggested 
appeared  distinctly  beneficial  in  one  case,  the  sequel  of  which  renders 
it  peculiarly  instructive.  A  gentleman  aged  forty,  who  had  probably 
not  had  syphilis,  presented  entire  loss  of  the  reflex  action  of  each  iris, 
with  large  pupils  ;  accommodation  was  normal,  and  the  iris  contracted 
with  it.  There  was  also  slight  double  ptosis,  weakness  of  both  inter- 
nal, of  the  left  superior,  and  of  the  right  inferior  recti,  and  great 
diminution  in  the  right  knee-jerk,  all  of  gradual  onset  and  from  six 
to  eighteen  months'  duration.  At  the  end  of  a  three  months'  treat- 
ment the  external  ocular  muscles  had  become  normal,  although  the 
reflex  action  was  still  lost,  and  the  right  knee-jerk  had  increased  to 
the  same  degree  as  the  left.  He  continued  without  relapse  for  nearly 
two  years,  and  then  suddenly  presented  the  acute  mental  derangement 
of  general  paralysis  of  the  insane,  from  which  he  quickly  died.  But 
we  do  not  yet  possess  the  means  of  combating  with  success  the  toxemic 
influences  that  are  probably  the  most  frequent  cause. 

Recorded  cases  of  the  recurrent  or  periodical  palsy  do  not  show 
that  any  treatment  has  a  marked  influence  on  the  attacks.  Early 
counter-irritation  probably  affords  most  prospect  of  modifying  their 
course,  and  tonic  treatment  may  be  adopted  before  an  expected  attack. 
In  cases  in  which  the  attacks  recur  frequently,  the  treatment  adopted 
should  be  that  for  migraine.    . 

Direct  Treatment. — Electricity  has  been  recommended  and  em- 
ployed in  the  treatment  of  these  paralyses,  but  its  influence  is  not 
great.  Direct  application  to  the  affected  muscle  is  scarcely  practi- 
cable. It  has,  indeed,  been  carried  out  by  a  very  small  electrode, 
or  by  a  wet  camel-hair  brush  in  the  centre  of  which  is  a  conducting 
wire.  The  extreme  sensitiveness  of  the  conjunctiva  renders  the 
application,  most  painful,  and  although  the  pain  may  be  lessened  by 
cocain,  the  application  of  a  voltaic  current,  sufficiently  strong  to 
stimulate  the  muscle,  in  such  proximity  to  the  retina  and  on  such  a 
delicate  structure  as  the  conjunctiva,  is  scarcely  safe.  In  most  ocular 
palsies  the  muscles  do  not  respond  to  faradisation.  The  voltaic 
current  may  be  applied  through  the  eyelid,  in  the  case  of  a  superior 
or  inferior  muscle,  the  eye  being  turned  in  the  opposite  direction.  The 
considerable  diffusive  power  of  this  current  makes  it  probable  that  the 


OCULAR    NERVES.  203 

electricity  would  reach  the  muscle,  although  even  thus  a  current  can- 
not be  safely  used  of  sufficient  strength  to  produce  evidence  of  stimu- 
lation. The  application  of  a  faradic  current  through  the  eyelid  is 
useless,  even  if  the  muscle  would  respond  to  it,  because  a  thin  layer 
of  contractile  muscle  prevents  any  stimulation  of  the  subjacent  tissues. 
For  these  reasons,  most  authorities  are  agreed  in  deprecating  any 
direct  application.  A  method  of  indirect  electrisation  has  been  re- 
commended (by  Benedikt  and  others)  which  consists  in  placing  one 
pole  (anode)  on  the  forehead,  the  other  (kathode)  on  the  margin  of 
the  orbit  near  the  affected  muscle.  If  the  faradic  current  is  em- 
ployed, the  orbital  pole  is  kept  still ;  if  the  voltaic  current  is  used, 
this  pole  is  stroked  along  the  skin,  or  the  circuit  is  alternately  made 
and  broken  by  an  interrupter.  A  slight  increase  of  power  in  the 
muscle  may  be  observed  after  the  current  has  been  so  applied  for  a 
few  minutes,  but  it  quickly  passes  off,  and  in  cases  free  from  sources 
of  fallacy  I  have  never  been  able  to  trace  any  permanent  effect.  It 
is  true  that  works  on  electro-therapeutics  contain  cases  in  which  im- 
provement or  cure  was  ascribed  to  this  agent,  but  in  most  instances 
the  authors  have  ignored  the  tendency  to  spontaneous  improvement 
in  recent  cases,  and  the  influence  of  drugs,  as  iodide  of  potassium, 
which  were  given  at  the  same  time  in  mauy  instances. 

The  diplopia  due  to  partial  paralysis  of  a  muscle  may  be  removed 
by  the  use  of  a  prism.  One  strong  enough  to  completely  fuse  the 
images  is  undesirable,  because  it  tends  to  prevent  the  strengthening 
influence  of  effort.  A  weak  prism,  strong  enough  so  to  approximate 
the  images  as  to  permit  their  fusion  by  muscular  action,  sometimes 
does  good.  It  may  be  used  for  an  hour  daily  as  a  gymnastic  exercise. 
The  giddiness  due  to  erroneous  projection  can  only  be  removed  by 
putting  the  eye  out  of  action  by  an  opaque  glass;  this  glass  may  be 
in  a  pair  of  spectacles,  the  other  glass  being  merely  tinted;  the 
opacity  is  then  inconspicuous  to  an  observer.  But  this  has  the  same 
disadvantage  of  withdrawing  the  stimulus  of  exertion.  An  opaque 
glass  over  the  sound  eye  is  useless  for  the  vertigo,  and  increases  the 
amount  of  the  secondary  deviation. 

Operative  interference  can  do  little  in  cases  of  ocular  palsy.  The 
only  condition  in  which  it  is  admissible  is  that  in  which  antagonistic 
contracture  has  been  developed,  and  the  paralysed  muscle  has  re- 
gained power,  but  cannot  overcome  the  opposing  contracture.  In  such 
a  case  the  tendon  of  the  contractured  muscle  may  be  divided  without 
disturbing  its  other  connections ;  it  forms  a  fresh  attachment  a  few 
millimetres  further  back,  and  the  result  on  the  movement  of  the  eye 
is  often  very  stitisfactory. 

The  treatment  of  paralytic  ptosis  is  that  of  disease  of  the  third 
nerve.  The  muscle  itself  is  not  accessible  to  electrical  stimulation. 
In  the  double  ptosis  of  nervous  debility,  nervine  tonics,  quinine  and 
strychnia,  are  useful,  and  their  influence  is  aided  by  local  treatment, 
which  stimulates  the  fifth  nerve,  and  so  produces  a  reflex  action  on 


-204  CEANIAI    NEKVES. 

the  centre  of  the  levator.  Electricity  may  be  used,  either  the  voltaic 
or  induced  current  applied  to  the  skin  about  the  orbit,  but  a  stimu- 
lating liniment  which  stings  the  shin  (as  chloroform  hniment  on 
spongiopiline)  usually  answers  as  well.  The  morning  ptosis  can 
always  be  quickly  relieved  in  this  manner.  The  hysterical  form  is 
often  a  very  obstinate  affection.  Blisters  to  the  temple,  faradism, 
and  (in  the  unilateral  form)  tying  up  the  other  eye,  are  the  most 
efficient  means,  and  usually  in  time  remove  the  symptoms. 


Spas3t  op  the  Oculae  Muscles. 

The  varieties  of  spasm  of  the  ocular  muscles  are  numerous,  but 
only  a  few  are  of  medical  significance.  Two  classes  may  be  dismissed 
with  a  mere  mention.  (1)  Those  that  are  connected  with  disorder  of 
the  ocular  visual  process,  as  the  convergent  strabismus  of  hyperme- 
tropia,  the  divergence  of  myopia,  the  adaptive  deviation  that  occurs 
when  there  is  partial  opacity  of  the  media,  and  the  irregular  position 
that  often  accompanies  absence  of  sight.  (2)  The  secondary  deviation 
in  one  eye,  consequent  on  palsy  of  a  muscle  of  the  other  eye,  and  the 
antagonistic  contracture  in  the  same  eye.  The  second  class  has  been 
already  described  ;  those  of  the  first  do  not  come  within  the  scope  of 
ibis  work.  Of  the  remaining  forms,  one  of  great  importance — nys- 
tagmus— will  be  separately  described.  The  remainder  may  be  grouped 
into  five  classes. 

(1)  Associated  spasm  from  central  disease  is  not  uncommon.  Its 
•character  depends  on  the  position  of  its  cause  :  both  eyes  are  affected 
in  disease  of  the  hemispheres  ;  one  eye  only  in  some  cases  where 
the  lesion  is  in  the  nuclei  or  the  eye  muscles.  In  a  paralysing  lesion 
of  one  hemisphere  the  eyes  deviate  towards  the  diseased  side,  but  the 
deviation  is.  merely  due  to  the  unopposed  influence  of  the  opposite 
hemisphere.  An  irritating  lesion  of  one  hemisphere  causes  conjugate 
deviation  towards  the  opposite  side,  the  result  of  spasm ;  this  occurs 
■also  at  the  onset  of  unilateral  convulsions,  and  is  often  associated  with 
muscular  rigidity  of  the  limbs  on  the  side  towards  which  the  eyes  are 
directed.  In  one  interesting  case,  deviation  to  the  right  was,  during 
four  months,  a  persistent  symptom  of  a  depressed  fracture  below  the 
left  parietal  eminence,  and  it  ceased  when  the  depressed  bone  was 
raised  by  trephining.* 

Since  a  lesion  in  one  side  of  the  pons  causes  a  loss  of  the  conjugate 
movement  towards  the  side  of  the  lesion,  the  muscles  being  excited 
from  structures  in  this  position  (see  p.  186),  irritating  disease  may 

*  Thompson,  '  Brain/  April,  1883,  p.  99.  It  may  be  noted  that  the  fracture  was 
behind  the  region  in  which  experiment  places  the  centres  for  the  lateral  movement, 
which  is  in  front  of  the  central  convolutions  (see  p.  13).  But  the  structures  that 
overact  are  often  only  near  a  primary  lesion,  the  influence  of  which  is  exerted  on 
the  neighbourhood,  and  sometimes  only  in  one  direction. 


OCULAR   NERVES.  205- 

be  expected  to  cause  spasmodic  deviation  towards  that  side.  But 
such  spasm  is  seldom  observed,  apparently  because  the  structures  con- 
cerned are  readily  damaged  and  rendered  inactive.  An  acute  lesion 
which  causes  the  conjugate  paralysis  may,  however,  produce  a  dis- 
tinctly spasmodic  deviation  towards  the  opposite  side,  probably  by 
an  indirect  influence  on  the  corresponding  centre  of  the  other  side  of 
the  pons.*  Between  the  two  there  must  be  a  close  functional  relation, 
indispensable  for  their  normal  action,  and  throwing  light  on  many 
phenomena  of  disease  (see  "Nystagmus,"  p.  209). 

(2)  Irregular  spasm  from  brain  disease. — In  irritating  diseases  of 
the  base  of  the  brain,  especially  in  meningitis,  spasm  occurs  in  one  or 
more  of  the  ocular  muscles,  causing  slight  irregular  deviation  of  the 
visual  axes,  comparable  to  the  variable  rigidity  that  occurs  in  the 
limbs,  and  may  change  in  seat  and  degree  from  time  to  time.  It  is 
probably  due  to  irritation  of  the  motor  nerve-trunks.  Care  must  be 
taken  not  to  mistake  for  spasm  the  deviation  from  loss  of  power  which 
is  so  common  from  the  same  cause.  In  spasm  there  is  deviation  when 
the  eyes  are  at  rest  in  the  mid-position  ;  in  recent  paralysis  there  is 
not.  It  must  be  remembered  that  paralysis  and  spasm  are  often  con- 
joined.    Such  irregular  spasm  is  generally  tonic. 

Slight  irregular  spasm  of  the  ocular  muscles  sometimes  occurs  in 
chorea.  It  is  rarely  sufficient  to  be  seen,  but  causes  transient  diplopia, 
which  may  be  thought  to  indicate  organic  brain  disease  if  the  depend- 
ence on  chorea  is  not  known.  If  patients  are  questioned  on  the- 
point,  this  diplopia  will  be  found  to  be  by  no  means  rare. 

(3)  Chronic  spasm  in  individual  muscles  is  extremely  rare  apart 
from  the  secondary  deviation  already  mentioned.  In  the  best-marked 
cases  the  spasm  has  not  been  continuous,  but  has  occurred  on  certain 
movements  of  the  eyes,  sometimes  associated  with  pain.  Thus,  of 
two  cases  recorded  by  Hock,f  in  one,  as  soon  as  an  object  was  moved 
to  the  right  of  the  middle  line,  spasmodic  contraction  occurred  in  the 
right  inteimal  rectus  (with  great  pain),  bringing  the  eye  into  extreme 
adduction,  and  as  soon  as  the  object  was  moved  to  the  left  beyond  the 
middle  line  the  spasm  relaxed,  and  the  right  eye  moved  outwards  into 
the  fixing  position.  In  the  other  case  there  was  slight  weakness  of 
the  right  internal  rectus,  and  as  soon  as  the  object  was  moved  to  the 
left  of  the  middle  line,  spasm  in  the  left  external  rectus  moved  the 
eye  into  extreme  abduction.  The  spasm  thus  affected  the  muscle 
that  would  be  the  seat  of  secondary  deviation,  but  was  distinguished 
from  this  by  its  extreme  degree.  This  case  is  interesting  because 
the  spasm  occurred  with  slight  left  hemiplegia,  and,  from  some 
accompanying  disturbance  of  taste,  may  have  been  due  to  disease  in 

*  As  in  a  case  I  have  recorded  of  acute  anaemia  of  the  right  half  of  the  pons 
(due  to  arterial  obstruction)  which  caused  deviation  of  the  eyes  to  the  left.  It  was 
increased  from  time  to  time,  with  violent  nyst;igmus  ('Trans.  Ophth.  Soc./  1884,. 
p.  308). 

t  '  Wiener  Klinik,'  April,  1876,  p.  116. 


206  CEANIAL   NERVES. 

the  upper  part  of  the  pons.  Sometimes  two  muscles  acting  together 
are  involved  in  the  spasm,  as,  in  one  case,  the  superior  oblique  and 
inferior  rectus,  which  are  normally  associated  (Stilling). 

(4)  Hysterical  Spasm. — In  hysterical  fits  the  eyes  are  usually 
directed  either  upwards  and  to  one  side,  often  so  as  to  almost  entirely 
conceal  the  cornea,  or  they  are  directed  inwards  in  strong  conver- 
gence— a  common  symptom.  They  never  diverge  as  they  do  in 
organic  disease.  Sometimes  the  convergence  persists  during  the 
intervals,  and  is  then  usually  associated  with  spasm  of  accommo- 
dation. 

(5)  Paroxysmal  Spasm. — In  convulsive  attacks  in  which  the  con- 
vulsion is  unequal  on  the  two  sides,  the  eyes  constantly  deviate  (with 
the  head)  towards  the  side  most  convulsed,  and  if  the  second  side  is 
affected  in  greater  degree  after  the  first,  the  eyes  subsequently  deviate 
towards  that  side.  When  the  fit  is  over  there  may  also  be  a  deviation 
from  the  side  most  convulsed,  accompanying  the  transient  weakness 
common  in  that  side.  Such  spasm  is  seldom  unilateral,  but  during 
brief  attacks  of  clonic  torticollis  (in  a  child  of  eleven  months)  drawing 
the  head  to  the  right,  there  was  strong  deviation  of  the  left  eye  in  the 
same  direction.  A  single  muscle  may  be  the  seat  of  brief  spasm, 
resembling  in  miniature  an  epileptoid  seizure,  and  sometimes  attended 
with  transient  obscuration  of  consciousness.  During  the  attack  there 
is  diplopia,  and  often  giddiness  from  the  erroneous  projection.  Clonic 
spasm  in  the  orbicularis  may  occur  at  the  same  time.  Such  attacks, 
for  instance,  occurred  in  a  man  aged  forty-seven  ;  there  was  very  slight 
permauent  defect  of  power  in  the  left  external  and  both  internal 
recti.  Occasionally,  without  any  exciting  movement  of  the  eye, 
tonic  spasm  in  the  external  rectus  would  draw  the  left  eye  strongly 
outwards  for  about  thirty  seconds.  During  this  time  there  was  con- 
stant winking  with  both  eyelids,  which  seemed  to  the  patient  to  be 
due  to  an  effort  to  get  the  eye  right,  but  could  not  be  prevented.  The 
deviation  suddenly,  ceased,  but  for  a  few  minutes  afterwards  the  left 
eyelid  was  about  one  twelfth  of  an  inch  lower  than  the  other,  and  then 
both  were  alike.  There  was  no  history  of  venereal  disease,  and  syphilis 
was  for  other  reasons  very  improbable. 

Another  patient,  aged  thirty-six,  also  without  history  of  syphilis, 
suffered  from  frequent  attacks  (lasting  only  a  few  seconds),  two  of 
which  I  witnessed.  There  was  a  sudden  sensation  of  heat,  spreading 
from  the  left  inner  can  thus  and  extending  over  the  eye  and  temple, 
accompanied  with  impairment  of  sight  of  both  eyes,  varying  from  slight 
dimness  to  absolute  loss  of  sight,  and  with  abduction  of  the  left  eye 
from  mid-position  to  about  halfway  to  the  outer  canthus,  the  right 
eye  being  still.  If  walking,  he  deviated  to  the  left  during  the  attack, 
probably  from  erroneous  projection  of  the  left  field.  In  the  intervals, 
movements  of  the  eyes  were  perfectly  normal.  The  attacks  consisted 
of  tonic  and  then  clonic  spasm,  and  resembled  perfectly  miniature 
epileptic  convulsions.     Some  years  later  this  spasm  had  ceased,  but 


OCULAR    NERVES.  207 

the  patient  presented  complete  internal  and  partial  external  ophthal- 
moplegia, clearly  dne  to  nuclear  degeneration. 

Nystagmus. — Rhythmical  movements  of  the  eyes,  involuntary, 
frequent,  usually  bilateral  and  similar  in  each  eye,  produced  by 
alternating  contractions  in  opposing  muscles,  are  termed  "  nystag- 
mus." Two  forms  must  be  distinguished :  (a)  that  in  which  slight 
movement  is  associated  with  weakness  of  the  muscles,  and  occurs  only 
when  the  weak  muscles  are  put  in  action;  (&)  that  in  which  the 
movement  goes  on  continuously  in  all  positions  or  only  in  some,  with 
or  without  loss  of  power,  but  more  than  the  mere  tremor  of  weakness. 
Only  the  second  form  is  here  considered.  Among  its  causes  the  fol- 
lowing are  the  chief : 

(1)  Local  affections  of  the  eyes  which  interfere  with  sight,  but  have 
no  other  character  in  common, — opacities  of  cornea  or  lens,  and  inflam- 
mations or  degenerations  of  retina  and  choroid.  It  scarcely  ever  results 
from  simple  errors  of  refraction,  however  considerable.  These  eye  dis- 
eases cause  nystagmus  chiefly  when  they  occur  in  infancy  or  early 
childhood.  Nevertheless  it  is  doubtful  whether  nystagmus  results 
from  blindness  which  is  actually  congenital,  although  slow  rolling 
movements  of  the  eyes  are  observed  in  such  cases.  In  adult  life 
ocular  disease  alone  rarely  causes  nystagmus,  but  it  certainly  aids  the 
development  of  nystagmus  due  to  other  causes. 

(2)  In  albinism  this  condition  is  very  common. 

(3)  It  occurs  in  miners,  chiefly  in  those  who  work  in  coal-mines, 
and  who  use  the  pick  in  a  stooping  or  lying  posture,  in  which  the 
eyes  are  habitually  turned  to  one  side.  It  is  also  far  more  frequent 
where  the  dim  safety-lamp  is  used  than  in  mines  which  can  be 
worked  with  brighter  naked  lights.  This  form  has  been  admirably 
investigated  and  elucidated  by  Snell. 

(4)  It  occurs  in  diseases  of  the  nervous  system  of  the  most  varied 
seat  and  character,  especially  in  degenerative  affections  of  most  forms, 
but  sometimes  accompanies  the  chronic  stage  of  acute  maladies,  such 
as  disseminated  myelitis.  It  is  usually  conspicuous  in  insular  sclerosis 
and  also  in  hereditary  ataxy,  but  not  in  ordinary  locomotor  ataxy. 
In  other  diseases  attended  with  tremor  it  is  rare.  In  paralysis 
agitans  it  is  never  met  with— a  curious  fact,  considering  how  closely 
the  alternating  movement  of  nystagmus  resembles  that  of  shaking 
palsy.  It  occurs  in  many  diseases  of  the  brain,  diffuse  and  focal; 
meningitis,  meningeal  hemorrhage,  thromboses  in  sinuses,  and  in 
cases  of  tumour,  haemorrhage,  and  softening  in  various  situations.  It 
is  common  in  tumours  of  the  cerebellum,  but  the  most  intense 
nystagmus  I  have  seen  was  due  to  a  tumour  in  the  right  optic 
thalamus.  I  have  also  known  it  to  occur  in  disease  of  one  side  of  the 
pons  (arterial  occlusion  causing  local  anaemia,  fatal  before  softening 
could  occur)  ;  the  quick  movement  was  from  the  side  of  the  lesion, 
and  there  was  associated  palsy  of  the  lateral  movement  towards  the 


208  CEANTAL    NERVES. 

diseased  side.  In  an  analogous  case,  seen  only  during  life,  a  chronic 
lesion,  evidently  on  the  right  side  of  the  pons,  caused  partial  palsy  of 
the  right  fifth  nerve,*  and  loss  of  the  movement  of  both  eyes  to  the 
right.  An  attempted  movement  to  the  right  produced  no  nystagmus, 
but  when  the  eyes  were  moved  to  the  left  this  at  once  set  in,  the 
quick  motion  being  in  that  direction.  Nystagmus  often  occurs  in 
cases  of  degenerative  disease  of  the  spinal  cord  and  brain,  in  which 
there  is  no  evidence  of  a  focal  lesion. 

The  movement  is  usually  bilateral ;  very  rarely  it  affects  one  eye- 
only.  Horizontal  (lateral)  movement  is  the  most  common  ;  next  a 
rotatory  motion;  vertical  movement  when  the  eyes  are  directed 
upwards  will  be  found  far  from  rare,  if  looked  for,  but  is  seldom 
continuous  when  the  eyes  are  at  rest;  one-sided  nystagmus  has  been 
said  to  be  generally  vertical.  Eotatory  nystagmus  may  occur  only 
when  the  eyes  are  moved  in  a  certain  direction.  Its  character  may 
show  clearly  its  sources ;  e.  g.  in  one  case  the  quick  movements  were- 
manifestly  due  to  the  superior  oblique.  I  have  once  seen  the  motion 
limited  to  the  internal  recti  and  the  mid-position,  ceasing,  or  almost 
ceasing,  on  lateral  movements.  It  was  a  case  of  tumour  of  the  right 
optic  thalamus,  which  might  have  pressed  on  the  corpora  quadri- 
gemina.  It  probably  did  so,  since  the  upward  movement  and  right 
external  rectus  were  enfeebled.  The  extent  of  the  movement  in 
nystagmus  varies  from  one  to  ten  millimetres  ;  from  two  to  four  milli- 
metres is  the  common  range.  Occasionally,  when  it  is  too  slight  to 
be  seen  with  the  naked  eye,  it  may  be  observed  with  the  ophthalmo- 
scope when  the  fundus  is  examined.  The  frequency  is  usually  from 
60  to  200  separate  movements  (i.  e.  in  the  same  direction)  per  minute ; 
rarely  it  is  slower  than  60;  occasionally  it  is  too  frequent  to  be 
counted.  The  rhythm  is  usually  regular ;  in  some  cases  there  are 
slight  variations  in  frequency  from  time  to  time.  If  there  is  slow 
nystagmus  when  the  eyes  are  at  rest,  the  oscillations  often  become 
more  frequent  when  the  eyes  are  moved.  The  alternating  movements 
are  not  equally  quick ;  there  is  a  sudden  rapid  movement  in  one 
direction  and  slow  return.  In  describing  nystagmus,  it  is  said  to  be 
to  the  side  towards  which  the  movement  is  most  rapid.  In  many 
continuous  cases  the  quick  movement  is  in  the  direction  in  which  the 
nystagmus  is  most  energetic  on  voluntary  movement. 

The  symptom  may  be  constant,  or  it  may  occur  only  when  the  eyes 
are  moved  in  a  certain  direction,  sideways,  upwards,  or  downwards. 
In  the  second  form  it  is  often  associated  with  weakness  of  the 
muscles,  to  which  it  may  be  due.  Very  rarely  there  is  a  slight  move- 
ment of  the  head,  corresponding  to  that  of  the  eyes  in  time  and  in 
direction,  or  in  the  opposite  direction  to  that  of  the  eyes.f    All  forms 

*  Chiefly  of  the  motor  division,  accompanied  by  slight  paralysis  of  all  parts  of 
the  right  side  of  the. face,  constant  blinking  of  left  eyelids,  not  of  the  right,  and 
vertigo,  objective  and  subjective,  to  the  left. 

f  In  a  case  lately  under  my  care,  with  symptoms  of  cerebellar  tumour  and  lateral 


OCULAR    NEBVES.  209 

cease  during  sleep.  In  cases  that  date  from  infancy  the  patient  is 
never  conscious  of  the  movement,  nor  is  there  any  apparent  move- 
ment of  objects;  in  cases  which  commence  in  later  life  there  some- 
times is  an  apparent  movement  of  objects  ;  more  frequently  there  is 
not.  The  apparent  movement  of  objects  is  generally  in  the  direction 
of  the  quick  movement  of  the  nystagmus.  Rarely  there  is  a  move- 
ment of  the  upper  lid  synchronous  with  that  of  the  eye ;  this  associa- 
tion occurs  chiefly  when  the  nystagmus  is  vertical,  but  I  have  seen  it 
once  when  the  movement  was  horizontal.  In  vertical  nystagmus 
there  is  often  a  slight  movement  of  the  lid  communicated  to  it  from 
the  eye,  which  must  be  carefully  distinguished  from  the  actual 
spasm  of  the  lid. 

The  nystagmus  of  miners  presents  considerable  variations  in 
different  cases.  Any  form  of  movement  may  be  met  with,  and  it  may 
occur  in  all  or  only  in  one  position  of  the  eyes.  It  often  occurs  only 
in  the  recumbent  posture,  such  as  the  miner  assumes  in  his  work,  and 
may  cease  when  he  is  upright.* 

The  physiological  pathology  of  nystagmus  is  still  to  a  large  extent 
obscure.  The  perfect  bilateral  symmetry  of  the  movement,  con- 
.  sj>icuous  in  the  vast  majority  of  cases,  indicates  its  central  origin, 
and  is  opposed  to  the  simple  but  inadequate  explanation  which 
ascribes  it  to  muscular  fatigue.  "Why  the  steady  tonic  contraction  of 
health  should  be  broken  into  clonic  contraction  no  one  has  yet  been 
able  to  say ;  but  the  physiological  associations  of  the  ocular  move- 
ments enable  us  to  understand  something  of  the  influences  that  pro- 
duce it.  We  may  take  as  the  simplest  form  that  in  which  the  move- 
ment is  lateral.  For  lateral  movement  of  the  eyes,  there  is  a  separate 
centre  in  the  pons  on  the  side  towards  which  the  movement  takes 
place.-  The  movement  of  lateral  nystagmus,  like  that  of  health, 
must  be  directly  produced  from  this  centre.  Every  normal  movement 
involves  the  activity  of  the  centre,  and  also  a  lesseued  action  of  that 
on  the  other  side,  causing  relaxation  of  the  antagonists,  and  this  is 
followed  by  increased  activity,  so  as  to  bring  the  eyes  back  to  the 
middle  line.f  Hence  there  must  be  a  mutual  connection  between  the 
functional  states  of  the  antagonistic  centres  on  the  two  sides,  and  this 
probably  underlies  the  alternation  of  movement  in  nystagmus.  It  is 
probable  that  the  intermittence  is  due  to  a  derangement  of  their 
function,  necessarily  produced  whenever  the  eyeballs  are  the  seat  of 
spasm.  If  so,  the  oscillations  may  be  neglected  in  considering  the 
nystagmus,  the  pharynx  and  larynx  were  the  seat  of  similar  movement;  that  in  the 
pharynx  was  horizontal,  towards  the  middle  line ;  in  the  larynx  there  was  a  similar 
lateral  movement  of  the  arytenoid  cartilages.  The  rate  of  the  movement  was  the 
same  as  in  the  ocular  muscles,  ISO  per  minute  (Spencer,  '  Lancet/  1886,  vol.  ii, 
p.  702). 

*  See  Snell,  'Trans.  Oph.  Soc.,'  vol.  iv,  p.  315. 

f  That  mere  elasticity  hrings  the  eyes  back  seems  improbable  from  what  we  know 
of  the  related  contraction  of  antagonists  elsewhere.      Moreover  any  such  action 
depends  on  muscular  tone,  and  is  absent  in  the  atonic  palsy  of  total  nerve  disease* 
VOL.  II.  14 


210  CEANIAL    NERVES. 

relations  of  the  symptom.  Their  origin  constitutes  a  separate  problem 
common  to  all  forms,  and  distinct  from  that  of  its  causation. 

The  relations  of  nystagmus  are  extensive.  The  nuclear  centres  are 
acted  on  by  centripetal  impressions  as  well  as  by  the  will.  They  are 
influenced  by  visual  impressions  to  a  degree  which  we  can  only 
discern  indirectly  (since  the  process  does  not  enter  into  the  region  of 
consciousness)  by  considering  how  accurately  and  yet  how  easily  we 
can  follow  with  the  eye  a  swiftly  moving  object.  This  ability  is 
apparently  acquired.  The  newly  born  child  never  "  fixes  "  an  object, 
never  follows  a  light,  however  brilliant.  Not  until  later  is  there 
established  the  functional  relation  of  the  motor  centres  to  the  visual 
impression,  in  what  is  essentially  a  reflex  process,*  and  for  this  to 
be  normally  developed  it  is  apparently  necessary  that  the  stimulation 
of  the  optic  nerve  should  correspond  to  the  average  degree  and 
character.  Hence  it  is  intelligible  that  if  this  visual  control  is 
partially  but  not  perfectly  established  (in  consequence  of  early 
ocular  disease  lessening  -vision)  the  action  of  the  motor  centres 
should  be  abnormal.  Hence,  too,  we  can  understand  that  imperfect 
ocular  guidance  (as  the  bad  light  of  the  safety-lamp)  may  aid  other 
causes  in  developing  derangement  in  later  life.  In  albinism  the 
early  visual  impressions  may  err  on  the  side  of  painful  and  disturbing 
excess,  from  the  absence  of  the  pigment  of  the  eye. 

Again,  the  ocular  motor  centres  must  be  acted  on  by,  as  they  cer- 
tainly act  on,  the  equilibrial  centres.  These  are  guided  by  the 
innervation  of  the  eyeball  muscles.  Thus  these  muscles  will  be 
brought  indirectly  under  the  influence  of  the  semicircular  canals. 
Nystagmus  can  be  induced  in  health  by  rotation  of  the  body 
(Donders) ;  quick  movements  of  the  eyes  occur  in  the  direction  in 
which  the  body  has  rotated,  and  there  is  a  slower  return.  The  quick 
movements  occur  towards  the  side  on  which  the  horizontal  semi- 
circular canal  has  been  subjected  to  increased  pressure  by  the  rota- 
tion. In  chronic  otitis,  pressure  on  the  ear  has  been  often  observed  to 
cause  a  nystagmus  precisely  similar,  ceasing  with  the  pressure  ;f  it 
is  usually  lateral,  but  sometimes  rotatory.     Vertigo  always  attends 

*  I  recorded  some  years  ago  (*  Brain,'  vol.  ii)  a  case  in  which  the  reflex  fixation  of 
the  eyes  was  brought  into  salience  by  disease.  If  the  patient,  looking  at  one  object, 
was  told  to  look  at  another  at  some  lateral  distance  from  the  first,  his  head  was 
instantly  turned  in  the  direction  of  the  second  object,  but  the  eyes  remained  fixed 
on  the  first  by  a  movement  as  rapid  as  that  of  the  head,  but  in  the  opposite  direc- 
tion, and  then  they  were  slowly  moved  into  the  position  corresponding  to  the  second 
object.     The  patient  was  in  the  last  stage  of  progressive  muscular  atrophy. 

f  Schwalbach,  Hughlings  Jackson,  Pfluger  (attempt  to  extrnct  a  polypus). 
Injections  into  the  ear  sometimes  excite  it.  Movements  are  also  related  to  true 
auditory  impressions,  at  least  in  so  far  as  rhythm  is  concerned,  as  musical  "  marches  " 
illustrate.  In  peculiar  hysteroid  states,  Hogyes  has  found  that  nystagmus  could 
be  produced  by  bringing  a  vibrating  tuning-fork  near  the  ear,  and  that  the  move- 
ments varied  with  the  rapidity  of  the  vibrations.  He  was  also  able  to  cause 
nystagmus  by  other  sensory  impressions  ('Orvosi-Hetilap,'  1886,  and  'Cent.  f. 
Nervenh.,'  p.  526). 


OCULAR    NERVES.  211 

it;  a  motor  sensation  which,  if  intense,  goes  on  to  movement  in 
which  the  ejes  and  head  lead  the  way.  Hence  involuntary  movement 
of  the  eyes  is  not  surprising,  the  cause  of  the  intermittence  being,  as 
already  stated,  a  separate  problem.  In  the  nystagmus  of  miners, 
which  may  occur  only  in  the  recumbent  posture,  we  may  also  trace,  as 
one  factor,  an  influence  of  the  equilibrial  centre  (and  probably  of  the 
canal  impressions)  on  the  centre  for  the  movement  of  the  eyes. 

The  wide  variation  in  the  position  of  organic  disease  that  may  cause 
nystagmus  is  scarcely  surprising  when  we  consider  how  wideand  various 
must  be  the  total  connections  of  the  functions  of  vision,  of  movement 
of  the  eyes,  and  of  the  maintenance  of  equilibrium  ;  and  that  we  can 
trace  a  connection  between  nystagmus  and  the  derangement  of  each 
of  these,  including  some  causes  of  vertigo.  But  it  is  also  common  in 
various  degenerative  diseases  in  which  we  cannot  trace  its  source, 
but  which  show  how  easily  deranged  must  be  the  mechanism  by  which 
in  health  the  muscular  contractions  are  kept  uniform.  It  would 
even  seem  as  if  the  nuclear  centres  have  a  tendency  to  rhythmical  or 
intermittent  action,  which  is  normally  counteracted,  possibly  by  the 
influence  of  the  corresponding  centres  on  the  other  side.  When 
deranged,  spasm  that  would  be  continuous  in  the  limbs  becomes 
intermittent  in  the  eyes.  This  view  is  suggested  by  the  case  of  arterial 
obstruction  in  the  pons  already  mentioned.  Nystagmus  was  clearly 
due  to  the  over-action  of  the  centres  on  the  undamaged  side,  under  the 
influence  of  loss  of  function  of  those  on  the  other.*  But  this  part  of 
the  subject  needs  far  more  systematic  study  than  it  has  yet  received. 

The  practical  significance  of  nystagmus  in  diagnosis  is  extremely 
great,  not  from  any  distinct  indication  of  the  seat  or  precise  nature 
of  the  disease,  but  because  it  shows  the  presence  of  more  than  merely 
functional  disturbance.  It  is  often  marked  at  the  early  stage  of 
degenerative  disease  when  other  symptoms  are  equivocal,  and  a 
search  for  it  should  never  be  omitted,  and  should  always  include  the 
upward  movement  of  the  eyes.  It  may  be  trusted  without  hesitation, 
and  prevents  a  mistake  in  diagnosis  in  a  very  large  number  of  cases. 

Spasm  of  the  levator  is  occasionally  met  with  as  an  isolated 
symptom,  and  also  as  one  of  the  features  of  exophthalmic  goitre. 
The  isolated  form  (sometimes  termed  lagophthalmos,  or  "  hare-eve  ") 
is  usually  due  to  some  inhibitory  irritation  in  the  region  of  the  fifth 
nerve.  Late  in  life  it  may  come  on  as  an  independent  affection, 
analogous  to  other  muscular  spasms,  as  torticollis  and  facial  spasm. 
The  contraction  is  usually  tonic,  an  excessive  degree  of  the  normal 

*  In  continuous  contraction  the  muscular  fibres  contract  alternately;  in  clonus 
all  seem  to  contract  together,  and  the  contraction  is  brief  but  renewed.  Such  a 
common  brief  contraction  would  explain  the  intermissions  of  nystagmus,  the  oppo- 
nents being  always  ready  to  contract  when  the  original  action  ceases.  This  readiness 
prevents  the  assumption  that  the  common  action  of  all  the  fibres  is  due  to  any  other 
cause  than  the  condition  of  the  centre  of  the  acting  muscles. 


212  CE AXIAL    NEliVES. 

tonic  contraction  of  the  levator  -which  keeps  the  eyelid  raised  ;  the 
muscle  is  imperfectly  relaxed  "when  the  eye  is  directed  downwards  or 
the  lids  are  closed.  Hence  the  eyelid  is  a  little  higher  than  the  other 
■when  the  eyes  are  directed  straight  forwards ;  and  on  looking  down, 
the  lid  does  not  descend,  so  that  a  wide  extent  of  sclerotic  is  exposed 
above  the  cornea.  When  the  lids  are  closed,  the  upper  lid  may  be 
brought  down  by  the  orbicularis,  but  not  to  the  same  extent  as  on  the 
other  side,  and  hence  the  lids  do  not  descend  equally.  The  exposure 
of  the  sclerotic  above  the  cornea  gives  the  impression  of  slight  pro- 
minence of  the  ball.  A  long-continued  spasm  in  the  levator  seems, 
indeed,  to  cause  the  eyeball  to  be  actually  a  little  more  prominent 
than  the  other,  in  consequence  of  the  origin  of  the  levator  being  below 
the  level  of  the  upper  part  of  the  eyeball;  but  the  apparent  pro- 
minence due  to  the  exposure  of  the  sclerotic  is  much  greater  than  the 
real  prominence.  The  retraction  of  the  upper  lid  may  cause  a  slightly 
greater  fulness  of  its  tissues  than  exists  on  the  other  side.  Unless  the 
affection  is  due  to  removable  irritation  of  the  fifth  nerve  it  is  extremely 
obstinate. 

Clonic  spasm  is  also  rare.  It  occurred  from  time  to  time  in  the 
case  of  reflex  ptosis  mentioned  on  p.  200.  A  very  singular  case  of  con- 
genital spasm  of  the  levator  was  exhibited  at  the  Ophthalmological 
Society  by  Mr.  Marcus  G-unn.  There  was  slight  ptosis  and  slight 
rnyosis  on  one  side,  and  the  eyelid  was  raised  by  slight  contraction  of 
the  levator  whenever  the  external  pterygoid  of  the  same  side  was  put 
in  action.* 

Spasmodic  elevation  of  the  upper  eyelid  also  occurs  from  irritation 
of  the  cervical  sympathetic.  "We  have  seen  that  this  nerve  supplies 
the  plain  muscular  fibres  of  the  orbit,  which  are  indirectly  connected 
with  the  eyelids ;  and  that,  as  their  paralysis  may  cause  slight  drooping 
of  the  lid,  so  their  stimulation  may  produce  slight  elevation.  It  is 
probable  that  this  spasm  is  the  cause  of  the  increase  in  the  normal 
elevation,  and  of  the  defective  descent  of  the  lid  in-  looking  down,  in 
many  cases  of  exophthalmic  goitre  (Graves'  disease).  But  this  form 
will  be  considered  in  the  account  of  that  disease.  I  have  once  seen  a 
similar  slight  retraction  and  defective  descent,  on  the  left  side  only,  in 
a  girl  of  seventeen,  who  had  distinct  myxcedematous  swelling  of  the 
breasts,  neck.,  and  face,  bilateral,  but  not  elsewhere,  and  with  no  sym- 
ptom of  Graves'  disease,  and  also,  as  a  transient  symptom  on  one  side 
only  (after  anxiety),  associated  with  cardio- thyroid  disturbance  so 
slight  that  alone  it  would  scarcely  have  been  noticed.  Similar  spasm 
is  said  to  have  been  met  with  in  pregnancy  as  a  reflex  symptom. 

*  'Ophthalmological  Transactions/  vol.  iii,  p.  283.  As  one  of  a  committee 
appointed  to  report  on  the  case,  I  had  an  opportunity  of  carefully  examining  it. 
The  simplest  explanation  for  the  condition  seemed  to  he  that  some  of  the  levator 
fihres  of  the  third  nerve  arose  from  the  motor  nucleus  of  the  fifth  nerve.  The  small 
size  of  the  pupil  might  he  due  to  the  influence  of  those  cells  of  the  third  nerve- 
nucleus  which  ought  to  have  heen,  hut  were  not,  connected  with  the  levator. 


FIFTH    NERVE.  213 

Treatment. — Little  can  be  done  for  the  treatment  of  these  ocular 
spasms  beyond  the  removal  of  their  cause  as  far  as  this  can.  be 
effected.  Hock's  second  case  was  apparently  cured  by  specific  reme- 
dies, his  first  case  by  tenotomy.  Hysterical  convergence  can  generally 
be  removed  by  a  small  blister  to  each  temple,  if  the  potent  influence  of 
neglect  is  ineffective.  The  paroxysmal  epileptoid  form  of  ocular  spasm 
is  very  obstinate.  Bromides  have  little  influence  upon  it,  and  tonics 
do  more  good  than  sedatives.  Counter-irritation  to  the  temple  some- 
times seems  to  produce  a  beneficial  effect. 

In  the  treatment  of  nystagmus,  the  improvement  of  vision,  if  this 
is  defective,  and  the  removal  of  any  cause  that  can  be  discovered,  are 
the  chief  measures.  The  form  that  occurs  in  miners  needs,  as  a  rule,  a 
change  of  occupation,  or  at  least  of  habitual  position,  so  as  to  relieve 
the  eyes  from  this  postural  strain,  together  with  an  improvement  in 
the  light  by  which  the  work  is  done.  For  other  forms  very  little  can 
be  effected.  The  application  of  a  feeble  voltaic  current,  from  the 
mastoid  process  to  the  closed  eyelids,  was  recommended  by  Svetlin, 
but  has  failed  in  the  hands  of  others.  But  the  symptom,  in  many 
cases,  scarcely  calls  for  treatment. 

Spasm  of  the  levator  is  a  most  intractable  affection,  unless  there  is 
irritation  of  the  fifth  nerve  or  any  other  cause  which  can  be  removed. 
When  no  cause  can  be  traced,  the  most  varied  treatment  by  counter- 
irritation,  sedatives,  and  electricity  usually  fails.  Associated  with 
any  symptoms  of  exophthalmic  goitre,  the  treatment  is  that  of  the 
'atter  disease. 


THE    FIFTH   NERVE. 

The  fifth  nerve,  it  will  be  remembered,  has  an  extensive  deep  origin, 
not  only  from  the 'middle  nucleus  at  the  level  of  its  surface  attach- 
ment, but  also  by  an  upper  root  of  descending  fibres  from  beneath 
the  corpora  quadrigemina,  and  by  a  lower  root  of  ascending  fibres 
from  a  tract  of  grey  matter  which  extends  into  the  medulla  oblongata 
(see  p.  50),  continuous  with  that  from  which  the  posterior  cervical 
roots  arise.  The  cutaneous  distribution  of  the  fifth  nerve  is  con- 
tinuous, on  the  head  and  neck,  with  these  cervical  roots,  and  the 
nuclear  grey  matter  similarly  continuous.  This  enables  us  to  under- 
stand the  radiation  of  pain  from  one  nerve  region  to  the  other.  The 
nucleus  of  the  motor  root  is  at  the  level  of  the  origin  of  the  nerve 
from  the  pons.  The  Gasserian  ganglion  lies  in  a  hollow  on  the  petrous 
part  of  the  temporal  bone,  and  thence  the  three  divisions  pass  from 
the  cranial  cavity,  the  first  by  the  sphenoidal  fissure  to  the  orbit, 
the  second  by  the  foramen  ovale,  and  the  third  by  the  foramen 
rotundum,  of  the  sphenoid  bone  to  the  spheno-maxillary  fossa.     The- 


214  CRANIAL    NERVES. 

first  part  supplies  the  skin  of  the  forehead  aud  anterior  part  of  the 
hairy  scalp,  the  upper  eyelid,  and  the  bridge  and  tip  of  the  nose ;  the 
second  part,  the  lower  eyelid,  cheek,  anterior  part  of  the  temples,  side 
of  the  nose,  upper  lip,  upper  teeth,  aud  upper  part  of  pharynx, 
tonsils,  soft  palate,  and  uvula  and  roof  of  mouth ;  the  third  part 
supplies  the  rest  of  the  temple,  the  anterior  and  upper  part  of  the 
ear,  the  auditory  meatus,  the  lower  part  of  the  cheek  adjacent  to  the 
mouth,  the  lower  lip,  chin,  lower  teeth  and  gums,  and  the  tongue,  part 
of  the  mucous  membrane  of  the  mouth,  and  the  salivary  glands.  The 
function  of  taste  in  the  anterior  part  of  the  tongue  is  subserved  by 
the  lingual  branch  of  the  third  division,  but  the  fibi'es  pass  from  this 
to  the  facial  nerve,  and  thence  to  the  spheno-palatine  ganglion  and 
the  second  division,  as  will  be  explained  immediately.  The  motor 
part  supplies  the  muscles  of  the  lower  jaw,  temporal,  masseter  and 
pterygoid,  the  mylohyoid,  and  the  posterior  belly  of  the  digastric. 

The  connections  of  the  fifth  nerve  are  numerous,  and  some  of  them 
are  of  considerable  importance.  The  first  part  receives,  at  the 
Grasserian  ganglion,  fibres  from  the  sympathetic,  which  pass  with  it  to 
the  eye,  and  are  the  fibres  that  innervate  the  radiating  muscle  of  the 
iris.  The  second  part  gives  off,  from  the  spheno-palatine  ganglion, 
the  Vidian  nerve,  which  (after  a  connection  with  the  tympanic  branch 
of  the  glossopharyngeal)  joins  the  facial.  It  is  called  the  large 
superficial  petrosal,  after  it  has  given  off  a  branch  to  the  sympathetic. 
The  lingual  branch  of  the  third  part  gives  off  the  chorda  tympani, 
which  joins  the  facial  in  the  Fallopian  canal,  a  little  below  its  junction 
with  the  large  petrosal  (Vidian).  There  is  strong  reason  to  believe 
that  most  of  the  fibres  of  the  chorda  tympani  pass  into  the  petrosal 
(Vidian),  aud  thus  reach  the  spheno-palatine  ganglion  and  the  second 
part  of  the  fifth  nerve.  These  fibres  not  only  conduct  taste  impres- 
sions from  the  front  of  the  tongue,  but  perhaps  also  subserve  some 
tactile  sensibility,  since  this  has  been  lowered  by  disease  of  the 
chorda  tympani.  Lastly,  the  otic  ganglion  of  the  third  part  gives 
off  the  small  superficial  petrosal  nerve,  which  is  connected  with  the 
facial  nerve  where  the  Vidian  joins  it,  and  ends  in  the  tympanic 
branch  of  the  glosso-pharyngeal. 

Paralysis  of  the  Fifth  Nerve. 

Causes. — The  course  of  the  fifth  nerve  renders  it  liable  to  damage 
from  disease  in  various  situations,  but  its  deep  position  protects  it 
from  some  influences  to  which  nerve-trunks  of  superficial  course  are 
exposed,  such  as  rheumatic  neuritis,  which  is  as  rare  in  the  fifth  as 
it  is  common  in  the  facial  nerve.  The  chief  causes  of  damage  are  the 
following : 

(1)  Disease  within  the  pons,  especially  focal  lesions,  haemorrhage, 
softening,  tumours,  and  sometimes  an  islet  of  sclerosis  at  the  level  of 
the  origin  of  the  nerve,  damaging  either  the  root-fibres  or  the  nuclei. 


FIFTH    NERVE.  215 

The  most  considerable  symptoms  are  produced  by  damage  to  the 
root-fibres.  The  nuclear  origin  of  the  sensory  fibres  is  so  extensive 
that  disease  never  affects  more  than  a  portion  of  it.  Degenerative 
disease  is  rare  ;  the  motor  nucleus  usually  escapes  even  in  wide-spread 
nuclear  degeneration. 

(2)  The  nerve  is  often  damaged  by  disease  at  the  base  of  the  brain, 
by  tumours,  chronic  meningitis,  especially  of  syphilitic  nature,  and 
caries  of  the  bone.  It  is  liable  to  suffer  in  disease  of  either  the  posterior 
or  middle  fossa,  or  of  the  petrous  bone  between  the  two.  Inflamma- 
tion may  affect  the  root,  primary,  or  secondary  to  a  slowly  growing 
tumour,  and  the  resulting  symptoms,  in  the  hitter  case,  may  subside 
until  renewed  by  pressure. 

(3)  Each  division  of  the  nerve  has  a  course  that  exposes  it  to 
special  lesions :  the  first,  in  the  wall  of  the  cavernous  sinus,  may  be 
damaged  by  growths  in  the  pituitary  region,  or  aneurism  of  the 
internal  carotid,  and  within  the  orbit  it  may  suffer  from  growths  or 
inflammation,  such  as  orbital  cellulitis;  the  second  and  third  pass 
into  the  spheno-maxillary  fossa,  which  is  often  invaded  by  tumours 
from  the  parotid  region  and  adjacent  bones. 

(4)  Traumatic  injury,  especially  punctured  and  bullet  wounds, 
through  the  mouth  and  nose.  On  the  other  hand,  the  nerve  is  rarely 
damaged  in  fracture  of  the  skull. 

(5)  While  secondary  neuritis  is  common,  arising  by  extension 
from  bone  or  membranes,  primary  neuritis  is  rare,  although  now  and 
then  it  is  excited  by  cold,  with  or  without  a  like  affection  of  other 
cranial  nerves,  as  the  facial  (q.  v.).  It  may  be  predisposed  to  by 
gout,  or  caused  by  syphilis.  Any  part  of  the  nerve  may  be  thus 
damaged,  and  even  the  root  may  be  inflamed  through  cold.  A  gouty 
man  drove  forty  miles  in  a  cold  wind,  and  towards  the  end  of  the 
drive  had  transient  double  vision.  Two  days  later  the  left  fifth 
nerve  became  paralysed.  In  a  case  recorded  by  Ziehl*  the  neuritis 
apparently  extended  from  the  foramen  ovale  to  below  the  junction 
with  the  chorda  tympani.  The  peculiar  neuritis  that  seems  to  be  the 
cause  of  herpes  zoster  is  frequent  in  this  nerve,  but  must  be  dis- 
tinguished from  the  ordinary  form  of  inflammation.  Interstitial 
neuritis  has  been  found  in  hemiatrophy  of  the  face  (Mendel,  &c). 

Symptoms. —  (a)  Sensory  Portion. — The  chief  symptom  of  an  affec- 
tion of  the  fifth  or  of  its  branches  is  loss  of  sensation  in  the  region  of 
the  skin  supplied  by  it,  universal  in  severe  disease  of  the  trunk  of  the 
nerve,  or  when  all  three  branches  are  damaged  by  a  growth  in  the 
middle  fossa  of  the  base,  but  in  disease  of  the  branches  limited  to 
areas  supplied  by  them.  The  loss  of  sensation  is  commonly  preceded 
by  symptoms  of  irritation,  sharp,  darting,  burning  pains  referred  to 
the  region  of  its  distribution,  closely  i*esembliug  those  of  neuralgia, 

*  '  Virchow's  Archiv/  117,  1889. 


216  CiiANIAL    NEltVES. 

and  often  accompanied  by  tender  points  in  the  course  of  the  nerves. 
There  may  be  increased  sensitiveness,  especially  to  pain.  The  dura- 
tion of  the  stage  of  simple  irritation  varies  according  to  the  quick 
or  slow  progress  of  the  disease;  sometimes  it  is  absent,  and  the 
anaesthesia  is  the  first  symptom.  Tactile  sensibility  is  usually  lost 
first,  and  there  is  often  sensitiveness  to  pain,  when  a  touch  cannot  he 
felt.  Ultimately  both  are  lost.  The  muscles  of  the  face  are  insensi- 
tive, but  are  not  weakened,  although  the  movements  of  the  face  have 
been  observed  to  be  a  little  slower  than  normal,  apparently  from 
defective  sensation.  The  mucous  membranes,  as  well  as  the  skin, 
become  insensitive.  The  conjunctiva  can  be  touched  and  even 
pricked  without  discomfort  or  reflex  action.  The  mucous  membrane 
of  the  nose  can  no  longer  be  irritated  by  snuff  or  ammonia.  Odours 
can  at  first  be  perceived  perfectly ;  after  a  time  the  sense  of  smell  is 
blunted,  in  consequence  of  the  dryness  of  the  mucous  membrane  and 
secondary  changes  in  its  epithelial  tissues.  The  anaesthesia  extends 
over  the  mucous  membrane  of  the  lips,  mouth,  and  tongue,  up  to  the 
middle  line.  When  the  patient  drinks,  the  cup,  felt  only  on  the  un- 
affected side,  may  seem  broken.  Food  is  not  chewed  on  the  para- 
lysed side  because  it  cannot  he  felt,  or  because  the  muscles  of 
mastication  are  weakened.  Hence,  fur  accumulates  on  the  anaesthetic 
half  of  the  tongue:  this  accumulation  has  been  ascribed  to  defective 
innervation,  but  it  is  common  in  all  conditions  which  lead  to  one- 
sided chewing,  and  is  probably  merely  due  to  the  fact  that  the  food 
no  longer  removes  the  epithelium.  In  some  cases,  at  least,  the  back 
of  the  tongue,  the  anterior  arches  and  the  palate,  soft  as  well  as  hard, 
are  insensitive.  In  other  cases,  in  which  the  extent  of  the  cutaneous 
anaesthesia  suggests  disease  of  the  whole  of  the  fifth  nerve,  the  loss  of 
sensibility  is  confined  to  the  anterior  two  thirds  of  the  tongue.  It  is 
not  known  whether  this  difference  is  due  to  individual  variations  in 
the  distribution  of  the  nerve,  or  to  differences  in  the  seat  of  the  dis- 
ease, but  it  is  certain  that  disease  of  the  fifth  may  cause  anaesthesia  in 
the  root  of  the  tongue  and  palate. 

Another  frequent  symptom  of  disease  of  the  fifth  nerve  is  loss  of 
taste.  Disease  of  th§  root  of  the  fifth  nerve  may  cause  complete  loss 
of  taste  in  all  the  gustatory  region  of  the  one  side,  tongue  and  palate. 
A  syphilitic  man,  with  paralysis  of  the  left  fifth  and  third  nerves,  had 
also  complete  loss  of  taste  on  that  side ;  ultimately  there  remained 
only  slight  defect  of  sensibility  on  the  cheek,  weakness  of  the  muscles 
of  mastication,  and  loss  of  taste  on  that  side,  coinj)lete  on  the  back  of 
the  tongue,  partial  in  the  front.  Exceptions  are  probably  cases 
either  of  partial  disease  of  the  root  or  of  disease  within  the  pons, 
where  the  taste-path  has  a  separate  course.  Disease  of  the  lingual, 
alter  the  chorda  tympani  has  joined  it,  causes  loss  of  taste  in  the 
anterior  two  thirds  of  the  tongue  ;  above  the  junction  with  the  chorda 
tympani  disease  of  the  third  division  seems  to  cause  no  loss  of  taste. 
Other  facts  are  stated  in  the  section  on  affections  of  taste. 


FIFTH   NERVE.  217 

Trophic  changes  may  result  from  disease  of  the  fifth  nerve. 
Alterations  in  the  vascularity  of  the  face  have  been  described,  but  are 
certainly  rare.  The  secretions  from  the  mucous  membranes  and 
special  glands,  lachrymal  and  salivary,  are  lessened  in  paralysis,  and 
increased  for  a  time  in  irritation.  Rarely  there  is  swelling  and  ulce- 
ration of  the  gums.  An  accidental  bite  of  the  insensitive  cheek,  for 
instance,  heals  slowly  and  tends  to  ulcerate.  In  long-standing  cases 
the  teeth  have  become  loose.  But  the  most  important  disturbance  in 
nutrition  is  that  of  the  eye.  Inflammation  of  the  eyeball  is  a  common 
result  of  section  of  the  nerve  in  animals,  and  has  been  frequently  ob- 
served in  man.  The  cornea  becomes  cloudy,  then  opaque,  and  ulcers 
form  upon  it,  which  may  perforate  and  lead  to  a  destructive  inflam- 
mation of  the  globe.  The  conditions  that  determine  this  "  neuro- 
paralytic ophthalmia"  (as  it  has  been  termed)  have  been  the  subject 
of  much  discussion.  It  is  not  simply  the  result  of  interruption  of  the 
sensory  fibres,  since  such  interruption,  with  complete  anaesthesia,  has 
been  repeatedly  observed  without  any  ocular  disturbance.  In  a  patient 
under  my  care,  complete  paralysis  of  the  fifth  nerve,  motor  and 
sensory,  has  existed  for  seven  years  without  a  trace  of  ophthalmia. 
This  fact,  and  the  absence  of  inflammation  in  facial  palsy,  show  that 
it  cannot  be  due  simply  to  irritation  of  the  conjunctiva  by  foreign 
bodies,  dust,  &c,  which  are  not  felt,  although  such  irritation  may 
act  as  an  excitant.  From  various  experimental  and  clinical  facts  it 
seems  probable  that  the  inflammation  is  due,  not  to  mere  interruption, 
but  to  irritation  of  the  fifth  nerve,  and  is  analogous  to  the  acute 
trophic' changes  in  the  skin  that  depend  on  irritation  of  the  sensory 
nerves  (see  vol.  i,  p.  22).  An  unsuccessful  attempt  to  divide  the 
nerve,  which  caused  considerable  irritation  but  no  anaesthesia,  has 
caused  characteristic  inflammation  of  the  eyeball  (Meissner),  and 
electrical  irritation  of  the  ganglion  causes  ocular  inflammation,  which, 
although  transient,  is  intense.  It  is  probable,  moreover,  that  such 
irritation  is  most  powerful  when  it  involves  the  G-asserian  ganglion 
(especially  the  inner  part,  according  to  Meissner)  or  the  nerve-fibres 
in  front  of  the  ganglion.  It  is  frequently  absent  in  disease  of  the 
nerve  within  the  pons,  and  of  its  root  at  the  surface  of  the  pons,  and 
although  it  may  occur  when  the  disease  is  in  this  situation,  it  is 
probable  that  a  greater  degree  of  irritation  is  required  to  produce  it 
there  than  when  the  disease  is  at,  or  in  front  of,  the  G-asserian 
ganglion.  Excision  of  the  ganglion  has  caused  such  intense  and  un- 
controllable inflammation  as  to  necessitate  the  removal  of  the  eye  in  a 
few  days.* 

Herpes  zoster  is  frequent  in  the  region  supplied  by  the  fifth  nerve, 
especially  in  that  of  the  first  division.  The  observations  of  v.  Baren- 
sprung  and  others  make  it  probable  that  the  eruption  is  due  to  in- 
flammation of  the  G-asserian  ganglion,  or  of  the  nerve-trunks  in  front, 
of  this,  although  it  is  doubtful  whether  the  cause  is  an  ordinary 
*  Rose,  '  Lancet,'  Nov.  1st,  1890. 


218  CRANIAL    NERVES. 

neuritis.  It  is  usually  preceded  or  followed  by  much  pain  and  hyper- 
esthesia, sometimes  accompanied  also  by  lessened  tactile  sensibility, — 
evidence  of  irritation  and  damage  to  the  conducting  nerve-fibres.  In 
the  old,  the  pain  that  follows  herpes  is  often  peculiarly  enduring,  and 
may  last  for  months  or  years.  Ophthalmitis  or  iritis  may  also  occur. 
Herpes  has  been  observed  to  follow  other  lesions  of  the  fifth,  but  is 
not  common  in  such  cases,  although  it  may  attend  the  neuritis  that 
is  produced  by  cold.  Catarrhal  herpes  of  the  lips  has  been  attributed 
to  neuritis  of  peripheral  branches  of  the  nerve,  but  without  the 
pathological  evidence  that  is  desirable  in  the  case  of  an  eruption 
that  differs  so  markedly  from  zoster  in  its  irregular  bilateral  distribu- 
tion and  in  its  common  cause. 

Facial  hemiatrophy  is  certainly,  as  Mendel  has  shown,  due  in  many 
cases  to  disease  of  the  fifth  nerve,  but  as  we  do  not  jet  know  that  the 
relation  is  invariable  it  is  described  in  a  later  part  of  this  volume. 

(b)  Motor  Portion. — The  resulting  loss  of  power  in  the  muscles  can 
be  recognised  by  placing  the  finger  on  each  masseter  or  temporal 
muscle,  and  making  the  patient  bring  the  teeth  forcibly  together  as 
in  the  act  of  biting.  The  feebleness  or  absence  of  contraction  on  the 
affected  side  is  then  evident.  When  the  loss  of  power  is  slight,  the 
affected  muscles  may  contract  a  little  later  than  the  others.  The 
paralysis  of  the  external  pterygoid  causes  two  characteristic  sym- 
ptoms :  the  patient  cannot  move  the  jaw  towards  the  unaffected  side, 
and  when  the  lower  jaw  is  depressed  it  deviates  towards  the  paralysed 
s.de,  because,  in  depression,  the  external  pterygoids  draw  the  condyles 
forwards,  and  this  movement  occurs  only  on  the  unparalysed  side. 
The  mylohyoid  and  posterior  part  of  the  digastric  act  only  with  other 
muscles  that  are  not  supplied  by  the  fifth,  and  hence  their  paralysis 
does  not  perceptibly  impair  the  movement  of  the  hyoid  bone,  which 
they  help  to  raise.  Although  the  tensor  palati  and  tensor  tympani  are 
supplied  from  the  fifth,  no  evidence  of  the  paralysis  of  these  muscles 
has  been  observed  in  cases  of  disease  of  this  nerve.  It  has  been 
assumed  that  the  palsy  of  the  tensor  tyrnpani  would  cause  defect  in 
hearing  low  notes,  but  I  am  not  aware  that  the  defect  has  been 
detected,  and  I  have  failed  to  discover  it  in  cases  that  I  have  examined 
with  special  reference  to  this  point.  It  is  probable  that  the  fibres 
to  the  tensor  palati,  although  they  may  come  from  the  fifth,  are 
ultimately  derived  from  the  spinal  accessory.  After  a  time  the 
paralvsed  muscles  of  mastication  waste,  the  temporal  and  zygomatic 
fossae  become  flattened,  and  ultimately  a  little  secondary  shortening 
of  the  muscles  may  limit,  in  a  slight  degree,  the  downward  movement 
of  the  jaw. 

Diagnosis. — The  diagnosis  of  paralysis  of  the  fifth  nerve  is  easy 
when  its  degree  is  considerable,  when  the  motor  part  is  affected,  and 
when  the  sensory  part  suffers  without  anaesthesia  elsewhere,  or  with 


FIFTH    NEHVE.  219 

only  paralysis  of  other  cranial  nerves.  A  diagnostic  difficulty  arises 
only  when  there  is  other  sensory  paralysis,  or  when  the  disease  of  the 
fifth  causes  only  sensory  irritation,  and  the  resulting  pain  is  like  that 
of  neuralgia.  In  hemianesthesia  the  parts  supplied  by  the  fifth  nerve, 
skin  and  mucous  membranes,  are  insensitive,  but  so  also  are  the  back 
of  the  head,  trunk,  and  limbs,  and  in  many  cases  the  special  senses 
are  impaired.  As  long  as  the  only  symptom  of  disease  of  the  nerve 
is  pain,  due  to  irritation  of  the  fibres,  and  referred  to  their  distribution, 
the  condition  may  be  indistinguishable  from  ordinary  neuralgia.  The 
pain  may  be  of  the  same  character  and  seat,  most  intense  in  the  same 
localities,  and  sometimes  accompanied  by  the  same  tender  points. 
Persistent  hyperesthesia  of  the  skin  is  more  marked  and  extensive  in 
cases  of  organic  disease  than  in  neuralgia,  and  the  pain  radiates  less 
frequently  to  other  nerve  regions,  e.  g.  to  that  of  the  cervical  plexus. 
In  some  cases  there  are  peculiar  abnormal  sensations  other  than  pain, 
and  these  are  probably  characteristic  of  slight  disease  of  the  nerve. 
The  most  conclusive  evidence,  however,  is  the  development  of  anes- 
thesia, corresponding  in  range  to  the  fifth  nerve  or  one  of  its  branches, 
which  is  proof  of  definite  arrest  of  conduction.  Another  important 
symptom  of  such  disease  is  loss  of  taste,  which,  as  we  have  seen,  may 
occur  independently  of  anaesthesia.  It  should  be  carefully  sought  for 
in  every  case  in  which  an  organic  lesion  is  possible. 

The  diagnosis  of  the  seat  of  the  disease  depends  ou  the  extent  of 
the  symptoms,  especially  of  the  anaesthesia,  and  on  the  associations  of 
the  paralysis.  When  all  parts  are  affected,  the  disease  is  commonly 
at  the  base  of  the  brain  or  at  the  Gasserian  ganglion.  A  lesion  of  the 
first  part  only  is  usually  at  the  sphenoidal  fissure,  or  in  the  orbit. 
If  the  symptoms  are  limited  to  the  distribution  of  the  second  part,  the 
disease  is  probably  in  the  spheno-maxillary  fissure,  or  the  superior 
maxillary  bone.  Such  symptoms  are  occasionally  the  first  indication 
of  a  tumour  of  this  bone.  The  third  part  is  rarely  diseased  alone. 
An  affection  of  the  second  and  third  divisions  without  the  first  is 
generally  due  to  disease  of  the  sphenoid  bone  or  in  the  spheno-maxil- 
lary fossa. 

The  nerves  to  the  eyeball  are  those  most  frequently  associated  with 
the  fifth  in  disease  at  the  side  of  the  pons  and  in  the  middle  fossa  of 
the  skull.  In  the  former  case  all  parts  of  the  fifth  suffer,  in  the 
latter  only  the  first  division.  At  the  side  of  the  pons  the  sixth  nerve 
is  more  often  associated  with  the  fifth  than  any  other,  and  next  in 
frequency  the  third  ;  disease  of  these  nerves,  and  of  all  parts  of  the 
fifth,  points  conclusively  to  this  position.  Less  commonly  the  facial 
and  auditory  suffer  with  the  fifth.  Paralysis  of  one  fifth,  and  of  the 
arm  and  leg  on  the  opposite  side,  if  of  sudden  onset,  is  due  to  a  lesion 
within  the  pons ;  if  of  gradual  onset,  it  may  be  due  to  disease  in  or 
outside  the  pons.  An  instance  of  the  former  (in  which,  however,  ar- 
terial disease  caused  separate  foci  of  softening)  is  shown  in  Fig.  53. 
Inability  to  move  both  eyes  towards  the  side  of  the  lesion  is  conclusive 


220  CEANIAL    XEKYES. 

evidence  of  disease  within  the  pons ;  and  probably  loss  of  taste,  with 
palsy  of  the  motor  part  of  the  fifth  oniy,  has  the  same  significance. 

Treatment. — The  most  important  element,  as  in  other  cranial  nerve 
palsies,  is  the  removal  of  the  morbid  process  as  far  as  this  is  practi- 
cable; the  special  measures  adopted  must  depend  on  its  nature,  syphi- 
litic or  other,  as  in  the  case  of  other  nerves.  When  there  is  reason 
to  suspect  inflammation,  a  blister  should  be  applied  to  the  side  of  the 
occiput,  or  behind  the  ear,  but  not  to  the  temple,  lest  it  set  up  ulce- 
ration. If  the  affection  has  followed  exposure  to  cold,  hot  fomenta- 
tions may  be  applied  to  tbe  side  of  the  head  and.  face,  during  the  first 
three  days,  but  not  after  the  fourth  day,  or  vesication  may  ensue. 
The  pain  is  often  very  troublesome.  Sometimes  gelsemium  relieves 
it,  Cocain  injected  locally,  by  arresting  peripheral  impressions,  may 
lessen  the  pain  of  orgauic  irritation.  Often,  however,  only  hypo- 
dermic injection  of  morphia  gives  relief.  A  weak  voltaic  current  occa- 
sionally lessens  pain  that  is  moderate  in  severity,  but  it  is  powerless 
over  the  more  intense  suffering.  When  there  is  anaesthesia  without 
pain,  stimulation  of  the  terminal  sensory  fibres  may  be  tried.  If 
the  continuity  of  the  nerve-fibres  is  interrupted  such  stimulation 
is  necessarily  powerless,  but  in  many  cases  of  partial  and  stationary 
or  regressive  disease  the  fibres  are  slow  in  regaining  functional 
activity,  and  this  may  be  distinctly  increased  by  their  peripheral 
stimulation,  which  tends  to  overcome  the  resistance  at  the  diseased 
spot.  The  best  means  of  effecting  this  stimulation  is  the  faradisation 
of  the  skin.  A  dry  electrode  influences  the  cutaneous  nerves  more 
than  a  moist  sponge,  and  the  wire  brush  is  the  most  effective.  The 
brush  should  be  stroked,  over  the  anaesthetic  areas,  and  the  other 
electrode,  which  may  be  a  wet  sponge,  should  be  placed  behind  the  ear 
or  at  the  occiput.  The  current  should,  be  strong  enough,  if  possible, 
to  cause  some  sensation,  and  it  should  be  applied  for  two  or  three 
minutes.  Faradisation  is  much  better,  for  this  purpose,  than  the 
voltaic  current,  since  the  latter,  if  strong  enough  to  be  effective,  is  apt 
to  cause  giddiness.  Electricity  is  far  better  than  irritating  liniments, 
which  readily  set  up  trophic  disturbance.  The  skin  may  with  advan- 
tage be  gently  rubbed,  so  as  to  increase  its  vascularity,  before  the 
application. 

As  soon  as  there  are  any  indications  of  disturbed  nutrition  of  the 
eyeball,  it  should  be  kept  covered  to  exclude  the  foreign  bodies  that 
aid  in  exciting  inflammation.  The  occasional  application  of  a  drop  of 
castor  oil  to  the  conjunctiva  aids  the  subsidence  of  commencing  affec- 
tion. The  success  of  such  measures  depends,  however,  on  the  degree 
of  irritation  of  the  nerve.  When  intense,  the  rapid  inflammation 
baffles  every  attempt  to  arrest  it,  and  exertion  is  needed  to  obviate  the 
danger  of  a  "  sympathetic  "  affection  of  the  other  eye. 


FIFTH    NEIiVE.  221 


Spasm  op  the  Muscles  of  Mastication. 

Spasm  of  the  muscles  supplied  by  the  fifth  nerve,  the  "masticatory 
spasm  "  of  Romberg,  may  be  either  tonic  or  clonic. 

Tonic  spasm  keeps  the  jaws  together  so  that  the  two  rows  of  teeth 
cannot  be  separated  ("  lockjaw  "),  or  can  only  be  separated  for  a  short 
distance,  a  quarter  or  half  an  inch.  Sometimes  the  teeth  are  pressed 
together  with  considerable  force.  The  masseters  and  temporals  can 
be  seen  to  be  prominent,  and  felt  to  be  hard.  An  attempt  to  depress 
the  lower  jaw,  and  overcome  the  rigidity  by  force,  causes  pain  in  the 
muscles,  and  sometimes  the  spasm  is  itself  painful.  The  muscular 
contraction  is  almost  always  bilateral.  It  is  a  conspicuous  and  early 
symptom  in  tetanus,  traumatic  and  idiopathic,  and  is  an  occasional 
and  late  symptom  in  severe  cases  of  tetany.  It  occurs  also  in  hysteria ; 
sometimes  frequent  brief  paroxysms  last  a  quarter  of  an  hour  or  more, 
sometimes  a  more  enduring  form  succeeds  a  hysteroid  fit,  and  usually 
lasts  until  another  convulsion,  which  leaves  the  patient  free.*  This 
spasm  was  unilateral  in  one  hysterical  case  recorded  by  Travers. 

In  rare  cases  tonic  spasm  has  been  produced  by  sensory  irritation 
elsewhere,  generally  due  to  injury,  and  has  passed  away  when  the  irri- 
tation was  removed.  Romberg  has  recorded  several  instances  of  this. 
Unhappily,  trismus,  so  produced,  is  in  most  cases  the  first  symptom 
of  general  tetanus.  This  is  true  also  of  trismus  following  exposure  to 
cold,  but  in  one  case  paroxysmal  and  transient  spasm  of  the  jaw  and 
tongue,  accompanied  by  a  "  dying  away  of  the  extremities,"  was  pro- 
duced by  any  considerable  exposure  to  cold  (Romberg).  In  a  few 
cases,  prolonged  trismus,  without  other  symptoms,  has  followed  similar 
exposure,  but  in  most  instances  the  patients  were  young  women,  and 
it  is  possible  that  the  cases  were  hysterical  in  nature. 

Another  occasional  and  rare  cause  is  irritation  in  the  sensory  region 
of  the  fifth  nerve,  due  to  carious  teeth,  ulceration  in  the  mouth,  and 
other  causes.  The  tonic  spasm  has  been  observed  to  coincide  with 
paroxysms  of  pain,  and  to  be  removed  for  a  time  by  pressure  on 
tender  points  in  the  branches  of  the  nerve.  It  is  said  to  be  produced 
especially  by  irritation  of  the  last  molar,  either  from  caries  with 
alveolar  abscess,  or  during  the  eruption  of  the  tooth.  In  the  latter 
case  the  spasm  has  been  known  to  continue  for  several  months 
(Germain). 

Lastly,  tonic  spasm  is  an  occasional  symptom  of  organic  disease  of 
t|ie  pons,  due  to  disease  irritating,  but  not  destroying,  the  motor 
nucleus  of  the  fifth.  The  spasm  may  be  unilateral,  but  it  is  more 
frequently  bilateral  (although  sometimes  greater  in  degree  on  one 
side)  even   when  the  disease  is  one-sided.     It  is  often  permanent. 

*  There  can  be  little  doubt  that  the  case  recorded  by  Romberg  ('Dis.  Nerv. 
Syst./  Syd.  Soc.  trans.,  vol.  i,  p.  305)  of  trismus  after  "  epilepsy "  was  an  example 
of  this  form. 


222  CRANIAL    NERVES. 

A  tumour  is  the  most  frequent  cause  of  the  symptom.  Of  recorded 
cases,  in  one  (Marot)  there  was  a  small  tubercle  at  the  junction 
of  the  pons  and  medulla  on  the  right  side;  in  another  (Wernicke! 
the  tumour,  also  a  tubercle,  occupied  almost  the  whole  vertical 
extent  of  the  left  half  of  the  pons,  and  had  caused  loss  of  the 
movement  of  both  eyes  to  the  left,  paralysis  of  the  facial  nerve, 
exti-eme  tension  of  the  left  masseter,  and  numbness  of  the  right  side 
of  the  head.  Somewhat  similar  symptoms  in  a  woman,  aged  forty- 
two,  under  my  care,  were  probably  due  to  syphilitic  disease  of  the 
basilar  artery  ;  they  developed  in  the  course  of  two  days,  and  then 
remained  stationary.  On  account  of  the  spasm  of  the  muscles,  which 
was  bilaterial,  the  jaws  could  only  be  separated  for  a  quarter  of  an 
inch  ;  in  this  movement  the  jaw  deviated  quite  the  same  distance  to 
the  left,  and  hence  there  was  probably  some  weakness  of  the  left 
muscles,  although  the  voluntary  contraction  seemed  equal.  The  sen- 
sory parts  of  the  fifth  nerve  were  unaffected,  but  there  was  entire  loss 
of  all  lateral  movements  of  the  eyes,  and  limitation  of  the  vertical 
movements ;  nystagmus,  lateral  in  the  right  and  rotatory  in  the  left 
eye,  which  was  strongly  inverted;  complete  paralysis  of  all  parts  of 
the  left  facial  nerve  with  degenerative  reaction,  and  right  hemiplegia, 
considerable  in  degree.  Three  years  after  the  onset  the  spasm 
remained  the  same,  and  the  other  symptoms  presented  only  trifling 
improvement. 

Partial  tonic  spasm,  affecting  only  some  of  the  muscles  supplied  by 
the  fifth  nerve,  is  extremely  rare.  In  the  case  of  a  girl  suffering  from 
hysteria  and  chorea,  recorded  by  Leube,*  the  jaw  was  fixed  for  several 
days  in  the  position  of  lateral  deviation,  and  as  there  was  no  spasm 
in  the  masseters  or  temporals  the  symptom  was  apparently  due  to 
spasm  in  the  pterygoid  muscles  of  one  side. 

Clonic  spasm  of  the  muscles  supplied  by  the  fifth  nerve  is  met  with 
in  two  forms  :  (1)  quick  contractions  frequently  repeated ;  (2)  single 
sudden  contractions  occurring  at  considerable  intervals. 

(1)  The  serial  clonic  spasm  is  the  most  common.  It  causes,  if  con- 
siderable, successive  upward  movements  of  the  lower  jaw,  bringing 
the  teeth  together,  sometimes  with  sufficient  force  to  cause  the  sound 
popularly  known  as  "  chattering  of  the  teeth. "f  If  slight,  there  may 
be  only  a  tremulous  movement  of  the  jaw,  although  the  spasm  of  the 
muscles  may  be  felt  when  the  fingers  are  placed  on  them.  The  move- 
ment is  almost  always  vertical ;  a  lateral  movement,  from  spasm  in 
the  pterygoids,  has  been  described,  but  is  extremely  rare.  Clonic 
spasm  is  bilateral  in  most  cases.  It  is  a  conspicuous  feature  of  many 
forms  of  general  clonic  spasm,  as  convulsion  and  rigor.  It  may  occur 
also  in  paralysis  agitans ;  in  rare  cases  the  muscles  on  one  side  may 
be  affected  before  those  on  the  other. 

As  an  isolated  symptom  such  clonic  spasm  is  rare,  and  most  cases 

*  '  Arch.  f.  klin.  Med.,'  1869,  vi,  273. 

t  Pr  >bably  modified,  by  false  analogy,  from  "clattering  of  the  teeth." 


FIFTH    NERVE.  223 

have  occurred  late  in  life  and  in  women.  Romberg  relates  an  in- 
stance in  a  woman  aged  sixty-five,  who  had  previously  suffered  from 
facial  spasm.  The  spasm  affected  the  right  masseter  more  than  the 
left,  and  not  the  temporals.  It  caused  a  constant  chattering  of  the 
teeth.  Towards  evening  the  movement  became  very  forcible  and  vio- 
lent ;  it  ceased  during  sleep  and  also  during  mastication.  Pain  was 
felt  only  when  the  spasm  was  very  violent.*  I  have  met  with  one 
case  in  a  woman  aged  fifty-five,  in  which  similar  spasm  was  associated 
with  neuralgic  "shooting"  pain  in  the  left  side  of  the  face,  especially 
round  the  orbit,  and  about  the  malar  bone,  darting  through  the 
head,  and  sometimes  along  the  lower  jaw  and  down  the  neck.  The 
pain  was  most  intense  in  wet  weather.  The  spasm  appeared  secondary 
to  the  pain,  and  was  greatest  when  the  pain  was  severe.  Both 
masseters  and  temporals  were  involved.  The  spasm  was  not  quite 
regular,  but  the  frequency  of  the  contractions  was  72  to  80  per 
minute.  At  times  it  could  not  b-j  felt.  It  ceased  when  the  jaws  were 
opened  widely.  It  was  rather  stronger  on  the  left  side  than  on  the 
right,  and  in  gradually  passing  away  (after  some  months  of  tonic  and 
sedative  treatment)  it  ceased  on  the  right  side  sooner  than  on  the  left. 
Attacks  of  tonic  and  clonic  spasm  on  one  side,  ultimately  spreading 
to  the  tongue,  have  coincided  with  hemiatrophy  of  the  same  parts  in 
a  girl.f 

(2)  The  second  form  of  clonic  spasm,  in  which  there  are  occasional 
severe  single  contractions,  sometimes  occurs  in  chorea,  but  as  an 
isolated  affection  it  is  very  rare.  The  jaws  are  bi-ought  together 
with  considerable  force,  and  the  tongue  or  cheeks  are  sometimes 
bitten.  An  instance  of  this  form  occui'red  in  a  woman  aged  twenty-six. 
It  commenced  suddenly  ;  at  first,  whenever  she  tried  to  eat  or  began 
to  talk,  and  also  on  going  to  sleep  at  night,  the  jaw  would  be 
suddenly  jerked  up  and  her  tongue  was  several  times  badly  bitten, 
She  had  no  other  symptom  except  slight  weakness  of  the  lower  part 
of  the  face  on  the  left  side.  She  presented  no  evidence  of  hysteria. 
A  heavy  weight  had  fallen  on  the  head  about  three  months  before  the 
onset.  Tito  symptoms  continued,  decreasing  in  severity,  for  about  a 
month,  but  for  six  months  she  had  an  occasional  attack  leaving 
tenderness  in  the  masseters,  and  there  was  some  reason  to  think  that 
on  one  occasion  in  the  night  she  had  an  epileptic  fit.  I  have  known 
similar  spasms  to  occur  during  sleep,  chiefly  in  men  during  middle 
life.  They  wake  the  patient,  and  the  tongue,  if  it  happens  to  be 
between  the  jaws,  may  be  bitten.  The  affection  appears  to  depend 
on  enfeeblement  of  the  nervous  system,  and  ceases  when  this  is 
strengthened. 

Diagnosis. — The  existence  of  spasm  in  the  muscles  of  mastication 
is  readily  recognised.      The  only  conditions  which  simulate  spasm 

*  Romberg, '  Diseases  of  the  Nervous  System,'  Syd.  Soc.  trail*.,  1853,  vol.  i,  p.  301. 
t  Sachs,  «  Med.  Record,'  1890. 


224  CRANIAL    NERVES. 

are — (1)  interference  with  the  movement  of  the  jaw  by  a  tumour  or 
inflammatory  swelling  near  the  ramus,  conditions  sufficiently  obtru- 
sive ;  (2)  disease  of  the  joint,  usually  rheumatoid,  limiting  the  move- 
ment of  the  articular  surfaces ;  here  there  is  no  tension  of  the 
muscles,  and  other  joints  are  commonly  affected.  In  one  case,  for 
instance,  that  of  a  man  thirty  years  of  age,  in  whom  the  lower  jaw 
could  not  be  depressed  for  more  than  half  an  inch,  a  similar  condi- 
tion had  fixed  the  articulations  of  the  cervical  spine,  so  that  the  neck 
was  as  rigid  as  if  it  had  been  composed  of  wood. 

The  prognosis  of  isolated  spasm  is  good,  except  in  the  cases  which 
are  due  to  organic  disease  of  the  nerve-centres.  These  are  usually 
permanent.  In  other  cases  the  spasm  usually  passes  away,  but  often 
only  after  a  somewhat  prolonged  treatment. 

Treatment. — The  treatment  of  the  forms  of  spasm  that  are  part 
of  diseases  of  wider  nature  is  necessarily  that  of  the  primary  affection, 
and  is  described  elsewhere.  Hysterical  spasm  is  sometimes  removed 
by  a  blister  behind  the  ramus  of  each  jaw.  In  the  isolated  form  it 
is  important  to  search  for  and  remove  all  sources  of  irritation  of  the 
sensory  nerves,  to  lessen  pain  by  sedatives,  and  to  strengthen  the 
nervous  system  by  tonics,  especially  iron  and  quinine.  When  a 
carious  molar  is  the  cause  of  the  spasm,  it  may  be  necessary  to  relax 
the  muscles  by  chloroform  or  ether,  that  the  tooth  may  be  extracted. 
If  the  spasm  is  apparently  due  to  cold,  a  hot  air  or  vapour  bath 
should  be  used  in  the  early  stage.  Yoltaic  electricity  has  been  said 
to  do  good  in  some  cases — the  positive  pole  being  placed  on  the  back 
of  the  neck,  the  negative  on  the  contracting  muscles,  and  if  no  result 
follows,  the  position  of  the  poles  may  be  reversed  ;  but  it  is  doubtful 
whether  the  current  can  reach  the  overacting  centres.  The  par- 
oxysmal form  of  clonic  spasm  is  certainly  lessened  by  bromides,  and 
they  usually  prevent  the  occurrence  of  nocturnal  spasm,  but  they 
have  no  influence  on  the  tonic  form.  Cauterisation  beside  the 
cervical  spine  has  been  recommended  for  trismus  due  to  cold  (Petrone). 
In  prolonged  cases  of  tonic  spasm  in  which  the  jaws  are  completely 
closed,  the  feeding  of  the  patient  is  a  matter  of  difficulty,  and  the 
extraction  of  a  tooth  may  be  needed  for  the  purpose. 

Affections  of  Taste. 

The  sense  of  taste,  it  must  be  remembered,  includes  only  the 
recognition  of  the  qualities  known  as  "  bitter,"  "  sweet,"  "  sour,"  and 
"  salt,"  with  certain  metallic  sensations.  It  does  not  include  what 
are  called  flavours ;  %these,  as  we  have  seen,  are  really  perceived 
through  the  olfactory  nerve.  Gustatory  sensation  is  subserved  by  the 
mucous  membrane  of  the  tongue,  palate,  and  palatine  arches,*  but  in 

*  Also  on  the  posterior  surface  of  the  epiglottis,  and  even  within  the  larynx 
(Michelson,  '  Virchow's  Arehiv,'  1801,  Bd.  cxxiii). 


AFFECTIONS    OP   TASTE.  225 

the  forepart  of  the  tongue  the  function  is  chiefly  localised  in  the  tip 
aud  edges,  and  is  very  slight  on  the  upper  surface.  Each  quality  can 
be  perceived  in  all  parts  of  the  gustatory  region,  but  bitterness  and 
sweetness  are  more  readily  appreciated  at  the  back  of  the  tongue, 
sourness  and  saltness  at  the  tip  and  edges.  Moreover,  if  minute  areas 
are  tested,  there  are  found  to  be  spots  in  which  one  quality  can  be 
perceived  and  not  another.  There  seem  also  to  be  individual  differences 
in  the  relative  power  of  detecting  the  various  qualities  in  the  several 
regions.  The  sense  is  also  influenced  by  age,  being  greater  in  the 
young  than  in  the  old. 

In  testing  taste,  substances  should  be  used  that  do  not  appeal  to 
any  other  sense, — colouidess  solutions  or  white  powders.  Care  must 
be  taken  that  their  action  is  limited  to  the  sj>ot  examined.  If  powders 
are  used,  a  little  time  must  be  allowed  for  their  solution  by  the  mois- 
ture of  the  mucous  membrane,  aud  slight  friction  facilitates  the  stimu- 
lation. Salt,  sugar,  citric  acid,  and  quinine  answer  very  well ;  in 
spite  of  the  slight  solubility  of  solid  quinine,  its  intense  bitterness 
renders  it  readily  perceived.  The  voltaic  current  affords  a  very 
convenient  means  of  examination  ;  it  should  be  applied  by  two  insu- 
lated wires  twisted  together,  with  exposed  ends  a  few  millimetres 
apart.  A  current  of  one  or  two  cells  causes  a  metallic  taste  wher- 
ever the  function  is  intact.  More  cells  should  not  be  used,  because 
pain  is  then  produced,  and  obscures  the  sensation.  The  advantage 
of  this  test  is  that  it  influences  directly  the  nerve- endings. 

There  is  much  difference  of  opinion  as  to  the  cranial  nerve  or  nerves 
by  which  the  sense  of  taste  is  subserved,  and  in  connection  with  which 
its  disorder  should  therefore  be  described.  Hardly  any  question  in 
physiology  has  been  the  subject  of  more  discussion  and  of  more 
experimental  research.  But,  from  its  nature,  the  subject  is  one  on 
which  experiment  can  give  no  very  certain  sound,  and  has  far  less 
significance  than  observations  on  the  effect  of  disease  on  man.  Two 
separate  questions  are  involved  in  the  problem  :  first,  the  nerve-roots 
by  which  the  taste-fibres  pass  to  the  brain  ;  and  secondly,  the  course  of 
the  fibres  from  the  mucous  membrane  to  those  roots. 

With  regard  to  the  first  of  these  questions  we  have  two  important 
facts.  First,  taste  has  been  abolished  by  disease  of  the  root  of  the 
fifth  nerve.  There  are  many  observations  of  loss  of  taste  in  the  front 
of  the  tongue  from  this  cause.  One  unequivocal  case  has  been  re- 
corded by  Erb,  in  which  the  fifth  nerve  in  the  middle  fossa  was  in- 
volved in  a  mass  of  inflammatory  connective  tissue,  and  the  nerves  of 
the  medulla  were  normal.*     In  most  of  these  cases  the  state  of  taste 

*  Erb,  '  Neur.  Cent.,'  1882,  pp.  73  and  149.  In  a  previous  careful  review  of  the 
subject  ('Handb.  der  Krankh.  der  periph.  Nerven,'  2nd  ed.,  1876,  p.  220)  he  had 
come  to  the  same  conclusion,  that  the  balance  of  evidence  is  in  favour  of  the 
passage  of  the  taste-fibres  of  the  chorda  tyinpani  to  the  brain  by  the  fifth  nerve. 
Schiff  has  arrived  at  the  same  opinion  from  experiments  .on  animals,  aud  has 
summarised  his  conclusions  in  a  lecture  published  in  the  (  Revue  med.  de  la  Suisse 
Romande,'  18 ;7,  No.  1.  Vulpian  found  the  fibres  of  the  chorda  degenerated  after 
VOL.   II.  15 


226  *      CKANIAL    NEEVES. 

on  the  back  of  the  tongue  has  not  been  noted.  In  almost  every  case 
I  have  seen  in  which  there  were  symptoms  of  disease  of  the  root  of 
the  fifth  nerve,  outside  the  pons,  I  have  found  taste  abolished  on  the 
corresponding  side,  not  only  on  the  front  of  the  tongue,  but  also  on 
the  back  of  the  tongue  and  on  the  arches  of  the  palate.*  On  the 
other  band,  cases  occur  in  which  there  are  symptoms  of  disease  of 
the  fifth  nerve  without  loss  of  taste.  It  is  probable  that,  in  these 
cases,  either  disease  of  the  root  is  partial  and  the  taste-fibres  escape, 
or  else  that  the  disease  is  within  the  pons,  and  that  the  path  of  the 
fibres  for  taste  quickly  separates  from  that  of  cutaneous  sensibility, 
and  so  may  escape  when  the  latter  is  damaged.  The  latter  hypo- 
thesis receives  strong  support  from  a  case  under  my  care  in  which 
there  were  symptoms  of  a  small  tumour  within  the  pons  near  the 
level  of  origin  of  the  fifth.  In  addition  to  palsy  of  the  conj  ugate  late- 
ral movement  of  the  eyes  to  the  right,  there  was  paralysis  of  the 
muscles  of  mastication  on  that  side,  and  entire  loss  of  taste  on  the 
same  side  of  the  tongue  and  palate,  without  any  impairment  of  cuta- 
neous sensibility.  This  case  proves  that  the  path  of  taste  lies  near 
and  may  be  affected  with  the  motor  fibres  or  nucleus  of  the  fifth,  and 
without  the  fibres  for  cutaneous  sensibility,  and  it  indirectly  shows 
the  possibility  of  an  affection  of  the  latter  without  the  path  of  taste. 
The  second  fact  is  that  there  is  no  recorded  case  in  which  the  roots  of 
the  glosso-pharyngeal  nerve  have  been  diseased,  and  indeed  no  case 
in  which  there  were  symptoms  of  disease  limited  to  the  nerve-roots  of 
the  medulla,  and  in  which  there  was  any  loss  of  taste. f  These  two 
facts  constitute  strong  evidence  that,  in  man,  the  fibres  for  taste 
reach  the  brain  by  the  roots  of  the  fifth  nerve. 

The  peripheral  path  of  the  taste-fibres  is,  in  part  at  least,  strangely 
circuitous.  It  does  not  admit  of  doubt  that  the  fibres  from  the  front 
of  the  tongue  are  contained  in  the  chorda  tympani,  which  passes  from 
the  facial  nerve  to  the  lingual  branch  of  the  fifth.  Apart  from  the 
results  of  experiment,  it  is  only  thus  that  we  can  explain  the  loss  of 
taste  in  the  front  of  the  tongue  that  occurs  in  rheumatic  facial 
neuritis,  and  in  disease  of  the  middle  ear. J  Moreover,  that  these 
section  of  the  fifth  nerve  within  the  skull,  and  not  after  section  of  the  facial  ('  Gaz. 
med.  de  Paris,'  1878,  No.  19). 

*  One  case,  in  which  there  had  been  loss  of  taste  for  several  years,  with  palsy 
of  the  fifth,  and  afterwards  slight  weakness  of  the  sixth,  but  no  affection  of  the 
facial,  auditory,  or  any  other  nerve,  was  published  in  the  '  Journal  of  Physiology/ 
vol.  iii,  1881.  Since  then  I  have  met  with  many  other  cases.  In  all,  the  loss  was 
proved  by  electrical  examination  as  well  as  by  the  ordinary  tests. 

f  In  a  case  of  fracture  of  the  skull,  and  symptoms  of  injury  to  the  nerves  of  the 
medulla,  with  loss  of  taste,  recorded  by  Lehinann  (Pfluger's  '  Archiv,'  xxxii,  p.  194), 
direct  injury  to  the  nerves  passing  through  the  petrous  bone  was  the  probable  cause 
of  the  symptoms.     Cf.  Ferguson,  '  Med.  News,'  1890. 

$  Apart  from  the  overwhelming  evidence  that  has  been  accumulated,  a  crucial 
observation  has  been. recorded  by  Urbantschitsch.  In  a  case  of  disease  of  the 
membrana  tympani  and  middle  ear,  causing  loss  of  taste  and  some  diminution  of 
tactile  sensibility  in  the  front  of  the  tongue  on  that  side,  chemical  and  mechanical 


AFFECTIONS    OF    TASTE.  227 

fibres  run  from  the  facial  nerve  towards  the  lingual,  and  are  distri- 
buted to  the  tongue  with  the  latter,  is  shown  by  the  fact  that  section  of 
the  lingual  for  neuralgia,  below  its  junction  with  the  chorda  tyrnpani, 
has  abolished  taste.*  But  disease  of  the  facial  nerve  within  the  skull 
does  not  impair  taste  ;  the  fibres  that  reach  the  facial  by  the  chorda 
tympani  leave  the  nerve  again,  passing  from  the  geniculate  ganglion 
of  the  facial  by  the  Vidian  nerve  to  the  spheno-palatine  ganglion. 
Destruction  of  the  Yidian  nerve  by  an  exostosis  has  abolished  taste 
in  the  front  of  the  tongue.f  After  reaching  the  fifth  nerve  they  seem 
to  ascend  in  the  second,  division  to  its  root  and  the  brain. X 

Eegarding  the  course  of  the  taste-fibres  from  the  posterior  part  of 
the  tongue  and  palate,  we  have  far  fewer  facts.  Indeed,  as  regards 
man,  the  facts  are  practically  limited  to  two  :  the  loss  from  disease  of 
■  the  roots  of  the  fifth  nerve  already  mentioned,  and  the  facts  that 
taste  is  often  lost  on  the  back  as  well  as  on  the  front  of  the  tongue  in 
caries  of  the  middle  ear,§  and  has  been  totally  abolished  by  a  pro- 
bable fracture  of  the  base  which  paralysed  the  facial  nerve  on  the 
same  side. ||  On  the  other  hand,  the  distribution  of  the  glossopha- 
ryngeal nerve  to  the  "  taste-buds  "  compels  us  to  adhere  to  the  view 
that  the  fibres  subserving  the  function  are  distributed  in  this  nerve. 
But  it  has  connections  with  the  fifth  which  may  carry  the  taste-path 
to  this  nerve,  and  this  affords  the  best  explanation  of  the  facts.  The 
spheno-palatine  ganglion  (which  supplies  the  mucous  membrane  of 
the  palate  and  its  arches)  is  connected  with  the  glossopharyngeal  by 
a  branch  from  the  large  superficial  petrosal  to  the  tympanic  nerve  (of 
Jacobson),  perhaps  by  a  second,  and  from  the  otic  ganglion  the  small 
petrosal  goes  to  the  same  nerve.  If  the  tympanic  nerve  of  Jacobson 
and  the  chorda  tympani  are  the  two  chief  paths  of  the  taste-fibres, 
their  easy  damage  in  disease  or  fracture  explains  the  facts  mentioned, 
while  the  proximity  of  the  facial  enables  us  to  understand  its  simul- 
taneous paralysis.^" 

stimulation  of  the  chorda  tympani  produced  sensations  of  taste  and  of  touch  on  the 
part  of  the  tongue  in  which  the  sensibility  was  impaired  ('  Archiv  f.  Ohrenheilk.,' 
xix,  p.  135). 

*  lnzani,  'Meissner's  Jahresbericht,'  1864,  p.  555;  Lussana,  'Arch,  de  Phys.,' 
1871,  p.  152 ;  Mader,  '  Cent.  f.  med.  Wissensch.,'  1879,  p.  395. 

t  Ferguson,  '  Med.  News,'  Oct.  1890  •  the  patient  died  from  phthisis.  He 
adduces  additional  evidence  in  support  of  the  view  that  the  path  from  the  back  of 
the  tongue  is  by  the  tympanic  plexus  and  the  root  of  the  fifth  nerve. 

J  In  a  case  in  which  there  were  the  symptoms  of  a  lesion  of  the  third  division 
high  up,  above  its  junction  with  the  chorda  tympani,  there  was  no  loss  of  taste 
(Erb,  'Neur.  Cent.,'  1882,  p.  104). 

§  Urbantschitsch,  '  Beob.  fiber  Anomahen  des  Geschmacks  in  Erkrank.  der  Pau- 
kenhohle,'  Stuttgart,  1876.  1  have  several  times  satisfied  myself  of  the  occurrence 
of  the  loss  of  taste  in  these  cases. 

||  Bruns,  *  A.  f.  Psych.,'  xx,  1889.  On  the  other  side  the  fifth  nerve  was  paralysed 
without  loss  of  taste.  This  anomalous  lesion  suggests  that  the  branches  may  have 
been  damaged  in  different  positions,  and  where  they  do  not  contain  taste-fibres. 

%  The  nerve  of  Jacobson  is  that  most  frequently  damaged  -in  suppuration  o?  the 


22S  CRANIAL    NERVES. 

We  still  need  more  facts  as  to  the  backward  extent  of  the  loss  of 
taste  from  disease  of  the  chorda  tympani.  In  all  observations  on 
taste  it  is  desirable  that  the  thi-ee  regions,  front  of  tongue,  back  of 
tongue,  and  palate,  should  be  specially  tested.  Opportunities  for 
observation  of  the  highest  importance  sometimes  occur  to  surgeons, 
and  it  is  very  desirable  that  they  should  be  utilised. 

The  peripheral  nervelesions  that  may  cause  loss  of  taste  have  been 
just  mentioned.  It  may  also  occur  as  part  of  general heinianaesthesia, 
in  disease  of  the  cerebral  hemisphere,  and  also,  in  the  same  associa- 
tion, in  the  functional  disturbance  of  hvsteria.  When  the  loss  is  par- 
tial, the  perception  of  some  qualities  maybe  more  impaired  than  that 
of  others,  but  there  is  never  such  complete  loss  of  some  perceptions 
without  impairment  of  others  as  could  be  compared  to  colour-blind- 
ness. It  is  said  to  be  sometimes  due  to  local  disease  of  the  mucous 
membrane,  but,  on  account  of  the  wide  area  in  which  this  function  is 
subserved,  the  loss  is  probably  never  complete.  The  evidence  of  the 
loss  is  inability  to  perceive  the  qualities  mentioned  on  p.  224.  Its 
treatment  is  chiefly  that  of  the  disease  causing  it.  If  stimulation  of 
the  nerves  is  thought  desirable,  this  can  be  readily  effected  by  the 
voltaic  current.  One  rheophore  may  be  placed  behind  the  mastoid 
process,  and  the  other,  a  flat  piece  of  metal,  on  the  surface  of  the 
tongue.  A  tongue-depressor,  insulated  where  it  comes  in  contact  with' 
the  lips,  answers  very  well. 

Perversion  of  the  sense  of  taste,  which  has  been  termed  parageusia, 
sometimes  occurs  in  neurotic  maladies,  especially  in  hysteria  and 
insanity,  and  also  as  an  effect  of  the  influenza  poison,  apart  from 
catarrh.  It  has  also  been  observed  in  tabes,  associated  with  perversion 
of  the  sense  of  smell,  but  distinct  from  it.  In  this  condition  a 
substance  gives  rise  to  some  other  sensation  than  that  which  it 
ordinarily  causes.  The  symptom  is  often  associated  with  morbid 
dislike  to  certain  tastes.  Increased  sensitiveness,  hypergeusia,  is  said 
to  be  met  with  occasionally  under  the  same  conditions  as  perversion 
of  the  sense,  and  so  also  -are  subjective  sensations  of  taste,  usually  of 
an  unpleasant  character.  These  are  also  met  with  as  a  result  of 
irritating  disease  of  the  nerves,  such  as  disease  of  the  ear,  and  they 
have  been  experimentally  produced  by  electrical  stimulation  of  an 
exposed  chorda  tympani.  Such  sensations  sometimes  occur  as  the 
aura  of  an  epileptic  fit,  and  as  part  of  the  hallucinations  of  the  insane. 
They  must,  of  course,  be  distinguished  from  actual  sensations  due  to 
abnormal  buccal  secretions,  and  from  those  due  to  the  presence  in  the 
blood  of  substances  that  can  stimulate  the  gustatory  nerves.  The 
various  subjective  sensations  or  perversions  of  taste  scarcely  ever  call 
for  special  treatment. 

middle  ear,  and  next  the  chorda  tympani,  according  to  Godsderm,  of  Copenhagen. 
(1888). 


1'ACIAL   NERVE.  229 


FACIAL   NERVE. 

The  facial  nerve,  portio  dura  of  the  seventh  pair,  has  a  tortuous 
course  both  within  the  pons  and  through  the  wall  of  the  skull.  Its 
deep  origin  has  been  described  at  p.  49.  At  the  surface  of  the  brain 
and  within  the  internal  auditory  meatus  the  facial  and  auditory 
nerves  lie  together  and  suffer  together  in  disease.  From  the  auditory 
meatus  the  nerve  has  a  winding  course  through  the  temporal  bone, 
passing  first  outwards  to  the  inner  wall  of  the  tympanum,  and  then 
backwards  above  the  foramen  ovale,  and  downwards  behind  the  tym- 
panum to  the  stylo- mastoid  foramen.  It  lies  throughout  this  course 
in  the  bony  "  Fallopian  canal,"  but  the  layer  of  bone  which  separates 
it  from  the  cavity  of  the  tympanum  varies  in  thickness,  and  may  even 
be  incomplete.  Moreover  two  nerves  pass  from  it  into  the  cavity  of  the 
tympanum,  the  small  nerve  to  the  stapedius  muscle,*  and  the  chorda 
tympani,  which  leaves  the  facial  a  few  millimetres  above  the  lower 
opening  of  the  canal,  and  courses  across  the  upper  part  of  the  tympanic 
cavity  and  membrane,  to  pass  again  through  the  bone  and  join  the 
third  division  of  the  fifth.  An  arterial  twig  also  passes  from  the 
canal  into  the  tympanum.  These  connections  are  important,  since 
the  nerve  is  often  damaged  by  disease  of  the  middle  ear,  and 
they  afford  considerable  and  variable  anatomical  facility  for  this 
damage.  At  the  bend  in  the  temporal  bone  there  is  a  gangliform 
enlargement  on  the  nerve,  the  "  geniculate  ganglion,"  from  which  the 
large  petrosal  nerve  passes  (as  the  "Vidian)  to  the  spheno-palatine 
ganglion;  and,  as  already  stated  (p.  214),  there  is  reason  to  believe 
that  most  of  the  fibres  from  the  chorda  tympani  leave  the  facial  by 
this  nerve  and  reach  the  brain  through  the  fifth.  The  gangliform 
enlargement  also  receives  a  twig  from  the  nerve  (small  petrosal) 
which  connects  the  otic  ganglion,  through  the  nerve  of  Jacobson, 
with  the  glosso-pharyngeal.  Outside  the  skull  the  nerve  gives 
branches  to  the  occipital  part  of  the  occipito-frontalis,  to  the  external 
ear,  to  the  stylo-hyoid  and  digastric,  and  then  divides,  opposite  the 
posterior  edge  of  the  masseter,  into  numerous  branches  which  pass  to 
all  the  muscles  of  the  face,  and  to  the  platysma  myoides  beneath  the 
skin  of  the  neck. 

The  path  from  the  facial  nucleus  to  the  cerebral  hemisphere  crosses 
the  middle  line  of  the  pous  above  the  nucleus,  so  that  if  the  face  is 
paralysed  by  one-sided  disease  above  the  middle  of  the  pons,  the  para- 
lysis is  on  the  side  opposite  to  the  lesion,  as  in  ordinary  hemiplegia. 
The  further  course  of  this  path  has  been  described  at  p.  75.     It  is 

*  It  is  not  unlikely  that  the  fibres  for  the  stapedius  come  from  the  small  "inter- 
mediate nerve  of  Wrisberg,"  since  this  arises  from  the  accessory  auditory  nucleus. 


230  CftANIAL    NtiRVES. 

probable  tbat  the  bilateral  muscles  of  the  upper  part  of  the  face  are 
also  connected  with  the  hemisphere  of  the  same  side.* 

Facial  Paralysis. 

Paralysis  of  the  face  results  from  any  interruption  to  the  path  from 
the  cortex  to  the  muscles.  The  character  of  the  paralysis  differs 
according  as  the  disease  involves,  on  the  one  hand,  the  path  above  the 
nucleus  (which  we  may  term  supra-nuclear  palsy),  or,  on  the  other 
hand,  the  nucleus  itself  or  the  fibres  of  the  nerve,  whether  within  the 
pons  or  outside  it  (nuclear  and  infra-nuclear  palsy).  In  the  latter  case 
all  parts  of  the  face  are  affected,  the  orbicularis  palpebrarum  and 
frontal  muscle,  as  well  as  the  muscles  of  the  mouth  ;  but  in  the 
former  the  upper  muscles  of  the  face  are  little  or  not  at  all  affected, 
and  the  muscles  which  go  to  the  angle  of  the  mouth  suffer  chiefly. 
Another  difference  is  that  in  supra-nuclear  paralysis  voluntary  move- 
ments are  often  more  impaired  than  emotional  movements  ;  in  nuclear 
and  infra-nuclear  disease  they  suffer  equally. 

Lastly,  there  is  an  important  difference  between  the  two  forms  in 
the  reaction  of  the  nerve  and  muscles  to  electricity.  In  supra-nuclear 
disease  the  reaction  is  normal,  or  presents  only  a  trifling  change,  which 
is  the  same  to  the  voltaic  and  to  the  induced  current.  Acute  lesions 
of  the  nucleus  or  nerve,  unless  trifling  in  degree,  cause  secondary 
degeneration  of  the  fibres,  with  loss  of  all  irritability,  and  preserva- 
tion only  of  the  voltaic  irritability  of  the  muscle-fibres. 

It  is  customary  to  term  paralysis  from  disease  of  the  nerve 
"peripheral;"  that  from  disease  of  the  nucleus  or  root-fibres  in  the 
pons  is  also  sometimes  termed  peripheral,  because  it  resembles  that 
from  disease  of  the  nerve  ;  sometimes  it  is  termed  "  central ;"  paralysis 
from  disease  of  the  path  above  the  nucleus  is  also  sometimes  termed 
"central,"  sometimes  "cerebral."  The  latter  term  should  be  used 
only  with  the  understanding  that  a  similar  paralysis  may  occur  from 
disease  of  the  crus  or  upper  part  of  the  pons.  Moreover  the  word 
"  peripheral "  is  sometimes  applied  to  disease  of  the  extremities 
of  the  fibres.  Paralysis  from  disease  of  the  convolutions  is  termed 
"  cortical."  Otherwise  the  nomenclature  given  above  is  preferable, 
disease  of  the  root-fibres  being  termed  "radicular." 

The  supra-nuclear  palsy  has  been  already  considered  in  the  chapter 
on  hemiplegia ;  we  have  now  to  consider  only  that  which  results  from 
disease  of  the  nucleus,  the  root-fibres,  or  the  nerve. f 

Causes. — (1)  "Within  the  pons  the  nucleus  or  root-fibres  may  be 
damaged  by  various  focal  lesions,  usually  in  association  with  the  motor 
tract  of  the  opposite  limbs,  or  with  the  sixth  nerve  of  the  same  side, 

*  In  the  rabbit,  medial  section  of  the  pons  paralyses  the  elevator  of  the  upper 
lip  on  both  sides,  even  to  stimulation  of  the  cortex  (Exner  and  Paneth,  1888). 

t  It  is  often  termed  "Bell's  paralysis,"  after  Sir  Charles  Bell,  who  first  explained 
its  nature. 


FACIAL    NERVE.  231 

round  the  nucleus  of  which,  the  facial  fibres  course  (Fig.  38,  p.  50). 
In  very  rare  cases  of  anterior  pulio-myelitis  (infantile  paralysis),  the 
facial  nucleus  suffers ;  I  hare  seen  one  instance  of  this.  Primary 
degeneration  rarely  affects  all  parts  of  the  facial  nuclei,  hut  the  neiwe- 
cells  related  to  the  orbicularis  oris  often  degenerate  with  those  for  the 
hypoglossal  nerve,  in  chronic  "  labio-glossal  paralysis."  Diphtheritic 
palsy  involves  the  face  in  rare  cases,  and  probably  consists  in  a  sub- 
acute affection  of  the  cells  of  the  nucleus  and  the  fibres  of  the  nerve. 

(2)  At  the  base  of  the  brain  the  nerve  may  be  compressed  by  tu- 
mours or  damaged  by  meningitis  or  hemorrhage.  The  auditory  nerve 
is  usually  affected  with  it. 

(3)  Within  the  canal  in  the  temporal  bone  the  nerve  suffers  in 
various  forms  of  otitis  and  bone  disease,  especially  in  children.  In 
most  cases  there  is  caries  of  the  bone  and  suppuration  in  the  middle 
ear,*  and  the  disease  of  the  bone  between  the  Fallopian  canal  and  the 
tympanum  extends  to  the  nerve.  This  may  be  merely  inflamed,  or 
may  be  destroyed  by  the  spreading  disease.  The  amount  of  ear  dis- 
ease that  exists  before  the  facial  nerve  is  affected  varies  much,  and 
the  readiness  with  which  the  nerve  suffers  doubtless  depends  in  part 
on  the  thinness  of  the  protecting  lamina  of  bone.  It  is  said  that  the 
nerve  may  be  paralysed  when  only  the  lining  membrane  of  the  tym- 
panum is  inflamed  and  the  bone  is  not  diseased.  I  have  known  para- 
lysis to  occur  when  caries  was  certainly  limited  to  the  mastoid  bone. 
In  such  cases  we  must  assume  an  extension  of  inflammation  along 
the  chorda  tympani,  the  nerve  to  the  stapedius,  or  the  arterial  twig 
already  mentioned,  unless  the  layer  of  bone  is  imperfect.  It  is  perhaps 
by  such  extension  that  facial  paralysis  has  sometimes  followed  sore 
throat  — simple,  or  such  as  occurs  in  some  acute  diseases. f 

(4)  Injury.  Fracture  of  the  base  of  the  skull  often  passes  through 
the  petrous  bone,  and  the  nerve  may  be  torn  or  bruised.  The  face  is 
then  at  once  paralysed,  but  in  some  cases  the  nerve  is  damaged  only 
some  days  (three  to  five)  after  the  injury,  and  the  mechanism  must 
then  be  a  secondary  process,  probably  inflammation. J  Meningeal 
haemorrhage  is  possibly  a  rare  cause,  especially  that  which  occurs 
from  the  cerebellum  during  birth ;  this  may  explain  some  "  congen- 
ital "  cases  in  which  it  has  been  associated  with  weakness  of  the  neck 
due  to  damage  to  the  spinal  accessory  nerve.§  Outside  the  skull,  the 
nerve  or  some  of  its  branches  may  be  divided  by  wounds  about  the 
ramus  of  the  jaw,  and  especially  in  operations  for  the  removal  of  tu- 
mours in  the  parotid  region.  A  simple  blow  on  this  part  mav  also 
damage  the  nerve.  An  angry  schoolmaster  struck  a  boy  with  the  corner 
of  a  book  just  below  the  ear.  Much  pain  followed  about  the  ear  and 
the  side  of  the  head ;  in  a  day  or  two  facial  paralysis  came  on,  com- 

*  It  is  not,  however,  a  frequent  consequence  of  caries,  although  the  calculation 
of  only  1  per  cent,  made  by  Bezold  is  perhaps  too  low  (Bezold, '  Labyrinth-Necrose/ 
1886).  t  Wendt, « Archiv  der  Heilkunde,'  1870. 

1  See  Demoulin,  *  Gaz.  med.  de  Paris/  18S8.       §  Stephan,  'Rev.  de  Med.,'  1887. 


232  CRANIAL    NERVES. 

plete  and,  as  it  turned  out,  permanent,  in  spite  of  all  treatment. 
The  blow  cost  the  schoolmaster  a  thousand  pounds.  Facial  paralysis 
is  sometimes,  although  rarely,  caused  during  instrumental  delivery, 
by  the  pressure  of  the  blades  of  the  forceps  on  the  nerve  over  the 
jaw,  and  such  paralysis  has  even  been  produced  on  both  sides.  Com- 
pression by  the  shoulder  has  also  been  effective.* 

(5)  Neuritis  is  the  cause  of  the  common  facial  paralysis,  due  to 
cold,  and  often  termed  "rheumatic."  The  majority  of  cases  of  facial 
paralysis  seem  to  be  of  this  nature ;  and  although,  often,  no  special 
exposure  to  cold  can  be  traced,  there  has  then  been  usually  some 
habitual  exposure.  The  features  of  these  cases  are  so  uniform,  allow- 
ance being  made  for  differences  in  degree,  that  we  are  justified  in  re- 
garding the  pathological  condition  as  the  same  in  all — a  neuritis 
within  the  Fallopian  canal. f  The  iuflammation  perhaps  affects  chiefly 
the  sheath  of  the  nerve,  which  swells  and  compresses  the  fibres,  expan- 
sion outwards  being  prevented ;  but  in  a  case  in  which  the  actual  state 
could  be  observed  the  nerve  sheath  was  not  distinctly  inflamed; J  the 
external  restraint  may  indeed  cause  the  inflammation  to  spread  into 
the  nerve,  and  in  this  case  the  fibres  were  extensively  degenerated.  For 
a  long  time  a  very  different  explanation  was  given.  It  was  supposed 
that  cold  acts  by  paralysing  the  terminations  of  the  facial  nerve  in  the 
muscles.  But  there  is  no  evidence  that  cold  ever  paralyses  infra-mus- 
cular nerve-endings,  and  we  know  that  paralysis  of  all  fibres  of  one 
nerve,  and  of  no  other  fibres,  always  means  disease  of  the  trunk  of 
the  nerve. 

Inflammation  was  found  also  in  a  perfectly  similar  paralysis,  due 
to  a  different  cause,  recorded  by  May.§  The  patient  was  suffering 
from  leucocythasmia  (an  affection  which  may  cause  lymphoid  neuritis), 
and  the  nerve  within  the  Fallopian  canal  presented  a  fusiform  swel- 
ling three  tenths  of  an  inch  long,  due  to  an  infiltration  of  lymphoid 
cells  ;  the  nerve-fibres  at  the  spot  were  in  process  of  destruction. 

In  more  than  half  the  cases  a  special  and  considerable  exposure  to 
cold  can  be  traced ;  generally  a  draught  of  cold  air  has  blown  on  the 
side  of  the  face  and  head,  as  in  sitting  in  a  railway  carriage  opposite 
an  open  window,  standing  at  an  open  door,  driving  in  a  cold  wind. 
One  patient  had  ridden  a  bicycle  during  three  cold  nights  ;  another 
had  lingered  on  a  seaside  pier  in  a  cold  wind  ;  in  another  the  expo- 
sure to  cold  occurred  the  day  after  a  beard,  worn  for  thirty  years,  was 
shaved  off.  The  svmptoms  usually  commence  within  two  days  of 
such  exposure.  In  other  cases  there  has  been  more  or  less  constant 
exposure,  as  by  working  in  a  draughty  shop.  Occasionally  the  suf- 
ferer presents  other  evidence  of  rheumatism,  especially  of  the  fibrous 

*  Yarnier,  'An.  de  Gyn.,'  18S8. 

f  It  has  been  conjectured  that  the  inflammation  sometimes  affects  the  nerve  after 
its  emergence,  but  no  evidence  of  this  {e.g.  swe  liug  of  the  nerve)  has  been  noted. 
X  Minkowski,  'Berlin,  klin.  Wochenschr.,'  1S91. 
§  E.  ilav,  'Jlerztl.  Intell.  Watt.,'  1884,  Xo.  31. 


FACIAL    NERVE.  233 

tissues,  and  a  liability  to  a  similar  affection  of  other  nerves,  as  in  the 
cases  mentioned  on  p.  144.  But  many  of  the  subjects  of  facial  palsy 
present  no  other  evidence  of  rheumatism,  and  the  affection  may  be  an 
isolated  event  in  an  otherwise  healthy  life.  In  a  few  cases  there  is  a 
history  of  gout,  inherited  or  acquired,  which  may  have  predisposed 
to  the  disease  ;  but  it  is,  on  the  whole,  very  rare  to  obtain  evidence  of 
this.  In  some  instances  there  is  other  evidence  of  catarrh,  general 
fever,  sore  throat,  or  neuralgic  pain  in  the  neighbourhood  of  the 
affected  nerve.  The  neuritis  sometimes  arises  by  distinct  extension 
from  external  cellulitis ;  in  one  case  the  cellulitis  was  produced  by 
chronic  eczema  of  the  skin  in  front  of  the  ear,  over  the  place  of 
emergence  of  the  nerve.*  In  other  cases  such  cellulitic  swelling  is 
evidently  catarrhal ;  in  one  it  existed  beneath  each  jaw  for  a  week 
before  the  onset  of  one-sided  palsy. 

G-rouping  together  all  cases  which  may  be  due  to  Fallopian  neuritis 
(excluding  those  that  are  the  result  of  ear  disease  or  syphilis),  they 
appear  to  be  rather  more  common  in  males  than  in  females,  no  doubt 
from  the  greater  exposure  of  the  former.  Of  112  unselected  cases 
of  which  I  have  notes,  66  were  in  males,  46  in  females.  Rarely  more 
than  one  member  of  a  family  suffers— as,  for  instance,  a  man  and  his 
niece.  Such  coincidences  are  doubtless  sometimes  accidental.  The 
affection  may  occur  at  any  age,  but  is  rare  under  ten.  I  have  met 
with  it  at  seven,  and  twice  in  the  second  year  of  life.  It  is  most 
common  between  twenty  and  thirty  (27  cases),  and  is  equally  frequent 
in  each  of  the  other  decades  between  twenty  and  fifty  ;  after  fifty  it 
becomes  rare,  but  is  occasionally  met  with  even  in  old  age  (cases  at 
seventy-four  and  seventy-seven).  Of  80  cases  due  to  this  cause,  46 
occurred  between  October  and  March  inclusive,  and  34  between  April 
and  September.f  It  thus  occurs  at  all  seasons,  but  is  rather  more 
frequent  in  winter  than  in  summer. 

(6)  Syphilis  is  an  occasional  cause,  but  its  frequency  may  readily 
be  over-estimated  if  the  mere  fact  of  preceding  syphilis' or  of  improve- 
ment under  iodide  of  potassium  is  admitted  alone  to  be  evidence  of 
nature.  We  are  only  justified  in  regarding  the  paralysis  as  syphilitic 
when  there  is  or  has  been  other  evidence  of  active  syphilis,  and  when 
there  is  no  other  recognisable  cause;  the  syphilitic  nature  of  the 
case  is  more  probable  if  the  nerve  is  affected  within  the  cranium.     In 

*  It  has  been  thought  by  some  that  cold  affects  the  facial  nerve  by  causing  a 
catarrhal  inflammation  of  the  middle  ear,  which  spreads  to  the  nerve.  But  this 
seems  improbable  when  we  consider  how  frequent  catarrh  of  the  middle  ear  is  with- 
out facial  paralysis,  and  how  rare  are  obtrusive  signs  of  tympanic  inflammation 
when  the  nerve  is  affected,  and  that  slight  inflammation  of  the  tympanum  may  be 
produced  coiucidently  with  neuritis  by  cold  without  the  former  being  the  cause  of 
the  latter.  Earache  often  follows  the  onset,  but  very  seldom  precedes  it  even  for  a 
d;ty,  and  early  pain  is  more  common  in  other  situations. 

t  Twelve  cases  occurred  in  January;  10  in  November;  9  in  June;  7  in  each 
month,  May,  August,  October,  December;  5  in  February,  March,  and  in  April;  3 
in  July  and  in  September.  In  the  third  of  the  year,  October  to  January,  36 
cases;   February  to  May,  22;  June  to  September,  22. 


234  CRANIAL   NERVES. 

rnany  cases  of  facial  paralysis  in  the  subjects  of  syphilis,  the  paralysis 
is  distinctly  excited  by  cold,  but  it  is  possible  that  the  syphilis  may 
have  had  a  predisposing  influence.  The  mechanisms  by  which  syphilis 
causes  facial  paralysis  are  by  meningitis,  by  a  gumma  on  the  nerve- 
sheath  or  near  it,  and  probably  also  by  neuritis. 

(7)  Primary  haemorrhage  into  the  nerve-sheath  or  Fallopiau  canal 
is  a  rare  cause.*  There  are  cases  in  which  facial  paralysis  comes  on  in 
a  few  minutes  and  is  at  once  complete,  and  in  which  there  is  no  indi- 
cation of  any  central  disease.  Such  cases,  of  which  I  have  seen  five, 
may  be  due  to  an  extravasation  into  the  Fallopian  canal  or  the  nerve 
itself,  disposed  to,  perhaps,  by  some  peculiarity  of  vascular  arrange- 
ment. Thrombosis  in  a  vessel  of  the  nerve  is  also  a  conceivable 
mechanism,  especially  when  sudden  palsy  occurs  under  conditions 
favouring  this  lesion — as,  for  instance,  in  one  case,  a  week  after  child- 
birth. It  affords  a  possible  explanation  of  the  curious  cases  in  which 
such  an  onset  follows  emotion.  Complete  paralysis  occurred  quite 
suddenly  in  a  lady  who  was  at  the  time  watching  the  dressing  of  a 
huge  wound  in  her  own  breast,  produced  by  the  destruction  of  a 
cancer  by  caustic.  In  one  instance  the  onset  was  an  hour  after  a 
sudden  fright ;  in  another  it  coincided  with  a  sense  of  faintness. 

(8)  Facial  paralysis  has  been  observed  in  rare  cases  of  tabes,  in 
which  its  cause  resembles  doubtless  that  of  the  other  nerve  palsies 
that  are  met  with  in  the  disease.  The  nerve  may  also  be  paralysed 
by  an  islet  of  disseminated  sclerosis  within  the  pons,  when  others 
affect  the  spinal  cord. 

Hvsteria  may  coincide  with  facial  palsy,  especially  since  the  latter 
is  not  uncommon  in  young  adults.  The  coincidence  has  no  real 
significance ;  although  the  cases  have  been  needlessly  described  as 
"hysterical,"  they  present  no  feature  to  warrant  the  epithet,  except 
in  so  far  as  hysterical  contraction  lessens  movement. 

Double  facial  paralysis  is  rare.  Its  causes  are  (1)  disease  of  the 
pons  Yarolii ;  possibly  a  lesion  in  the  middle  of  the  pons,  where  the 
two  facial  paths  cross;  certainly  lesions  on  both  sides  of  the  pons, 
such  as  the  bilateral  softening  that  is  produced  by  disease  of  the 
basilar  artery.  (2)  Disease,  syphilitic  or  other,  of  the  nerves  at  the 
base  of  the  brain ;  by  this  usually  other  nerves  are  also  damaged. 
In  one  case  of  this  kind,  in  which  there  was  also  simultaneous  para- 
lysis of  both  auditory  nerves  (not  aural),  the  onset  occurred  after 
exposure  during  sleep  to  a  cold  wind,  but  the  patient  had  had 
syphilis.  In  another  case  only  one  auditory  nerve  was  involved.  (3) 
Simultaneous  double  otitis. f  (4)  In  paralysis  from  cold,  both  sides 
of  the  face,  as  they  are  occasionally  affected  at  different  times,  may, 
in    extremely   rare    cases,  suffer  at  the  same  time.  J      In    multiple 

*  Wilks  and  Moxon,  ( Path.  Anat.,'  p.  257,  and  Moxon,  '  Path.  Trans./  vol.  xx. 
t  Wright,  'Brit.  Med.  Journ.,'  Feb.  27th,  1869.     A  week  separated  the  onset  of 
the  palsy  on  the  two  sides.     The  patient  was  a  man  aged  sixty-five. 
%  Kruge, '  Neur.  Cent.,'  1890. 


PAGEAL    NERVE. 


235 


neuritis  the  face  is  sometimes  involved,  always  on  both,  sides,  and 
generally  in  association  with  the  limbs  as  part  of  a  wide- spread  affec- 
tion. It  is  met  with  chiefly  in  certain  rare  forms  of  polyneuritis, 
due  to  special  toxic  blood-states,  and  not  in  the  common  variety,  pro- 
duced bj  alcohol.  In  diphtheritic  paralysis,  in  which  polyneuritis  is 
the  chief  element,  double  facial  palsy  sometimes  occurs.  (5)  Partial 
paralysis  (of  the  lips  on  both  sides)  occurs  from  nuclear  degenera- 
tion in  labio-glossal  paralysis,  or  symmetrical  cortical  lesions,  and  (6) 
a  peculiar  form  of  facial  palsy  associated  with  palsy  of  the  eye  muscles, 
and  due  probably  to  nuclear  wasting  has  been  already  mentioned 
(p.  197).     It  may  be  congenital  or  come  on  during  infancy. 

Symptoms. — In  complete  facial  palsy  the  muscles  of  the  affected 
half  of  the  face  become  toneless  and  immobile.  In  all  movements, 
voluntary  or  emotional,  the  affected  half  of  the  face  is  still.  The  two 
sides  of  the  face  present  a  strange  incongruity,  and  the  smile  or  frown, 
deprived  of  half  its  range,  loses  more  than  half  its  character,  so  that 
it  is  difficult  to  recognise  the  expressional  significance  of  the  distorting 
contractions  of  cheek  and  brow  which  occur  on  the  unaffected  side. 
The  influence  of  the  loss  of  tone  on  the  position  of  the  features  at  rest 
differs  according  to  the  age  of  the  patient ;  the  smooth  features  of 
youth  are  largely  moulded  by  the  elasticity  of  the  skin,  and  are  little 
changed  by  the  paralysis  of  the  muscles  ;  slight  drooping  of  the 
angle  of  the  mouth  may  be  the  only  sign  of  paralysis  during  rest. 
But  it  is  otherwise  when  time  has  scoi*ed  the  face  with  furrows.  These 
are  due  to  the  loss  of  elasticity  of  the  skin,  and  their  position  is  chiefly 
determined  by  the  muscular  tension  that  is  caused  by,  and  expresses, 
the  emotions  dominant  in  the  past.  With  the  loss  of  this  tension, 
the  furrows  change  their 
place  or  vanish,  as  the 
flaccid  skin  adjusts  itself 
in  obedience  to  other  in- 
fluences (Pig.  103).  The 
effect  of  the  age-changes 
is  seen  conspicuously  in 
the  forehead  and  lower 
eyelid.  The  transverse 
furrows  of  the  forehead 
cease  suddenly  at  the 
middle  line.  In  the 
young  the  lower  eyelid  is 
held  by  the  elasticity  of 
the  skin  almost  as  close  to 


FiG.  103. — Facial  paralysis  in  a  man  aged  sixty-five, 
showing  the  influence  of  the  loss  of  tone  on  the 
inelastic  skin.  The  figure  on  the  right  represents- 
an  attempt  to  close  both  eyes.  (From  photo- 
graphs.) 


the  eyeball  as  on  the  unaffected  side.  In  the  old  it  falls  forwards,  and 
the  tears,  increased  by  the  irritation  of  the  unprotected  eye,  cannot 
reach  their  proper  duct,  and  the  eye  "  waters."  But  in  young  and  old 
the  loss  of  movement  is  the  same.     The  affected  side  takes  no  part  in 


"236  CEANIAL    NERVES. 

frown  or  smile.  The  eyelids  cannot  be  brought  together ;  in  a  strong 
effort  to  close  thern,  the  eyeball  is  rolled  upwards,  so  that  the  cornea 
is  beneath  the  upper  lid,  and  only  the  sclerotic  is  visible.  The  patient 
often  imagines,  ostrich-like,  that  bis  eye  is  shut,  because  the  cornea  is 
covered.  During  sleep  the  eye  remains  partly  open,  because  normally 
•closed  not  only  by  relaxation  of  the  levator,  but  by  contraction  of  the 
palpebral  part  of  the  orbicularis.  But  the  upper  lid  follows,  in  a 
normal  manner,  the  downward  movement  of  the  eyeball,  since  the 
-orbicularis  takes  no  part  in  this  descent,  except  in  keeping,  by  its  tone, 
the  lid  in  contact  with  the  eyeball.  In  the  old,  the  lower  lid,  on  looking 
up,  does  not  rise  so  well  as  on  the  other  side,  apparently  because  the  lid 
is  not  kept  in  sufficient  apposition  to  the  globe.  In  smiling  and  other 
movements  the  mouth  is  drawn  towards  the  unaffected  side,  the  zygo- 
matic muscles  being  unopposed  by  their  fellows.  From  the  displace- 
ment of  the  mouth  the  tongue  is  protruded  to  one  side  of  the  orifice, 
■and  thus  may  seem  to  deviate  even  when  it  is  exactly  in  the  middle 
line  of  the  face.  The  lips  cannot  be  pressed  together  on  the  paralysed 
side,  and  hence  the  air  cannot  be  so  compressed  within  the  mouth 
as  to  be  expelled  in  a  puff.  The  patient  accordingly  finds  that  he 
cannot  blow  out  a  candle.  In  drinking,  the  liquid  runs  out  of  the 
paralysed  corner  of  the  mouth,  and  the  patient  has  to  incline  his  head 
to  prevent  this.  "Whistling  is,  of  course,  impossible,  and  smokers  may 
first  discover  the  paralysis  by  finding  that  the  ejected  saliva  takes  an 
inconveniently  erratic  course.  Speech  is  frequently  a  little  changed 
by  the  imperfect  articulation  of  the  labial  consonants.  The  palsy  of 
the  buccinator  permits  food  to  get  between  the  teeth  and  the  jaws, 
and  it  is  found  more  convenient  to  chew  upon  the  other  side.  The 
palsy  of  the  stylo-hyoid  and  posterior  belly  of  the  digastric  does  not 
cause  recognisable  symptoms.  The  platysma  myoides  is  paralysed,  as 
may  be  observed  by  making  the  patient  depress  his  lower  lip,  an  action 
iu  which  the  platysma  contracts.  The  dilator  naris  being  inactive, 
the  nostril  does  not  expand  on  sniffing,  and  may  even  yield  to  the  pres- 
sure of  the  air ;  smell,  in  consequence,  is  less  acute  than  on  the  other 
side.  The  muscles  of  the  external  ear  are  also  paralysed  in  those 
persons  in  whom  these  muscles  were  under  the  influence  of  the  will. 
All  reflex  movements  are  of  necessity  lost  when  the  paralysis  is  due  to 
■disease  of  the  nerve-fibres  or  their  nucleus — an  important  distinction 
from  cerebral  palsy,  in  which  they  are  preserved. 

Palate. — It  has  been  said  that  the  palate  is  sometimes  paralysed  on 
the  same  side  as  the  face  from  disease  of  the  facial  nerve,  and  it  has 
been  supposed  therefore  that  the  levator  palati  is  supplied  by  fibres 
which  pass  from  the  geniculate  ganglion  of  the  facial,  by  the  large 
petrosal  nerve  and  Vidian,  to  the  spheno-palatine  ganglion.  But  the 
opinion  that  the  palate  ever  suffers  from  disease  of  the  facial  nerve 
seems  to  be  erroneous.  The  levator  is  supplied  from  the  spinal 
accessory  (q.  v.),  and  in  more  than  a  hundred  cases  of  facial  paralysis, 
due  to  disease  of  the  nerve  in  various  situations,  carefully  examined. 


FACIAL    KEEVE.  237 

I  have  never  observed  a  corresponding  defect  of  movement  in  the 
palate.  Deviation  of  the  uvula  was  occasionally  observed,  but  its- 
inclination  was  as  frequently  from  as  towards  the  paralysed  side. 
Such  obliquity  of  the  uvula  is  not  uncommon  in  those  who  present  no> 
facial  palsy,  and  sometimes  is  considerable  in  degree.  When  present 
in  facial  palsy  its  state  is  unchanged  after  the  face  has  recovered,  and 
it  is  not  associated  with  any  defect  in  the  movement  of  the  palate.  In 
rare  cases  in  which  there  has  been  actual  coincident  paralysis  of  the 
palate  there  was  probably  a  simultaneous  affection  of  the  spinal 
accessory  nerve  or  of  its  palatine  branch.  In  most,  other  nerves 
have  suffered,  and  this  may  be  damaged  not  only  at  the  medulla, 
but  outside  the  skull,  by  deep-seated  cellulitis  just  below  the  place 
of  emergence  of  the  facial.  Of  this  I  have  seen  some  well-marked 
instances,  with  and  without  implication  of  the  other  parts  of  the 
nerve,  or  of  the  hypoglossal.* 

Taste. — In  disease  of  the  facial  nerve  between  the  origin  of  the 
chorda  tympani  and  the  geniculate  ganglion,  taste  is  lost  in  the 
anterior  j>art  of  the  tongue  on  the  affected  side.  It  is  not  lost  when, 
the  lesion  is  of  the  root  of  the  facial  nerve.f  or  of  the  nerve-fibres 
within  the  pons.  It  is  lost  in  about  half  the  cases  of  paralysis  from 
cold,  doubtless  because  the  neuritis  extends  up  the  nerve  to  the  origin 
of  the  chorda.  "When  the  nerve  is  damaged  outside  the  skull,  taste  is 
generally  unaffected  ;  the  exceptions  are  probably  due  to  an  ascending 
neuritis.  The  affection  of  taste  may  persist  after  the  paralysis,  but 
usually  passes  away  before  it.  Sensation  in  the  face  is  generally  un- 
affected, but  I  have  several  times  found  in  early  and  severe  cases  a 
very  slight  diminution  in  the  sensitiveness  of  the  skin  on  the  motion- 
less side,  especially  on  the  cheek.  The  cause  may  be  an  altera- 
tion in  the  function  of  the  nucleus  of  the  fifth  nerve,  due  to  the- 
diminution  of  the  impressions  that  are  normally  produced  by  muscular 
action.  This  is  more  probable  than  that  the  facial  nerve  sometimes 
conveys  sensory  fibres  from  the  skin.  J  I  have  also  occasionally 
found  (in  early  cases)  an  area  of  anaesthesia  on  the  front  and  back 
of  the  concha,  in  the  region  of  skin  supplied  by  a  nerve  given  off  by 
the  facial  as  it  emerges,  and  which  is  probably  derived  from  the  fifth 
nerve. 

*  Dr.  Hughlings  Jackson  has  also  stated  that  he  has  never  seen  paralysis  of  the 
palate  due  to  disease  of  the  facial  nerve  ('  Lancet/  April  2nd,  1887).  He  made  this 
remark  in  connection  with  an  instructive  case  of  paralysis  of  the  face  and  palate, 
which  at  first  sight  seemed  to  prove  the  association,  hut  further  investigation  showed 
conclusively  that  the  palsy  of  the  face  was  of  cerebral  origin. 

f  Certain  recorded  cases  of  disease  of  the  root  and  loss  of  taste,  opposed  as  they 
are  to  the  usual  rule,  are  explicable  on  the  assumption  that  the  descending  degene- 
ration was  attended,  as  it  sometimes  is,  by  descending  neuritis,  and  that  this  invaded 
the  taste-fibres  at  or  below  the  geniculate  ganglion. 

X  Vaso-motor  disturbance,  oedema,  and  increased  sweating  have  been  observed, 
probably  also  of  secondary  relation  or  due  to  accidental  association  of  an  affection  of 
the  sympathetic  (Frankl  Hochwart,  'Neurol.  Centralbl ,'  1891). 


238 


CKANIAL    NERVES. 


Hearing  is  impaired  in  cases  of  facial  paralysis  due  to  the  extension 
of  inflammation  from  the  bone  or  tympanic  cavity,  and  also  when  the 
facial  and  auditory  nerves  are  affected  together  by  basal  disease. 
Impairment  is  occasionally  met  with  in  cases  due  to  cold,  but  is  slight 
unless  there  is  also  a  catarrh  of  the  middle  ear.  Tinnitus  often 
attends  the  onset,  and  is  probably  due  to  the  same  cause;  it  may 
continue  for  weeks.  "When  the  disease  involves  the  middle  part  of  the 
nerve  in  the  canal  the  stapedius  is  paralysed,  and  the  tensor  tyinpani, 
being  unopposed,  often  increases  the  sensitiveness  of  the  ear  to 
musical  notes,  especially  to  those  of  low  tone  (Lucae).  A  subjective 
high-pitched  sound  has  been  referred  to  the  same  cause. 

The  electrical  reactions  in  facial  paralysis  are  those  characteristic  of 
peripheral  palsies, — the  degenerative  reaction  fully  described  at  vol.  i, 
p.  54.  The  charts  there  given  are  from  cases  of  disease  of  this  nerve. 
In  a  severe  case  the  nerve  rapidly  loses  its  irritability  to  faradic  and 
voltaic  stimulation  and  this  may  be  extinct  in  the  course  of  ten  days 

or  a  fortnight.  In  slighter 
cases  the  irritability  of  the 
nerve  is  lowered  but  not 
lost ;  a  strong  current  still 
excites  it.  In  most  cases 
the  fall  in  irritability  does 
not  commence  for  three  or 
four  days  after  the  onset 
of  the  paralysis,  and  in 
slight  cases  may  be  de- 
layed for  a  week  or  ten 
days.  It  may  be  distinct 
in  the  nerve-trunk  some 
days  before  it  is  found  in 
the  muscles,  i.  e.  in  the 
intra  -  muscular  nerves. 
During  the  first  few  days 
an  increase  of  irritability 
may  often  be  found  pre- 
ceding the  diminution.  In  extremely  slight  disease  of  the  nerve  I 
have  several  times  found  an  increase  corresponding  to  that  which 
precedes  the  fall  in  severe  cases,  but  followed  by  no  diminution. 
This  initial  increase  is  usually  the  same  to  both  forms  of  electricity, 
but  it  is  often  more  marked  to  the  isolated  faradic  shock  than  to  the 
serial  current*     In  the   muscle   the   initial  increase   may  also   be 


Fig.  104. — Kisrht  facial  paralysis,  due  to  ear  dis- 
ease in  childhood ;  simultaneous  faradisation  of 
hoth  facial  nerves.     (From  a  photograph.) 


*  It  is  said  that  in  the  slightest  cases  there  may  he  no  change  in  irritability,  and 
the  statement  is  doubtless  true.  But  in  the  cases  that  I  have  seen  in  which  the 
irritability  to  both  currents  was  normal,  I  have  seldom  failed  to  find  a  distinct 
increase  of  irritability  to  the  isolated  induction  shock.  An  increase,  with  sluggish 
effect,  was  persistent  for  months  in  a  somewhat  anomalous  case  observed  by  Koch 
(Hosp.  Tid.,  1889). 


FACIAL    NERVE.  239 

recognised,  and  depends  on  changes  in  the  intra- muscular  nerve-fibres. 
This  increase  is  followed  by  a  gradual  fall  in  the  faradic  irritability 
of  the  muscles,  corresponding  in  degree  to  that  of  the  nerve,  and  due 
to  the  fact  that  the  faradism  only  stimulates  the  muscles  through  the 
intra-muscuiar  nerve-endings.  With  this  loss  of  faradic  irritability, 
that  to  the  voltaic  current  is  preserved  and  increased  ;  to  it  the 
muscle-fibres  themselves  respond,  and  respond  with  undue  readiness, 
so  that  they  contract  with  a  weaker  current  than  is  required  by  the 
muscles  of  the  unaffected  side.  The  form  of  response  to  increasing 
currents  is  often  (but  by  no  means  always)  changed,  and  instead 
of  1  KCC  ;*  2  ACC,  AOC ;  3  KOC,  we  may  have  such  order  as  the 
following,  which  T  take  from  my  notes  of  actual  cases:  1  KCC  = 
ACC  ;  2  AOC ;  3  KOC  or  1  ACC ;  2  KCC,  AOC  ;  3  KOC  or  1  KCC, 
AOC  ;  2  ACC ;  3  KOC.  A  continuous  contraction  (tetanus)  is  also 
readily  produced  during  the  passage  of  the  current,  as  in  1  KCC ; 
2  ACC  =  KC  Tet.  ;  3  AC  Tet. 

"With  the  recovery  of  the  nerve  the  irritability  of  nerve  and  muscle 
slowly  returns  to  the  normal,  but  the  nerve-fibres  often  recover  some 
conducting  power  (i.  e.  the  paralysis  lessens)  before  they  regain  their 
local  excitability.  For  a  long  time  this  remains  below  the  normal. 
The  muscles  lose  their  excessive  degree  of  irritability  before  the  order 
of  response  becomes  normal. 

In  rare  cases  the  reaction  in  nerve  and  muscles  is  that  of  the 
mixed  form  (the  "middle  form"  of  Erb),  in  which,  with  only  slight 
diminution  in  the  irritability  of  the  nerve,  the  muscles  present  the 
increased  and  qualitative  change  characteristic  of  degeneration.  The 
varieties  in  the  course  of  the  reactions  are  illustrated  in  the  charts  in 
vol.  i  (Figs.  35—43). 

The  electrical  reaction  presented  by  one  muscle,  the  orbicularis  oris, 
merits  special  mention.  The  muscle  sometimes  illustrates  in  a 
striking  way  the  increased  but  slow  muscular  response  to  the  voltaic 
current  which  results  from  nerve  degeneration.  The  voltaic  current 
diffuses  itself  widely  ;  applied  to  the  angle  of  the  mouth  on  the  un- 
affected side  the  closure  of  the  circuit  causes  a  quick  sharp  contrac- 
tion in  the  normal  half  of  the  orbicularis,  distinctly  followed  by  a 
slower  contraction  on  the  paralysed  side.  If  the  strength  of  the 
current  be  then  reduced  until  it  is  too  small  to  cause  contraction 
in  the  normal  muscle,  it  may  still  cause  the  sluggish  contraction 
on  the  opposite,  paralysed,  side.  This  has  been  mistaken  for  a 
reflex  contraction;  it  is  no  doubt  the  result  of  the  diffusion  of  the 
current. 

In  cases  in  which  the  paralysis  of  the  face  remains  absolute,  the 
paralysed  half  of  the  orbicularis  usually  regains  some  power.  This 
is  doubtless  due  to  the  fact  that,  the  muscle  being  circular,  the  two 
halves  are  continuous,  and  the  nerve  influence  from  one  side  extends 

*  KCC,  kathodal  closure  contraction;  KOC,  kathodal  opening  contraction;  Tet.# 
tetanic  contraction  (see  vol.  i,  p.  56). 


240  CRANIAL   NERVES. 

beyond  the  middle  line.  It  is  indeed  probable  that  the  nerves  of  the- 
two  sides  join,  and  some  regeneration  from  the  sound  side  may  be 
possible.  I  have  occasionally  found,  in  old-standing  cases,  otherwise 
complete,  that  faradism  applied  to  either  angle  of  the  mouth  caused 
contraction  of  the  whole  of  the  orbicularis — a  fact  difficult  to  explain 
on  any  other  hypothesis  than  that  of  nerve  regeneration  from  the- 
healthy  side. 

Muscular  wasting  follows  the  nerve  degeneration  in  the  face  as  else- 
where, and  in  those  who  have  but  little  subcutaneous  fat  the  loss  of 
tissue  may  be  perceptible.  But  in  most  cases  the  atrophy  is  not 
revealed  by  any  change  in  the  contour  of  the  face,  because  the  thin 
muscles  constitute  but  a  small  part  of  the  subcutaneous  tissues,  and 
the  nutrition  of  these  is  unaffected.  True  facial  hemiatrophy  never 
results  from  disease  of  the  facial  nerve. 

The  loss  of  the  protective  movements  of  the  eyelids  exposes  the 
conjunctiva  to  various  irritant  influences,  but  inflammation  is  lim- 
ited to  slight  conjunctivitis.  The  increased  secretion  of  tears, 
although  a  source  of  annoyance  to  the  patient,  doubtless  supplements 
the  defective  action  of  the  lids  in  removing  foreign  particles.  In  the 
old  there  is  occasionally  a  slight  conjunctivitis  of  the  lower  lid, 
induced  by  the  exposure  which  is  the  consequence  of  its  recession 
from  the  eyeball  (see  p.  217).  I  have  once  known  a  small  ulcer  ta 
form  on  the  cornea,  but  it  quickly  healed. 

The  characters  of  the  facial  palsy  are  not  influenced  by  either  the 
seat  or  character  of  the  disease  of  the  nerve.  In  partial  lesions  some 
fibres  may  suffer  more  than  others,  with  a  corresponding  variation  in 
the  relative  degree  of  paralysis  in  the  several  parts  of  the  face.  But 
paralysis  due  to  disease  of  the  nucleus  presents  an  important  differ- 
ence from  that  which  is  produced  by  disease  of  the  nerve-trunk.  The 
fibres  for  the  orbicularis  oris  are  dissociated  from  the  other  facial 
fibres  in  their  nuclear  origin,  and  are  connected  with  the  fibres  for  the 
tongue  ;  the  two  suffer  together  in  nuclear  degeneration  (labio-glossal 
paralysis).  On  the  other  hand,  in  the  case  of  facial  palsy  from 
nuclear  inflammation  (part  of  polio-myelitis),  the  orbicularis  oris 
had  escaped  entirely,  although  the  rest  of  the  face  was  absolutely 
paralysed.* 

Certain  concomitant  symptoms  occasionally  attend  the  onset  of 
facial  paralysis,  and.  are  due,  for  the  most  part,  to  the  cause  of  the 
nerve-lesion.  In  neuritic  cases,  pain  about  the  ear  is  very  common, 
and  may  be  felt  for  a  day  or  so  before,  but  is  more  common  after  the 
onset.  It  may  be  like  "  earache,"  usually  slight,  but  is  more  frequent 
behind  or  below  the  ear,  and  may  extend,  down  the  neck  or  along  the 
ramus  of  the  lower  jaw  or  below  it.  In  the  latter  situations  it  is 
often  accompanied  by  tenderness.  It  sometimes  extends  over  the 
whole  of  the  corresponding  side  of  the  head,  and  radiates  to  the  face  ;. 

*  The  connection  between  the  fibres  for  the  orbicularis  oris  and  the  tongue  is- 
very  close  (see  note  on  p.  50). 


FACIAL    NERVE.  241 

there  and  in  the  neck  it  may  have  a  neuralgic  character,  and  some- 
times lasts  for  weeks.  More  often  its  duration  is  brief — one  or  a  few 
days.  A  little  swelling  in  front  of  the  ear  may  often  be  found,  if 
looked  for,  in  the  early  stage  ;  it  is  sometimes  considerable  and  exten- 
sive, and  is  no  doubt  due  to  cellulitis.  Auditory  symptoms  have 
been  already  mentioned.  In  one  case  the  patient  complained,  at  the 
onset  of  the  paralysis,  of  a  phosphorus-like  taste  in  the  back  of  the 
tongue,  explicable,  on  the  hypothesis  stated  at  p.  227,  by  irritation  of 
the  nerve  of  Jacobson  or  the  tympanic  plexus.  Slight  giddiness  not 
unf  requently  attends  the  onset,  and  may  be  due  to  a  disturbance  of  the 
labyrinth  ;  it  is  not  due  to  paralysis  of  the  stapedius.  Sometimes  the 
giddiness  is  intense,  especially  when  there  is  disease  within  the  skull, 
probably  from  injury  to  the  nerve-fibres  from  the  semicircular  canals, 
or  to  the  middle  peduncle  of  the  cerebellum.  In  some  cases  there  are 
the  signs  of  more  wide- spread  disturbance,  nervous  or  general,  from 
the  exposui'e  to  cold  that  causes  the  paralysis.  Beside  severe  neuralgia 
in  the  head  or  face  or  neck,  I  have  met  with  transient  dilatation  of 
the  pupil  and  derangement  of  the  movements  of  the  eyeball  on  the 
same  side,  and  also  on  the  other  side  ;  ptosis  on  the  other  side, 
hypersesthesia  of  the  side  of  the  tongue  and  gums  and  also  of  the 
cheek,  and  an  eruption  of  herpes  on  the  surface  of  the  tongue  on  the 
side  of  the  affection  of  the  face.  These  various  nerve  affections  must 
be  due  to  independent  associated  effects  of  cold.*  Coincident 
catarrhal  fever  is  met  with  rarely,  sore  throat  occasionally,  and  even 
transient  albuminuria. 

Course. — The  onset  of  facial  paralysis  is  usually  rapid  but  rarely 
sudden.  The  palsy  commonly  reaches  its  height  in  from  four  hours 
to  two  days.  Sometimes  the  affection  comes  on  during  the  night ;  it 
is  slight  in  the  evening  and  complete  next  morning ;  often  it  is  tri- 
fling on  first  rising,  and  becomes  considerable  or  complete  in  the  course 
of  the  day. 

Its  duration  varies  according  to  the  degree  and  character  of  the 
nerve-lesion,  which  may  be  severe  or  slight  from  any  cause.  In  the 
slightest  form  the  paralysis  may  last  only  for  a  week  or  ten  days,  but 
often  the  affection  lasts  for  months,  and  two  or  three  months  is  the 
average  in  cases  of  moderate  severity.  Those  of  greater  degeee 
last  for  six  or  eight  months,  and  it  is  very  common  for  the  ultimate 
recovery  to  be  incomplete.  Indeed,  whenever  there  is  nerve-degenera- 
tion, and  whenever  the  paralysis  is  complete  for  a  month,  some  trace 

*  The  herpes  on  the  tongue  has  been  referred  to  the  chorda  tympanij  but  this  is- 
unlikely,  because  it  may  precede  or  coincide  with  the  onset  of  the  affection  of  the 
facial  nerve,  and  may  exist  when  taste  is  unimpaired.  The  peculiar  hyperesthesia 
on  the  side  of  the  tongue  and  gums,  mentioned  above,  preceded  the  facial  palsy  for 
a  week  (the  cause  being  exposure  to  cold),  and,  from  its  distribution,  must  have 
been  due  to  an  affection  of  the  lingual.  Herpes  zoster  of  the  cheek,  such  as  must 
be  ascribed  to  the  fifth  nerve,  has  been  observed  as  a  coincident  effect  of  cold 
(Strubing,  'Arch.  f.  kl.  Med.,'  1885). 

VOL.  II.  16 


242 


CRANIAL    NERVES. 


of  it  usually  remains,  although  this  may  be  seen  only  on  close  scrutiny. 
In  rare  cases  no  recovery  takes  place. 

Secondary  Over-action. — In  all  severe  cases  some  muscular  contrac- 
ture comes  on,  usually  as  voluntary  power  returns.  When  the  palsy 
remains  absolute  the  contracture  is  absent;  the  muscles  remain  tone- 
less. The  first  trace  of  contracture  usually  manifests  itself  about 
four  or  six  months  after  the  onset  of  the  paralysis  ;  it  slowly  increases 
for  eight  or  twelve  months,  and  then  remains  stationary  or  lessens. 
It  is  most  marked,  at  rest,  in  the  zygomatic  muscles,  and  reproduces 
the  lost  naso-labial  wrinkle,  often  in  deeper  degree  than  on  the  other 
side,  so  that  on  looking  at  the  face  the  first  impression  is  that  the 
healthy  side  is  the  weaker.  The  impression  may  seem  to  be  confirmed 
by  a  slight  movement  of  the  face,  for  this  is  more  marked  on  the 
affected  side  than  on  the  other.*  But  if  the  movement  is  consider- 
able, the  side  that  moved  first  is  seen  to  move  much  less  than  the 
other.     With  this  contracture  is  constantly  combined  a  tendency  to 

associated  over-action. 
A  smile  is,  in  health, 
accompanied  by  a  slight 
contraction  in  the  orbi- 
cularis palpebrarum,  and 
this  contraction  is  in- 
creased on  the  affected 
side,  so  that  the  eye  may 
almost     close.  Con- 

versely,  when   the  eyes 

Fig.  105.— Old  paralysis  of  the  right  side  of  the  are  closed  hJ  a  strong 
face,  late  contracture  and  associated  over-action,  contraction  of  the  Ol'bi- 
The  figure  on  the  left  shows  an  attempt  to  raise  cularis,  the  zygomatic!  on 
the  upper  lip ;   that  on  the  right,  closure  ot  the  ,7  ■"• 

eyes.  In  the  latter  it  is  seen  that  while  the  the  affected  side  over-act 
patient's  right  eye  is  closed  less  firmly  than  his  and.  draw  outwards  the 
left,   the   naso-labial    furrow    is    rendered   much  ,        „    ,  , 

deeper  on  that  side  by  the  associated  over-action  angle  ot  tne  moutn  (Jj  ig. 
of  the  zygomatici.     (From  photographs.)  105).      The   contractions 

may  also  be  readily  ex- 
cited by  reflex  action  through  the  fifth  nerve.  In  many  cases  another 
symptom  is  added  after  a  time — spontaneous  twitchings,  isolated 
spasmodic  contractions,  recurring  at  irregular  intervals,  and  affecting 
chiefly  the  zygomatici.  These  various  spasmodic  symptoms  are  often 
considerable  when  the  amount  of  regained  power  is  slight. 

The  effect  of  the  muscular  contracture  on  the  aspect  of  the  face  at 
rest  varies  according  to  the  age  of  the  patient,  in  a  manner  opposite 
to  the  effect  of  the  palsy.  In  the  old  it  reproduces  the  lost  naso- 
labial furrow,  and  restores  the  symmetry  to  the  lower  face.  In  the 
young  it  develops  a  furrow  that   has  no  counterpart   on  the  other 

*  It  is  possible  that  there  is  not,  as  there  seems,  an  undue  initial  movement,  but 
that  the  previous  contracture  renders  the  effect  of  an  equal  voluntary  contraction, 
more  conspicuous  on  the  affected  side. 


FACIAL    NERVE.  243 

side,  and  so  adds  a  deformity  at  rest  to  the  distortion  during  move- 
ment, and  is  a  source  of  annoyance  scarcely  less  than  the  original 
palsy.  It  may  cause  the  tears  to  flow  on  to  the  cheek,  or  force  them 
into  the  nose  with  uudue  speed  so  that  an  increased  nasal  secretion 
is  simulated,  and  perhaps  a  real  excess  of  lachrymal  secretion  is  some- 
times induced.  The  condition  is  very  persistent.  When  slight,  and 
succeeding  a  trifling  paralysis,  it  may  pass  away  in  time,  but  when  con- 
siderable, and  after  a  severe  paralysis,  it  usually  lasts  unchanged  for 
years,  and  although  it  may  subsequently  lessen,  it  rarely  passes  away 
entirely.  I  have  known  it  to  be  still  considerable  twenty-five  years 
after  the  attack  of  facial  palsy.  It  has  been  attributed  to  the  use  of 
electricity  in  the  treatment  of  the  palsy ;  faradism  and  voltaism 
have  both  been  blamed,  but  the  contracture  and  over-action  develop 
in  as  marked  degree  in  patients  who  have  not  had  electrical 
treatment  as  in  those  who  have.  Its  probable  cause  will  be  presently 
considered. 

Second  attacks  of  facial  paralysis,  due  to  cold,  are  rare,  but  I  have 
met  with  eight  instances.  In  three  the  second  attack  was  on  the  same 
side,  and  in  all  the  first  attack  was  slight.  The  second  attack  was 
from  three  weeks  to  four  years  after  the  first.  In  most  cases  it  was 
distinctly  excited  by  a  fresh  exposure  to  cold.  I  have  also  twice 
known  a  slight  facial  paralysis,  which  was  improving,  to  relapse. 
Cases  have  been  met  within  which  there  were  more  than  two  attacks, 
and  these  have  been  termed  "  recurring  facial  palsy,"  and  compared 
with  the  recurring  paralysis  of  the  third  nerves  occasionally  met  with. 
Five  instances  are  recorded  by  Bernhardt :  in  four,  the  same  side  was 
affected  several  times ;  in  the  other  case  the  side  varied  several  times 
in  the  series  of  attacks.  The  precise  nature  of  such  cases  is  not 
known ;  they  probably  constitute  a  special  form.* 

Pathology. — The  evidence  of  the  nature  of  these  cases  has  been 
already  stated,  and  the  general  pathology  of  such  disease  has  been 
described  in  the  first  volume.  But  our  knowledge  of  the  special 
pathology  of  the  affection  is  meagre.  We  do  not  know  why  this 
nerve  suffers  with  such  frequency,  nor  have  we  any  adequate  infor- 
mation regarding  the  elements  of  the  nerve  that  are  primarily  inflamed. 
The  curious  absence  of  pain  in  the  affected  region  of  the  nerve  has 
been  already  mentioned  (vol.  i,  p.  67). 

The  cause  of  the  late  over-action  and  spasm  is  probably  a  change 
in  the  functional  state  of  the  cells  of  the  nucleus  of  the  nerve,  produced 
by  their  altered  functional  condition  during  the  complete  paralysis,  but, 
once  established,  permanent.  The  contracture  always  coincides  with 
some  recovery  of  power ;  in  a  case  of  absolute  and  lasting  paralysis 
there  is  no  contracture.  Since  the  associated  over-action  and  the 
clonic  spasm  accompany  the  contracture,  it  is  reasonable  to  refer  all 
to  the  same  cause.  The  tonic  conti'acture  and  associated  over-action 
*  Bernhardt,  '  Berlin,  klin.  Wocheuschr.,'  18S9. 


244  CRANIAL    NERVES. 

are  excessive  degrees  of  normal  phenomena,  and  the  latter  must  be 
due  to  the  connection  between  the  groups  of  cells.  The  resistance 
in  the  cells  and  between  them  becomes  lessened,  so  that  they  act  with 
undue  readiness  on  each  other  and  on  the  fibres.  Their  tonic  influ- 
ence on  the  muscles  is  increased,  the  action  of  one  part  of  the  nucleus 
spreads  too  widely  through  it,  and  the  cells  are  liable  to  spontaneous 
discharge.*  The  excited  cells  are  imperfectly  discharged  through 
their  fibres  during  the  palsy,  the  axis-cylinders  being,  it  will  be 
remembered,  really  parts  of  the  cells,  and  not  mere  effluent  channels. 
Another  mechanism  of  derangement  may  be  the  loss  of  the  afferent 
impulses  from  the  muscles  during  their  palsy.  These  (from  the  facts 
stated  at  vol.  i,  p.  204),  must  lower  the  abnormal  activity  of  the 
stimulated  cells,  because  their  deficiency  will  interfere  with  the  due 
limitation  of  the  excitation,  and  promote  the  diffusion  among  the 
cells  of  the  nucleus,  of  the  activity  which  should  influence  only 
certain  fibres  and  certain  muscles.  Once  established,  the  morbid 
action  tends  to  perpetuate  itself,  and  is  hence  most  intractable. 

Diagnosis. — The  existence  of  facial  paralysis  is  only  too  conspicu- 
ous as  soon  as  the  state  of  the  muscles  is  revealed  by  voluntary  or 
emotional  action.  But  when  the  face  has  partly  recovered,  and  is  the  . 
seat  of  late  contracture,  it  is  easy  to  mistake  the  side  affected,  unless 
attention  is  paid  to  the  strength  of  contraction,  and  the  significance 
of  the  associated  over-action  is  remembered.  A  slight  movement  is 
more  conspicuous  on  the  affected  side  ;  a  strong  one  is  far  less  in 
degree.  It  is  well  also  to  remember  that  patients  are  apt  to  misstate 
the  side  affected  in  consequence  of  their  frequent  impression  that  the 
smooth  unwrinkled  half  of  the  face  must  be  natural,  and  that  the 
side  which  is  distorted  by  movement  is  unnatural.  Often  no  reliance 
can  be  placed  on  the  statements  made  by.  patients  or  their  friends  as 
to  the  side  affected. 

The  distinction  of  paralysis  due  to  disease  of  the  nerve-fibres  from 
that  due  to  disease  of  the  motor  tract  from  the  hemisphere  (infra- 
nuclear  and  supra-nuclear  palsy)  rests  especially  on  the  distribution  of 
the  paralysis,  as  stated  on  p.  79.  The  most  important  guide  is  the 
condition  of  the  eyelids.  If  there  is  such  persistent  paralysis  of  the 
eyelids  that  they  cannot  be  perfectly  closed,  the  lesion  is  probably  in 
the  nucleus  or  nerve-fibres.  Cortical  disease  may  for  a  few  days 
paralyse  the  orbicularis,  but  other  symptoms  are  usually  present  in 
a  cerebral  lesion,  and  the  different  course  of  the  two  affections 
soon  renders  the  diagnosis  clear.  Moreover,  emotional  movement 
is  less  impaired  by  cerebral  disease  than  is  voluntary  movement,  or 

*  The  hypothesis,  so  far,  is  essentially  the  same  as  that  put  forward  hy  Jacobi 
('Inaug.  Diss./  ilarburg,  1S77)  in  regard  to  a  case  of  similar  spasm  after  palsy  of 
the  nerves  of  the  arm.  Hitzig  has  suggested  that  the  disease  of  the  nerve  leads  to 
a  state  of  "  irritation  "  in  the  centre,  but  the  significance  of  this  statement  depends 
upon  its  meaning. 


FACIAL    NEKVE.  245 

vice  versa ;  in  disease  of  the  nerve  the  two  are  equally  affected.  In 
the  latter,  reflex  action  is  lost ;  in  the  former  it  is  unchanged. 

In  nuclear  and  infra-nuclear  disease  the  reaction  of  degeneration  is 
found  in  the  nerves  and  muscles  ;  in  lesions  of  the  facial  path  above 
the  nucleus  the  reaction  is  normal  or  nearly  so.  Thus  the  degenera- 
tive reaction  is  proof  of  a  lesion  in  the  nucleus  or  nerve,  but  a 
normal  or  nearly  normal  reaction  does  not  prove  that  the  disease  is 
above  the  nucleus,  since  it  occurs  also  in  very  slight  lesions  of  the 
nerve. 

The  further  diagnosis  of  the  seat  of  the  lesion  in  the  nerve  rests  on 
the  associations  of  the  paralysis.  If  no  nerve  except  the  facial  is 
affected,  and  taste  is  unimpaired,  the  lesion  is  probably  in  the  lowest 
part  of  the  Fallopian  canal  or  outside  the  skull.  If  taste  is  lost  on 
the  front  of  the  tongue,  the  lesion  is  in  the  canal,  and  involves  the 
nerve  between  the  geniculate  ganglion  and  the  origin  of  the  chorda 
tympani.  It  does  not,  however,  prove  that  the  disease  began  in  this 
part ;  disease  may  spread  to  the  chordal  region.  Moreover,  taste  may 
be  lost  for  a  time,  afterwards  becoming  normal  although  the  face 
remains  affected ;  its  loss  is  often  unknown  to  the  patient,  and  needs 
to  be  sought  for.  Paralysis  of  the  palate  was  formerly  thought  to 
show  disease  of  the  geniculate  ganglion  or  nerve  above  it,  but  it  is  not 
produced  by  paralysis  of  the  facial  nerve.  Slight  deafness  is  of  little 
localising  value  ;  complete  deafness,  without  ear  disease,  coming  on  at 
the  same  time  as  the  paralysis  of  the  face,  indicates  disease  in  the 
internal  auditory  meatus  or  at  the  base  of  the  brain,  commonly  the 
latter,  since  disease  within  the  meatus  is  extremely  rare.  Paralysis 
of  the  facial  and  sixth,  without  the  auditory,  is  generally  due  to 
disease  in  the  posterior  part  of  the  pons,  where  the  facial  fibres 
curve  round  the  nucleus  of  the  sixth  nerve.  It  is  possible,  however, 
as  I  have  seen,  for  the  sixth  nerve  to  be  paralysed  by  a  simultaneous 
rheumatic  neuritis.  If  the  orbicularis  oris  is  quite  unaffected,  and 
all  other  parts  of  the  nerve  are  paralysed,  the  disease  is  within  the 
pons ;  if  the  orbicularis  only  is  paralysed  and  the  rest  of  the  face 
is  free,  the  disease  is  in  the  neighbourhood  of  the  hypoglossal 
nucleus,  and  the  tongue  is  almost  certain  also  to  be  involved. 

Prognosis. — The  cause  of  the  paralysis  is  of  less  prognostic  signi- 
ficance than  are  its  characters.  The  chief  etiological  indication  is  that 
the  pi-ognosis  is  good  in  pure  syphilitic  cases,  in  the  paralysis  from 
pressure  during  birth,  and  (if  the  patient  lives)  in  paralysis  from  the 
causes  of  polyneuritis,  including  diphtheria.  It  is  not  good  when 
the  onset  is  so  sudden  as  to  suggest  hemorrhage  into  the  nerve.  It 
is  said  to  be  better  in  ear  disease  if  the  tympanum  is  not  jjerf orated' 
(Dalby).  But  in  ear  disease  and  all  other  causes,  especially  in  those 
due  to  cold,  cases  of  slight  and  severe  character  are  met  with,  and  the 
prognosis  must  be  mainly  founded  on  the  electrical  reaction.  It  is 
true  that  signs  of  improvement,  and  its  rate,  may  enable  an  estimate 


246  CRANIAL    NERVES. 

to  be  formed  of  the  likelihood  of  recovery,  and  of  the  probable  dura- 
tion of  the  affection  ;  but  if,  as  is  often  the  case,  there  is  no  recovery 
of  power  when  we  have  to  form  an  opinion,  we  should  have  no  pro- 
gnostic guide  were  it  not  for  the  information  electricity  affords  us.  By 
its  means  we  can  ascertain  the  state  of  function  of  the  nerve-fibres, 
and  infer  the  state  of  their  nutrition,  and  thus  we  can  gain  more  infor- 
mation than  even  the  microscope  could  supply.  If  at  the  end  of  ten 
days  the  irritability  of  the  nerve  is  not  below  the  normal  the  face  will 
probably  be  well  in  a  few  weeks.  If,  on  the  other  hand,  at  the  end  of 
a  fortnight  the  irritabibity  of  the  nerve  is  absolutely  lost,  the  para- 
lysis will  certainly  last  for  several  months.  If  at  the  end  of  a  fort- 
night the  nerve  irritability,  although  lowei-ed,  is  not  lost,  recovery  will 
probably  occur  in  about  two  months.  Between  these  forms,  inter- 
mediate gradations  of  severity  occur,  for  which  the  prognosis  must  be 
correspondingly  modified.  When  the  faradic  irritability  has  been 
absent  for  some  weeks,  any  return  of  excitability  in  the  nerve-fibres 
indicates  a  speedy  return  of  some  power  in  them. 

Treatment. — The  first  element  in  treatment  is  to  arrest  and 
remove,  as  far  as  possible,  the  morbid  process  that  is  damaging  the 
nerve.  If  there  is  even  a  possibility  that  this  may  be  syphilitic, 
iodide  of  potassium  should  be  given,  and  if  there  is  no  speedy  improve- 
ment, mercury  should  be  added.  If  there  is  ear  disease,  free  exit  for 
any  discharge  should  be  secured.  When  exposure  to  cold  is  the 
apparent  cause,  or  in  similar  cases  in  which  no  cause  can  be  traced,  if 
the  paralysis  has  existed  for  a  few  days  only,  fomentations  should  be 
applied  to  the  region  in  front  of  and  below  the  ear,  as  hot  as  can  be 
borne,  for  half  an  hour,  and  repeated  every  three  hours  for  two  or 
three  days.  In  all  cases,  except  those  of  very  trifling  degree,  a 
blister  should  be  applied  behind  the  ear,  over  the  mastoid  process  if 
the  nerve  is  diseased  in  the  canal,  or  on  the  side  of  the  occiput  if  it  is 
at  the  base  of  the  brain.  In  rheumatic  cases,  the  patient  should  take 
a  smart  purge  and  avoid  alcohol.  An  alkaline  diuretic  mixture 
(bicarbonate  of  potash,  or  acetate  of  ammonia,  and  nitrous  ether)  may 
be  given  at  the  onset,  together  with  small  doses  of  mercury  during 
the  stage  of  active  inflammation.  If  there  is  evidence  of  general 
rheumatic  catarrh,  a  hot  bath  or,  better  still,  free  diaphoresis  may  be 
employed,  it  is  important  that  the  patient  should,  if  possible,  keep 
indoors.  If  this  is  impossible,  the  side  of  the  head  should  be  pro- 
tected. Subsequently  the  blister  may  be  repeated,  and  small  doses  of 
iodide  of  potassium  may  be  combined  with  the  mercury,  and  tonics, 
as  quinine  and  strychnine,  may  be  given  later. 

There  is  no  evidence  to  show  that  electricity  has  any  influence  over 
the  process  of  nerve  degeneration  or  recovery.  But  the  voltaic  current 
excites  the  muscles  to  contraction  when  they  are  otherwise  absolutely 
inert.  It  is  reasonable  to  conclude  that  such  functional  stimulation 
of  the  muscles  helps  to  keep  up  their  nutrition.     The  nerve-fibres  may 


FACIAL    NEBVE.  247 

recover  functional  power  after  months  of  interruption.  During  this 
time  the  muscles,  left  alone,  undergo  partial  atrophy,  and  it  is  pro- 
bable that  this  is  less  if  galvanism  has  been  sedulously  employed.  If 
a  case  has  not  been  galvanised,  after  several  months  of  absolute  para- 
lysis scarcely  any  contraction  may  be  obtained  the  first  time  the 
current  is  applied,  but  after  a  few  applications  the  muscles  may 
respond  vigorously,  and  it  sometimes  happens  that  the  first  indication 
of  returning  voluntary  power  follows  such  a  "  waking  up  "  of  the 
muscles.  The  positive  electrode  should  be  placed  below  the  zygoma 
and  the  negative  stroked  along  the  course  of  the  muscles,  along  the 
zygomatici,  the  orbicularis,  in  the  upper  and  lower  lip,  the  levator 
anguli  oris,  across  the  frontalis  and  the  eyelids,  the  upper  eyelid  being 
lowered.  The  strength  used  should  be  the  minimum  to  which  the 
muscles  will  respond ;  usually  from  four  to  eight  cells  of  an  active 
battery  are  sufficient,  the  current  used  for  the  eyelids  being  weaker 
than  for  the  other  mnscles.  It  has  been  said  that  the  positive  elec- 
trode should  be  applied  to  the  muscles,  because  these  respond  more 
readily  to  it  than  to  the  negative  pole.  But  this  is  not  always  the 
case;  sometimes  the  response  to  the  negative  pole  is  the  earlier; 
often  it  is  the  same  to  each  pole,  and  the  irritability  to  the  negative  is 
seldom  much  behind  that  to  the  positive.  The  rule  given  above  is, 
therefore,  on  the  whole  the  best.  The  application  should  be  made  for  a 
quarter  of  an  hour  once  or  twice  a  day.  It  can  be  made  perfectly  well 
by  the  patient  himself,  seated  before  a  looking-glass.  As  the  face 
recovers,  the  increased  voltaic  irritability  lessens  and  faradic  irri- 
tability returns,  slight  at  first,  but  gradually  increasing.  It  has  been 
advised  that  faradism  should  then  be  substituted  for  voltaism,  but  it 
is  very  doubtful  whether  faradism  does  good.  The  voluntary  power 
which  is  then  regained  constitutes  a  stimulus  to  the  muscles  far 
greater  and  better  than  that  of  faradism,  and  it  influences  the  same 
muscular  fibres.-  If  any  electrical  treatment  is-  continued  it  is  better 
to  still  use  the  voltaic  current,  which  not  only  stimulates  the  nerve- 
fibres  as  surely  as  faradism,  but  also  any  muscular  fibres  of  which  the 
nerves  have  not  yet  recovered.  When  there  are  indications  of  com- 
mencing late  contracture,  the  use  of  faradism  is  distinctly  contra- 
indicated,  and  it  is  perhaps  better  to  stop  all  electrical  treatment  that 
causes  discomfort.  Although  this  is  certainly  not  the  cause  of  con- 
tracture, it  may  yet  tend  to  increase  it,  and  when  this  stage  is  reached 
electricity  has  probably  effected  all  that  it  can  achieve. 

For  the  contracture  and  over-action  little,  unfortunately,  can  be 
done.  I  have  never  been  able  to  observe  any  beneficial  result  from 
either  drugs  or  local  treatment.  The  use  of  a  weak  unbroken  voltaic 
current  has  been  recommended,  but  its  influence  is  inappreciable. 
Warm  douches,  or  steaming  the  face,  and  the  internal  administra- 
tion of  bromide  of  potassium  have  been  recommended  (Rosenthal). 
Daily  gentle  shampooing  of  the  face,  by  moving  the  finger,  with 
gentle  pressure,  along  the  course  of  the  muscles  from  oi'igin  to  inser- 


248  CRANIAL    NERVES. 

tion,  may  be  adopted  as  having  an  influence  in  the  right  direction,  and 
at  least  incapable  of  doing  harm.  Faradisation  of  the  muscles  of  the 
sound  half  of  the  face  neither  has  nor  can  have  any  influence  on  the 
contracture,  beyond  a  tendency  to  increase  it  by  reflex  stimulation 
through  the  fifth  nerve. 

Facial  Spasm. 

Spasm  in  the  muscles  supplied  by  the  facial  nerve  may,  as  we  have 
just  seen,  be  secondary  to  a  paralysing  lesion,  but  it  occurs  also  apart 
from  preceding  paralysis,  and  this  primary  form  alone  is  here  con- 
sidered. It  is  sometimes  termed  "  mimic  spasm,"  from  the  semblance 
of  emotional  expression  which  results,  and  also,  after  the  French, 
convulsive  tie* 

Facial  spasm  may  affect  only  a  few  muscles  or  almost  all  those  of 
one  side,  and  either  form  may  be  unilateral  or  bilateral.  It  may  be 
due  to  organic  disease,  or  "  idiopathic,"  depending  on  functional  and 
nutritional  changes.  The  spasm  is  usually  clonic;  if  there  is  tonic 
spasm  there  is  almost  always  clonic  spasm  as  well. 

The  orbicularis  palpebrarum  and  zygomatici  are  more  prone  to 
spasm  than  other  muscles  of  the  face;  the  motor  mechanism  for  the 
•orbicularis  muscle  is  the  more  sensitive,  in  consequence  of  its  important 
function  and  energetic  reflex  action,  while  both  muscles  take  the  lead- 
ing part  in  emotional  expression.  Hence  spasm,  ultimately  general, 
often  commences  in  one  of  these,  and  partial  spasm  affects  them  far 
moi'e  frequently  than  any  other  part  of  the  face.  Tonic  spasm  limited 
to  the  eyelids,  is  termed  "blepharospasm,"  and  will  be  separately  de- 
scribed ;  while  the  habit-spasm  of  childhood,  a  totally  different  disease, 
is  considered  in  connection  with  chorea. 

Idiopathic  spasm  is  met  with  only  during  adult  life,  after  twenty 
years  of  age.  That  which  succeeds  paralysis  alone-  occurs  in  child- 
hood and  youth.  Ordinary  facial  spasm  usually  commences  between 
forty-five  and  sixty,  rarely  earlier,  but  sometimes  later.  The  earliest 
typical  case  I  have  met  with  commenced  at  thirty-two,  but  cases  are 
on  record  in  which  it  began  between  twenty  and  thirty.  Two  thirds 
of  the  cases  I  have  seen  commenced  between  fifty  and  sixty.  An  in- 
herited neurotic  tendency  to  insanity  or  epilepsy  in  relations  can 
sometimes  be  traced ;  direct  heredity  is  very  rare,  but  I  have  known  a 
mother  and  daughter  to  suffer,  each  in  late  life.f     Women  suffer  far 

*  This  is  the  original  meaning  of  the  word  "tic,"  concealed  in  part  by  its  use  as 
an  abbreviation  of  the  more  common  tic -douloureux  (neuralgia)  to  which  it  was 
applied,  either  metaphorically,  from  the  twitch-like  character  of  the  pain,  or  else  on 
account  of  the  spasm  that  may  accompany  severe  paroxysms  of  neuralgia.  The 
original  French  form  ticq  is  supposed  by  Skeat  to  be  allied  to  tukken,  Low  German 
to  twitch  (modern  German  zucken). 

f  Rosenthal  has  described  the  affection  of  five  members  of  a  family,  but  he  does 
not  state  the  form  of  spasm.  In  most  cases  of  direct  inheritance  the  affection  is 
not  true  facial  spasm,  but  a  kind  of  habit-spasm. 


FACIAL.  NERVE.  249 

more  frequently  than  men,  and  constitute  about  two  thirds  of  the 
cases.  It  does  not  seem  to  have  any  special  relation  to  hysteria ;  the 
tonic  contraction  of  the  eyelids  or  quivering  of  the  face  sometimes 
met  with  in  this  disease  is  quite  different  from  ordinary  facial  spasm. 
A  general  neuropathic  tendency  is  common,  and  many  sufferers  have 
been  liable  to  periodical  headaches.  Anaemia  and  general  defective 
nutrition  of  the  nervous  system  conduce  to  its  occurrence,  but  the 
cause  of  the  idiopathic  form  that  can  be  most  frequently  traced  is 
meutal  anxiety,  sometimes  a  sudden  shock,  more  often  prolonged 
grief  or  concern.  In  this  connection  it  is' instructive  to  note,  on  the 
•one  hand,  the  intensely  disturbing  influence  of  such  emotion  on  the 
nervous  system,  and,  on  the  other,  the  relation  of  contraction  in  the 
facial  muscles,  and  especially  of  those  in  which  the  spasm  often  begins, 
to  emotion  :  this  cause  lowers  the  nutrition  of  the  nervous  system, 
and  may  have  a  special  tendency  to  derange  the  structures  on  which 
it  chiefly  acts.  In  many,  the  disease  begins  about,  or  soon  after,  the 
climacteric  period.  In  one  case  it  existed  during  the  whole  of  two 
successive  pregnancies,  ceasing  on  delivery,  but  afterwards  coming  on 
without  this  cause. 

Another  occasional  cause  is  irritation  of  the  fifth  nerve,  to  which 
the  facial  has  a  special  reflex  relation.  The  irritation  may  be  in  the 
eye,  in  the  teeth,  or  through  the  cutaneous  branches  of  the  fifth 
nerve.  But  it  may  survive  the  irritation  which  sets  it  up  ;  it  followed 
a  fortnight's  severe  toothache  on  the  same  side,  in  one  instance,  but 
did  not  cease  when  extraction  of  the  decayed  teeth  relieved  the  pain. 
Another  patient  had  been  liable,  all  her  life,  to  attacks  of  migraine, 
with  severe  pain  in  the  eyeball  around  which  the  facial  spasm  began. 
Rarely  neuralgia  in  the  neck  has  preceded  the  spasm,  but  neuralgia, 
however  violent,  seldom  sets  up  spasm  of  independent  course,  in  spite 
of  the  fact  that  muscular  contraction  often  accompanies  paroxysms  of 
severe  pain.  Irritation  of  the  intestines  or  uterus  has  been  alleged 
as  a  cause,  but  on  insufficient  evidence.  Severe  cold  acting  on  the 
face  and  head  has  apparently  caused  the  disease  in  a  few  instances, 
perhaps  also  by  the  reflex  mechanism  of  irritation  of  the  fifth  nerve, 
since  in  some  of  these  cases,  although  not  in  all,  pain  has  preceded  the 
spasm.  It  is  to  be  noted  that  the  effect  of  these  influences  is  not  al- 
ways immediately  manifest.  Thus  a  man's  face  was  scorched,  and 
his  eyelashes  and  eyebrows  were  burned,  by  the  explosion  of  a  cart- 
ridge ;  a  month  later,  when  the  face  was  well,  spasm  commenced  in 
the  muscles  of  the  eyelids  and  nose,  and  continued  for  years.  A 
soldier  during  the  Franco-German  war  suffered  from  severe  neuralgia 
of  the  right  side  of  the  face,  induced  by  cold ;  two  years  afterwards 
this  side  of  the  face  became  the  seat  of  spasm  (Bernhardt).  In  such 
cases  we  must  assume  that  the  irritation  induces  a  susceptibility  in 
the  facial  centres  which  permits  slighter  influences  to  cause  a  morbid 
activity.  Such  susceptibility  must  also  be  assumed  in  the  cases,  con- 
siderable in  number,  in  which  no  cause  can  be  traced. 


250 


CBAXIAL  .NERVES. 


Two  other  causes  give  rise  to  special  varieties  of  the  affection. 
First,  it  may  develop  out  of  some  habitual  movement,  as  in  a  man  who 
was  in  the  babit  of  taking  snuff  on  the  affected  side.  Allied  to  such 
cases,  but  still  more  closely  to  habit  spasm,  are  the  cases  that  may 
be  called  "  senile  habit  spasm,"  in  which  there  is  some  frequently 
repeated  movement  of  the  face.  In  a  man  of  fifty-five,  strong  momen- 
tary contractions  of  both  orbiculares  recurred  continually,  and  were 
ascribed  to  working  by  a  strong  light.  In  another,  more  closely  allied 
to  the  typical  cases,  facial  spasm  develops  from  torticollis  by  exten- 
sion from  the  neck  muscles.  In  this  also  two  causal  varieties  may 
be  distinguished.  When  the  primary  spasm  is  in  the  muscles  of  the 
back  of  the  neck  on  both  sides,  the  frontales  contract  simultaneously, 
raising  the  eyebrows.  This  is  the  result  of  the  normal  association 
.  which  is  readily  observed  when  a  pei-son  looks  upwards.  When  the 
spasm  is  in  the  muscles  moving  the  head  to  one  side,  it  may  spread  to 
all  the  muscles  commonly  affected  in  facial  spasm  on  that  side.  If  such 
spasm  in  the  neck  is  bilateral,  both  sides  of  the  face  may  be  involved. 
Such  extension  to  the  face  seems  to  occur  when  the  spasm  inclines 
the  head  towards  the  shoulder,  rather  than  when  it  merely  rotates  it. 

Organic  disease  causing  facial  spasm  has  been  in  one  of  two  situa- 
tions ;  in  the  facial  nerve,  or  the  facial  centre  in  the  cortex  of  the 
opposite  hemisphere.  In  several  cases  spasm  has  been  produced  by 
a  tumour  pressing  on  the  nerve  at  the  base  of  the  brain,  a  smaD 


FlO.  106. — Aneurism  of  the  left  vertebral  artery,  compressing  the  facial 
nerve,  and  causing  facial  spasm.     (After  Schultze.)* 


*  The  patient  was  a  man,  aged  fifty-six,  who  had  received  an  injury  to  the  head 
ten  years  before.  For  a  year  before  death  he  had  suffered  from  short  quick  con- 
tractions  in  the  left  side  of  the  face,  increased  by  any  movement  of  the  jaws  or 


FACIAL    NERVE.  251 

sarcoma,*  a  cholesteatoma  (Schuh),  or  tumour  of  the  cerebellum 
(which,  however,  also  compressed  the  pons,  &c),  a  tumour  of  the 
auditory  nerve  close  to  the  pons,f  or  an  aueurism  of  an  adjacent 
artery.  An  instance  of  the  last,  an  aneurism  of  the  vertebral,  is  shown 
in  Tig.  106.  Spasm  does  not  seem  to  be  caused  by  disease  in  the 
petrous  bone,  in  spite  of  the  frequency  with  which  the  nerve  suffers 
in  this  situation,  and  it  does  not  seem  to  be  caused  by  neuritis  except 
as  a  sequel  to  paralysis.  In  organic  lesions  of  the  pons,  spasm  has 
only  been  observed  as  a  transient  symptom,  preceding  paralysis,  in 
consequence  of  an  abscess. 

On  the  other  hand,  persistent  facial  spasm  has  been  produced  by  a 
small  stationary  lesion  of  the  ascending  frontal  convolution  in  the 
position  of  the  facial  centre,  opposite  the  inferior  frontal  sulcus.  Fig. 
107  shows  a  point  of  softening  in  this  situation,  which  caused  persis- 


-i     ~ 


Hi* 


m 


iM 


Fig.  107. — Small  focus  of  superficial  softening,  S,  in  the  ascending 
frontal,  opposite  the  origin  of  the  fissure  between  the  middle  and 
lower  (L  F  C)  frontal  convolutions,  which  had  caused  persistent 
clonic  facial  spasm.  PCS,  pre-central  sulcus;  F  R,  fissure  of 
Rolando;  F  S  A,  anterior  limb  of  fissure  of  Sylvius.  (From  a 
photograph  kindly  furnished  by  Dr.  Berkeley,  of  Baltimore.) 

tent  clonic  spasm,  limited  to  the  zygomatic  muscles.  J  It  has  also  been 
the  first  symptom  of  a  tumour  in  this  situation. §  I  have  seen  one 
case  in  which  it  was  highly  probable  that  facial  spasm  was  the  result 
of   a  cortical  injury  during  birth.      In  other   cases  the  spasm  has 

face.  All  muscles  were  affected  except  the  frontalis;  the  palate  did  not  move.  There 
was  no  pain.  No  morbid  changes  could  be  found  in  the  nerves  on  naked-eye  or  micro- 
scopic examination  (Schultze,  '  Virchow's  Archiv,'  Bd.  lxv,  p.  385).  Compare  also  a 
case  narrated  by  Buss  ('  Neur.  Centralbl.,'  18S6)  in  which  the  posterior  cerebellar 
artery  was  dilated. 

*  Moos,  'Archiv  f.  Augenheilk.,'  1874,  Bd.  iv,  Abth.  1,  p.  179. 

t  Sharkey, '  Brain,'  1888. 

X  Berkeley,  '  Medical  News,'  July  15th,  1883.  The  case  recorded  by  Allen  Starr, 
•American  Journal  of  Med.  Science,'  1884,  Case  51,  is  the  same. 

§  Walton,  '  Boston  Journal,'  1889. 


252  CE.ANIAL    KEJSVES. 

followed  a  fall  on  the  head  ;  and  a  slight  injury  to  the  surface  of  the 
brain  on  the  opposite  side,  such  as  often  results  from  contusion,  ia 
highly  probable.  This  may  readily  have  occurred  even  when  the 
spasm  is  on  the  side  of  the  skull  which  received  the  blow.  But  the 
cases  in  which  there  is  reason  to  suspect  an  organic  lesion,  in  any 
situation,  form  only  a  small  minority. 

Symptoms. — In  some  cases  of  facial  spasm  the  muscles  of  one  side 
of  the  face  present  frequent  momentary  contractions,  resembling 
those  produced  by  the  stimulation  of  the  nerve  with  the  faradic 
shock.  In  others  there  is  a  single  contraction,  which  recurs  at 
irregular  intervals  of  seconds  or  minutes.  More  frequently  there  are 
brief  paroxysms  in  which  there  is  both  tonic  and  clonic  spasm,  and 
the  latter  sometimes  has  a  quick  quivering  character.  In  other  cases 
again  the  paroxysms  are  longer  and  more  violent,  lasting  several 
minutes,  and  consisting  of  quick  contractions,  two  or  three  per  second, 
with  imperfect  relaxation  between  them,  and  occasional  prolonged 
contractions,  lasting  five  or  ten  seconds.  A  paroxysm  may  begin  and 
end  with  clonic  spasm,  while  the  chief  part  of  it  consists  of  tonic 
-contraction.  Occasionally  the  attack  is  interrupted  by  brief  periods 
of  complete  relaxation,  or  complete  except  in  the  orbicularis  palpe- 
brarum. 

Tbe  orbicularis  and  zygomatici  are  generally  more  affected  than 
the  other  muscles,  so  that  the  eye  is  half  closed,  the  angle  of  the 
mouth  is  drawn  outwards,  and  the  naso-labial  furrow  is  deepened. 
In  a  few  cases  the  elevator  of  the  upper  lip  is  more  affected  than  the 
zygomatic  muscles.  Sometimes  the  spasm  involves  the  corrugator 
supercilii,  but  rarely  the  frontalis,  although  this  is  occasionally  involved 
in  either  one-sided  or  bilateral  spasm,  together  with  the  orbicularis ; 
the  contraction  in  either  may  preponderate,  so  that  the  eyebrow  is 
raised  or  lowered  during  the  attack.  Both  orbiculares  or  corrugators 
or  frontales  may  be  involved,  although  the  spasm  is  in  other  muscles 
one-sided.  The  depressor  of  the  angle  of  the  mouth,  the  levator 
menti,  and  the  platysma  myoides  are  sometimes  implicated.  The 
last  may  even  becoma  hypertrophied  from  the  continued  over-action 
(Fig.  108).  The  effect  of  the  preponderant  contraction  in  the  orbi- 
cularis and  zygomatic  muscles  is  a  curiously  mixed  emotional  aspect, 
a  sort  of  whimpering  smile.  The  orbicularis  oris  is  scai*cely  ever 
involved. 

The  spasm  may  be  confined  to  the  muscles  of  one  side,  and  is  almost 
always  so  confined  at  first.  It  usually  begins  gradually,  and  is  at 
first  slight  and  occasional,  often  occurring  only  under  some  exciting 
influence.  In  the  orbicularis  palpebrarum  it  may  be  at  first  so  slight  as 
to  resemble  the  familiar  quiveriug  popularly  termed  "  live  blood."  It 
may  cease  for  a  time,  and  then  return  in  more  persistent  form.  Often 
in  the  severer  paroxysms  there  may  be  slight  spasm  on  the  other  side, 
of  the  eyelids  or  angle  of  the  mouth,  or  of  the  levator  menti,  and  in 


FACIAL    NEEVE. 


25a 


rare  cases,  after  a  time,  the  spasui  becomes  altogether  bilateral. 
Spasm  limited  to  tlie  muscles  about  the  eyes  is,  indeed,  often  bilateral, 
involving  chiefly  the  orbiculares,  sometimes  the  corrugators,  but  it  is- 
exceptional  for  the  lower  muscles  to  be  equally  affected  on  both  sides^ 


FlG.  108. — Bilateral  facial  spasm  in  a  woman  of  sixty-one,  due  to  grief. 
Over-action  and  apparent  hypertrophy  of  platysma. 

The  spasm  is  usually  lessened  by  rest,  physical  and  mental.  It  is- 
always  increased  by  emotion,  and  by  movement  of  the  face,  whether 
in  speaking  or  chewing ;  in  slight  and  early  cases  it  may  occur  only 
under  these  influences.  Thus  a  schoolmistress  at  first  only  suffered 
when  speaking  under  excitement,  e.  g.  to  her  class,  and  only  after  many 
months  did  it  occur  in  quiet  conversation.  In  another  patient  the 
spasm,  always  worst  in  the  zygomatics,  began  in  them,  but  only  when 
reading  aloud.  When  the  influence  of  movement  is  great,  the  effect 
may  be  to  cause  the  spasm  very  closely  to  resemble  the  "  associated 
over-action"  seen  after  facial  paralysis.  Frequently  the  spasm  is 
increased  by  light  and  by  cold.  The  influence  of  light  is  intelligible, 
since  the  orbicularis  palpebrarum  is  almost  always  involved,  and  a. 
strong  light  produces  reflex  contraction  in  this  muscle  under  normal 
circumstances.  Conversely  the  spasm  is  lessened  by  warmth  and  by 
darkness. 

Facial  spasm  causes  no  pain  ;  when  pain  is  present  it  is  independent 
and  often  primary.  As  a  rule  there  is  no  paralysis.  Voluntary 
movements  may  be  interfered  with  by  the  spasm,  but  are  otherwise 
unimpaired.  Distinct  loss  of  power  only  exists  in  cases  of  progres- 
sive organic  lesions,  especially  in  compression  of  the  nerve,  the  effect 
of  which  is  to  cause  first  spasm,  and  then  paralysis  ;  or  weakness  and 
slight  spasm  may  come  on  together.*     Most,  if  not  all,  non-prog  1  ess 

*  As  in  the  case  recorded  hy  Sharkey. 


254  CRANIAL   NERVES. 

sive  cases,  in  which  considerable  loss  of  power  co-exists  with  spasm, 
are  cases  of  old  facial  paralysis  in  which  contracture  and  spasm  have 
supervened.  The  electrical  irritability  of  nerve  and  muscle  is,  as  a 
rule,  normal.  I  have  found,  however,  in  one  case  a  distinct  increase 
of  irritability  in  the  nerve. 

The  spasm  very  rarely  affects  the  muscles  of  the  palate,  even  when 
the  movement  of  the  face  is  violent  and  general.  In  the  case  already 
mentioned,  in  which  the  spasm  was  due  to  the  pressure  of  an  aneurism 
on  the  nerve-trunk,  the  palate  was  unaffected.  A  few  exceptions  are 
on  record.  Thus,  in  a  case  of  one-sided  spasm,  there  were  clonic  con- 
tractions of  the  uvula,  drawing  it  to  the  side  affected,  and  synchronous 
with  the  spasm  in  the  face  (Schiitz).  In  another  case  of  bilateral 
spasm  the  uvula  was  drawn  up  by  spasm  of  both  sides,  so  that  in  the 
stronger  contractions  it  almost  disappeared  (Leube).  The  palatine 
spasm  is  probably  merely  associated.  I  have  seen  bilateral  contrac- 
tions in  the  palate  with  unilateral  facial  spasm,  but  the  two  were  not 
synchronous.  In  spasm  of  the  two  from  pressure  there  has  been  com- 
pression also  of  the  spinal  accessory  nerve  (Oppenheim),  and  it  may 
be  noted  that  the  palate  and  eyes  have  been  affected  together  by 
nystagmus  (q.  v.). 

Symptoms  referable  to  spasm  of  the  stapedius  muscle  have  been 
very  rarely  noted,  except  in  cases  of  tonic  spasm  of  the  orbicularis 
(blepharospasm).  In  these  a  continuous  noise  has  been  noted,  and 
has  persisted  after  the  blepharospasm  ceased.*  Many  persons  can 
produce  a  quivering  noise  in  the  ear  by  a  strong  contraction  of 
the  orbiculares,  and  most  readily  if  they  try  to  turn  the  eyes  up  at 
the  same  time.  In  one  case  there  was  giddiness  during  the  height  of 
a  paroxysm,  with  conjugate  deviation  of  the  eyes  to  the  right,  sym- 
ptoms which  Moos,  who  has  recorded  the  case,  attributes  to  spasm  of 
the  stapedius,  suddenly  lowering  the  pressure  in  the  labyrinth  and 
semicircular  canals. 

Subjective  sensations  of  taste  have  not  been  noted,  but  taste  was 
lost  on  the  front  of  the  tongue  in  one  case,  in  which  there  was  pro- 
bably damage  to  the  nerve.  Equally  rare  is  disturbance  of  the 
secretion  of  saliva,  which  was  for  a  time  excessive  in  the  case  of 
bilateral  spasm  in  which  the  palate  suffered.  No  other  vaso-motor  or 
trophic  disturbance  has  been  observed. 

Occasionally  the  spasm  spreads  beyond  the  limit  of  the  facial  nerve, 
to  the  muscles  of  mastication,  the  tongue,  and  the  muscles  of  the 
neck,  and  even  of  the  arm.f  It  may  begin  in  the  tongue  and 
spread  to  the  face.J  Extension  to  the  eyeball  muscles  has  not  been 
hitherto  recorded.     In  a  case  of  my  own  there  was  slight  deviation 

•  Gottstein  found  that  in  such  cases  the  sound  could  be  arrested  by  pressure  on 
the  front  of  the  mastoid  process,  or  by  electrical  irritation  of  the  skin  at  the  same 
spot  ('Archiv  f.  Ghrenheilkunde,'  1880,  Bd.  xvi,  p.  61). 

t  Keen,  'Trans.  American  Surgical  Association,'  May  1st,  1886. 

%  Remak,  '  Berl.  kl.  Wochenschr.,'  1883,  No.  34. 


FACIAL   NERVE.  255 

inwards  of  the  eye  on  the  side  of  the  spasm  during  the  paroxysms, 
apparently  from  spasm  of  the  internal  rectus  or  inhibition  of  the 
sixth  nerve.  In  the  case  of  Moos  it  is  assumed  that  the  deviation 
was  secondary  to  derangement  of  the  equilibrium  centre  by  the 
labyrinthine  disturbance. 

Tender  points  in  the  fifth  nerve  are  rare  in  general  facial  spasm, 
although  they  have  been  noted  when  the  spasm  was  limited  to  the 
eyelids.  Pain  in  the  region  of  the  fifth  may  occur  at  the  onset,  and 
has  been  already  referred  to.  Occasionally  there  is  some  impaired  sen- 
sibility of  the  face,  due  to  greater  damage  to  the  fibres  of  this  nerve. 

Tonic  spasm  is  common  after  paralysis,  and  exists  in  slight  degree 
in  the  zygomatic  muscles  in  some  cases  of  old  hemiplegia,  and  on 
both  sides  in  paralysis  agitans,  in  some  cases  of  tetany,  and  in  con- 
siderable degree  in  tetanus.  Primary  tonic  spasm  is  said  to  have  occa- 
sionally resulted  from  exposure  to  cold,  to  be  unilateral  or  bilateral, 
and  sometimes  associated  with  trismus.  Deep  furrows  are  persistent ; 
the  mouth  deviates  towards  the  paralysed  side  ;  the  palpebral  fissure 
is  narrower  than  on  the  other  side,  the  eyebrow  is  raised,  there  is  a 
sense  of  tension  in  the  face,  and  movements  are  hindered. 

Tonic  spasm  of  the  face  may  be  produced  in  the  cataleptic  condi- 
tion of  hysteria.  A  curious  form  came  under  my  notice  in  a  man 
who,  after  sleeping  for  over  eighteen  hours,  woke  up  in  the  following 
condition :  there  was  some  weakness  of  the  left  arm,  none  of  the  leg, 
no  distinct  paralysis  of  the  tongue,  and  no  paralysis  of  the  face,  but 
conspicuous  over-action  of  the  left  side  of  the  face,  induced  by  the 
slightest  excitement,  coming  on  even  when  he  entered  a  room,  and 
passing  away  only  after  he  had  been  perfectly  quiet  for  a  time. 
Sometimes  it  would  occur  without  any  exciting  cause.  The  chief 
contracture  was  in  the  zygomatic  muscles,  causing  a  very  deep  naso- 
labial depression.  There  was  also  slight  contracture  of  the  orbicularis 
palpebrarum.  He  was  readily  excited  to  tears,  and  then  the  angle  of 
the  mouth  was  drawn  still  further  outwards  and  the  left  eye  almost 
closed.  There  was  also  a  little  rigidity  of  the  muscles  of  mastication. 
The  condition  presented  no  change  during  five  months  that  the  patient 
was  under  observation.  The  features  of  the  spasm  that  is  secondary 
to  torticollis,  and  of  that  which  is  allied  to  habit  spasm,  have  been 
already  mentioned. 

Course. — Facial  spasm  usually  begins  gradually  in  the  way  described 
above,  either  by  closure  of  the  eyelids,  or  traction  outwards  of  the  angle 
of  the  mouth,  and  often  many  months  pass  before  the  other  part  of  the 
side  of  the  face  is  involved.  The  course  of  the  affection  is  very  irregular. 
Sometimes  for  weeks  or  months  the  face  is  comparatively  or  absolutely 
free  from  spasm,  and  then  the  movements  return,  spontaneously  or, 
after  some  emotion.  The  same  proneness  to  relapse  is  seen  when 
arrest  has  been  obtained  by  treatment.  The  duration  of  the  affection 
is  always  long ;  it  generally  lasts  for  years,  and  not  unfrequently 
persists  to  the  end  of  life. 


256  CRANIAL    NERVES. 

Pathology. — The  facts  of  organic  disease  show  that  the  spasm 
may  be  clue  to  a  chronic  irritative  or  "discharging"  lesion  in  (1)  tbe 
facial  centre  in  tbe  cortex,  (2)  the  nucleus  in  tbe  pons,  or  (3)  tho 
nerve-trunk.  Since  nerve-cells  are  tbe  source  of  motor  impulses,  tbe 
two  former  are  readily  intelligible ;  whether  cortical  disease  causes 
such  spasm,  or  that  which  spreads  as  an  epileptiform  convulsion,  must 
depend  on  a  difference  in  the  nature  of  tbe  change  in  the  cells,  which 
is  at  present  beyond  our  power  of  detection.  It  is  less  easy  to  under- 
stand how  the  third  mechanism  acts,  although  it  bas  analogies  in 
other  parts  of  the  nervous  system.  It  may  be  by  disturbing  the  down- 
ward nerve- currents  from  the  facial  nucleus,  which  are  constant  even 
during  apparent  rest.  It  is  also  conceivable  that  the  pressure  on  the 
nerve  may  modify  and  derange  the  action  of  the  facial  nucleus  itself; 
or,  on  the  other  band,  that  the  mechanical  irritation  of  the  nerve-fibres 
may  excite  them  directly,  as  electrical  stimulation  does,  and  may 
intensify  the  impulses  that  descend  them,  continually  or  for  the  main- 
tenance of  tone,  and  for  emotional  and  other  expression.  But  we  cannot 
thus  explain  tbe  spontaneous  paroxysms  that  characterise  the  affec- 
tion. These  must  depend  on  a  morbid  state  of  the  nucleus  secondarily 
induced,  either  by  an  ascending  neuritis  or  by  the  conduction  of  an 
influence  in  the  opposite  direction  to  that  of  habitual  and  chief  func- 
tion— such  an  influence  as  must  descend  sensory  nerves  when  their 
irritation  causes  acute  trophic  disturbance.  In  the  idiopathic  form, 
we  must  assume  a  morbid  action  of  the  nerve-cells  either  in  the 
nucleus  or  the  cortex.  Its  persistent  nature,  even  when  its  cause  is 
transient,  may  be  referred  to  the  fact  that  functional  action  leaves  a 
residual  change  disposing  to  its  recurrence — an  effect  which  we 
express  as  "  lessened  resistance  "  or  "  instability  ;"  while,  on  the  other 
hand,  our  means  of  counteracting  this  tendency  are  extremely  limited. 

When  facial  spasm  is  due  to  a  reflex  cause,  as  neuralgia  or  expo- 
sure to  cold,  it  is  reasonable  to  regard  the  nucleus  as  the  part  chiefly 
affected.  In  the  cases  that  are  excited  by  depressing  emotion,  or 
develop  slowly  without  apparent  cause,  there  is  nothing  to  show 
whether  the  deranged  action  is  at  the  cortex  or  at  tbe  nucleus.  In 
either  position  the  extension  of  the  spasm  to  the  other  side  is  readily 
intelligible,  much  more  so  than  its  limitation  to  muscles  on  one  side 
(as  the  orbiculares  palpebrarum)  which  habitually  act  with  their 
fellows;  and  in  either  case,  the  very  different  associations  of  the 
orbicularis  oris  enable  us  to  understand  its  escape. 

Diagnosis. — The  chief  point  in  diagnosis  is  the  distinction  of 
primary  spasm  from  that  which  follows  paralysis,  and  this  rests  on 
the  history  or  the  presence  of  weakness,  which  may  always  be 
observed  on  energetic  movement,  and  on  tbe  existence  of  persistent 
contracture  and  over-action,  as  well  as  of  occasional  spasm.  In  rare 
cases  of  chorea  the  face  is  much  affected,  and  the  limbs  but  little; 
and  it  is  probable  that  such  a  case  has  been  mistaken  for,  and  even 


FACIAL   NEEVB.  257 

published  as,  a  case  of  simple  facial  spasm.  Attention  to  the  condi- 
tion of  the  limbs  will  prevent  error,  since  slight  movements  may 
always  be  observed  in  them.  In  hysteria  there  is  either  tonic  con- 
tracture, especially  in  the  orbicularis,  or  attacks  of  quiverino-  move- 
ment, which  do  not  resemble  true  facial  spasm. 

A  more  urgent  question  is  the  seat  and  nature  of  the  disease.  In 
forming  an  opinion  on  this  point  we  must  be  guided  by  the  considera- 
tions already  mentioned  in  the  sections  on  causation  and  patholo°w. 
More  facts  are  needed  regarding  the  relation  between  the  character 
of  the  spastn  and  the  seat  of  the  disease.  Partial  facial  spasm,  how- 
ever, e.  g.  limited  to  the  zygomatics,  is  more  likely  to  be  cortical  than 
that  which  involves  the  greater  part  of  one  side  of  the  face.  Any 
tender  points,  or  source  of  irritation  in  the  fifth  nerve,  or  a  history  of 
pain,  suggest  a  reflex  origin  and  nuclear  seat.  Indications  of  increas- 
ing weakness,  secondary  in  time,  suggest  a  progressive  organic 
cause. 

Prognosis. — The  prognosis  is  grave  in  all  cases  except  those  that 
are  of  recent  origin,  and  are  distinctly  due  to  a  reflex  cause  ;  and  even 
in  these  the  cessation  of  the  spasm  cannot  be  certainly  expected  to 
follow  the  removal  of  the  cause.  In  cases  which  have  lasted  more 
than  a  few  months  the  probability  is  against  recovery,  although  the 
fact  that  in  a  few  instances,  even  of  years'  duration,  recovery  has 
taken  place,  justifies  an  effort  to  relieve.  Only  when  the  symptom  is 
due  to  progi-essive  organic  disease  has  it  any  intrinsic  gravity.  But, 
trivial  as  it  is  in  other  cases,  it  causes  more  annoyance  than  many 
diseases  of  far  more  serious  nature. 

Treatment. — In  a  recent  case,  apparently  excited  by  cold,  free 
diaphoresis  should  be  employed,  and  the  face  and  side  of  the  head 
bathed  frequently  with  hot  water.  If  there  are  indications  of  organic 
disease,  the  nature  of  this  must  be  ascertained,  and,  as  far  as  possible, 
treated.  All  causes  of  reflex  irritation  must  be  sought  for  and 
removed;  decayed  teeth  should  be  extracted,  especially  if  they  are 
on  the  same  side  as  the  spasm.  Any  derangement  of  the  general 
health  should  also  be  treated,  and  in  the  cases  that  are  excited  by 
depressing  emotion,  tonics  are  usually  required.  So-called  nervine" 
tonics  and  stimulants,  zinc,  nitrate  of  silver,  asafoetida,  valerian,  have 
all  been  recommended,  but  in  the  vast  majority  of  cases  they  con- 
spicuously fail.  In  only  one  typical  case  have  I  known  recovery  to 
occur  under  such  treatment,  which  consisted  of  arsenic,  bromide,  and 
Indian  hemp.  Hypodermic  injections  of  strychnia  are  said  to  have 
cured  one  case  (Sanders). 

It  is  chiefly  by  the  administration  of  sedatives  that  attempts  have 
been  made  to  reduce  the  activity  of  the  cells  and  lessen  the  spasm. 
Almost  every  drug  of  the  kind  has  been  employed,  and  some  have 
been  said  to  be  successful  in  isolated  cases,  such  as  gelsemium,  conium, 

VOL.  II.  17 


258  CEANIAL  NERVES. 

and  morphia.  The  last,  given  under  the  skin,  lias  most  frequently 
done  good,  either  alone  or  combined  with  atropine.  From  the  results 
obtained  in  torticollis,  it  is  probable  that  a  permanent  effect  may  be 
produced  by  keeping  up  the  influence  of  morphia  for  many  months  ; 
but  this  course  of  treatment  may  easily  have  results  more  serious 
than  the  malady  itself. 

Electricity  has  been  largely  used,  and  has  been  highly  praised  by 
some  of  its  advocates,  but  in  most  cases  it  fails  even  to  relieve.  Only 
a  weak  voltaic  current  should  be  employed,  in  a  "  stabile,"  i.  e.  unin- 
terrupted manner.  Various  methods  of  application  have  been  re- 
commended, aud  may  be  tried.  One  is  to  place  the  anode  in  front  of 
the  ear,  the  kathode  on  the  muscle,  so  that  a  descending  current  may 
pass.  Another  is  to  place  the  anode  on  the  nerve,  or  behind  the  ear, 
or  at  the  occiput,  the  kathode  on  some  indifferent  place,  so  as  to  ob- 
tain the  simple  sedative  influence  of  the  positive  pole.  Another  is  to 
place  a  pole  on  each  mastoid  process. 

The  diminution  of  the  sensitiveness  of  the  fifth  nerve  by  cooaiue 
seems  useless.  Indeed,  it  is  important  to  remember  that  strong 
sensory  impulses  from  the  seat  of  the  spasm  have  more  power  than 
anv  other  agency  to  raise  local  resistance  and  arrest  over-action. 
This  opposition  of  reflex  influences  is  a  familiar  fact  (see  vol.  i,  p.  200). 
We  see  an  instance  of  the  mechanism  in  the  effect  of  a  blister  on 
convulsions  that  begin  locally,  but  the  effect  is  transient,  and  seldom 
obtained  in  persistent  spasm  outside  the  realm  of  hysteria.  I  have, 
however,  once  known  facial  spasm  of  two  months'  duration  to  cease 
permanently  on  an  attack  of  neuralgia  in  the  face.  Similarly,  the 
spasm  has  been  observed  to  cease  during  the  existence  of  a  painful 
affection  of  the  conjunctiva  (Bernhardt).  Counter  irritation,  as  by  a 
blister  behind  the  ear,  generally  causes  some  diminution  of  the  spasm 
for  a  time,  perhaps  by  the  inhibitory  influence  of  the  sensory  irri- 
tation, but  no  lasting  amelioration  results.  The  application  of  the 
actual  cautery  along  the  cervical  spine  is  said  to  have  cured  one  case 
(Eemak). 

Stretching  of  the  facial  nerve  has  been  of  late  adopted  in  these  cases, 
but  unfortunately  with  imperfect  realisation  of  the  hopes  that  were 
entertained  when  the  operation  was  introduced,  and  that  seemed  to 
be  justified  by  its  immediate  effect.  Slight  stretching  of  the  nerve 
seldom  has  any  influence.*  Vigorous  stretching  causes  paralysis  of 
the  face,  lasting  for  weeks  or  months,  with  degenerative  reaction  in 
the  nerve  and  muscle.  The  paralysis  in  time  passes  away.  In  many 
cases  the  spasm  has  returned  with  voluntary  power.  In  others  the 
face  has  remained  free  from  spasm  for  some  time  after  the  recovery  of 
the  nerve,  but  the  spasm  has  ultimately  returned,  either  spontaneously, 

*  In  a  case  recorded  by  Zeiss  ('  Wien.  med.  Wochenschr.,'  1884,  No.  2,  and  1885, 
No.  27),  stretching  insufficient  to  cause  paralysis  was  followed  by  slow  diminution  in 
a  spasm  of  eight  years'  duration,  wbich  disappeared  seven  weeks  after  the  operation, 
and  was  still  absent  two  and  a  half  \ears  later. 


FACIAL    NEKVE.  259 

or  on  some  fresh  exciting  cause,  such  as  an  emotional  shock.  Of  thir 
teen  cases  collected  by  G-odlee,*  in  only  one  (recorded  by  Southamf) 
was  the  patient  free  from  spasm  two  years  after  the  operation  ;  and  in 
a  more  recent  collection  of  twenty  cases  by  Keen,  the  only  other  case 
of  cessation  for  a  longer  period  than  six  months  is  that  of  Zeiss,  already 
mentioned.^  In  some  cases  the  spasm  became  as  severe  as  ever,  in 
others  it  was  distinctly  less  intense  thau  before  the  operation  and 
remained  so.  The  operation  should  probably  be  performed  only 
in  the  cases  in  which  there  is  a  possibility  that  the  source  of  the 
spasm  is  disordered  function  of  the  facial  nucleus,  and  it  would  be 
desirable  not  to  trust  to  the  operation  alone,  but  to  follow  it  up  by  a 
course  of  some  other  treatment,  such  as  the  hypodermic  injection  of 
arsenic  and  morphia,  which  is  known  to  have  some  power  of  lessening 
such  spasm;  this  should  be  commenced  when  the  palsy  is  passing 
away.  The  operation  may  perhaps  have  an  upward  influence  on  the 
nerve-cells  of  the  nucleus,  as  well  as  that  due  to  the  counter-irritation 
it  effects  through  the  fifth  nerve.  The  unfortunate  tendency  to  re- 
currence after  some  months,  which  most  cases  present,  may  perhaps 
be  due  to  the  same  influences  that  lead  to  secondary  spasm  after 
idiopathic  neuritis,  and  which  we  are  still  unable  to  counteract. 

Blepharospasm. — Spasm  confined  to  the  eyelids,  and  showing 
no  signs  of  extension  to  other  parts  of  the  face,  is  distinguished  from 
other  forms  of  facial  spasm  also  by  its  causes  and  its  bilateral  charac- 
ter. It  occurs  in  tonic  form  in  connection  with  photophobia,  as  a 
result  of  painful  affections  of  the  eye,  and  sometimes  of  other  branches 
of  the  fifth  nerve.  It  is"an  excessive  action  of  the  reflex  mechanism 
that  normally  guards  the  eye.  When  thus  set  up  it  may  persist  as  a 
troublesome  affection  in  excess  of  its  cause,  and  may  continue  in  the 
dark,  and  even  exist  in  an  eye  that  is  blind.  Clonic  spasm  of  the  eye- 
lids is  sometimes  dignified  by  the  name  "  nictitation,"  aud  sometimes 
occurs  in  hysteria,  and  also  in  children  as  part  of  "habit-chorea," 
which  is  elsewhere  described.  The  most  important  elements  in  treat- 
ment are  the  removal  of  nerve  irritation,  for  which  in  the  case  of 
conjunctival  disease  cocaine  is  useful,  and  the  diminution  of  the 
central  over-action  by  sedatives,  such  as  bromide  and  belladonna, 
and  by  tonics  such  as  iron  and  quinine.  Cold  douches  to  the  eye 
should  also  be  used. 

*  '  Trans.  Clin.  Soc.,'  vol.  xvi,  p.  220.  In  a  previous  paper  by  the  same  author 
(ib.,  vol.  xiv,  p.  44)  the  method  of  performing  the  operation  is  fully  described.  It 
is  also  described  by  Keen,  loc.  cit.  (p.  233). 

t  '  Lancet,'  August  27th,  1881,  and  a  later  note  in  Godlee's  table. 

X  In  the  case  of  a  man  of  fifty,  under  my  care,  in  whom  Mr.  Gotllee  stretched 
the  nerve,  the  contractions  have  now  been  absent  for  a  year  and  three  quarters. 
The  onset  was  after  exposure  to  malaria,  but  the  patient  has,  for  a  year,  returned  to 
the  same  conditions.  The  spasm  was  characteristic,  left-sided,  but  the  case  was 
unusual  in  that  there  was  slightly  lessened  sensibility  in  the  second  division  of  the 
fifth  nerve. 


2G0  CItANIAL    NEfiViSS. 


AUDITORY  NERVE;    DISTURBANCE   OF   HEARING. 

It  is  pi-obable  that  the  fibres  of  the  auditory  nerve  that  go  to 
the  cochlea  on  the  one  hand,  and  those  that  supply  the  semi- 
circular canals  on  the  other,  differ  in  function,  and  that  only  the 
former  are  excited  by  sound.  The  latter  seem  to  convey  impressions 
from  the  canals,  generated  by  the  pressure  or  movement  of  the  endo- 
lymph  in  various  postures  and  movements  of  the  body.  Hence  the 
latter  fibres  have  been  distinguished  by  Cyon  as  the  "  space-nerve  " 
(Bauimierv),  and,  although  the  term  is  awkward,  a  better  one  has 
not  hitherto  been  suggested.  The  two  sets  of  fibres  unite  in  a  common 
trunk,  in  which  they  cannot  be  distinguished.  Within  the  internal 
auditory  meatus  and  at  the  base  of  the  brain  the  auditory  nerve  is 
adjacent  to  the  facial.  The  deep  origin  of  the  nerve  has  been  already 
described  (p.  47),  and  we  have  seen  that  many  fibres  pass  by  the 
inferior  peduncle  to  the  cerebellum,  with  which  also  the  nuclei  are 
probably  connected.  The  former  probably  convey  impi'es^ions  from 
the  canals  to  the  equilibrial  mechanism  in  the  middle  lobe.  The  up- 
ward auditory  path  seems  to  pass  by  the  superior  fibres  of  the 
tegmentum  of  the  crus*  to  the  internal  capsule,  but  whether  it  reaches 
the  tegmentum  through  the  pons  or  through  the  cerebellum  has  not 
yet  been  ascertained.  There  is  certainly  a  decussation  above  (or  at 
the  level  of)  the  nuclei,  so  that  the  auditory  path  from  each  ear 
passes  to  the  opposite  hemisphere,  and  apparently  in  or  near  the 
posterior  extremity  of  the  internal  capsule.  The  cortical  centre  for 
hearing  is  seated  in  the  first  temporo-sphenoidal  convolution  (see 
p.  24),  and  that  of  the  left  side  subserves  the  auditory  use  of  words. 

Disturbance  of  the  functions  of  the  auditory  nerve  are  much  more 
often  due  to  disease  of  the  ear  than  to  affections  of  the  nerve-trunk 
or  centres.  Our  knowledge  of  the  symptoms  that  are  of  primary 
nerve  origin  is  still  very  imperfect,  because  they  are  for  the  most  part 
identical  with  those  due  to  lesions  of  the  labyrinth.  Exact  aural 
diagnosis  stops  at  the  middle  ear ;  beyond  this  it  resembles  that  of 
affections  of  the  eye  before  the  invention  of  the  ophthalmoscope. 
Labyrinthine  and  nerve  lesions  are  now  confused  under  the  term 
"nervous  deafness,"  just  as  affections  of  the  retina,  choroid, and  optic 
nerve  were  included  under  the  common  term  "amaurosis."  Indeed, 
since  labyrinthine  lesions  cause  symptoms  by  their  influence  on  the 
nerve-fibres,  the  confusion  seems  almost  inevitable,  unless  associated 
symptoms  point  definitely  to  a  given  seat  of  disease. 

Five  kinds  of  symptoms  may  result  from  disease  of  the  auditory 
nerve  in  its  course  or  termination.  (1)  Loss  of  function  :  deafness. 
(2)  Increased  action  :  auditory  hypersesthesia,  "  hyperacusis."  (3) 
Irritation  symptoms  in  the  auditory  function  of  the  nerve,  causing 

*  See  p.  49. 


AUDITORY    NERVE.  261 

subjective  sensations  of  sound:  "tinnitus  aurium."  (4)  Disturbance 
of  equilibrium,  or  sensations  of  such  disturbance,  due  to  derangement 
of  the  fibres  from  the  semicircular  canals.  (5)  Connected  with  the 
last  (but  too  rare  to  merit  more  than  a  passing  mention)  are  certain 
involuntary  movements  that  have  been  observed  in  cases  of  disease  of 
the  nerve  within  the  ear.  Pendulum-like  oscillations  of  the  head 
were  present  in  two  cases  recorded  by  Moos.*  The  fourth  class  of 
symptoms,  which  constitute  "labyrinthine"  or  "auditory  vertigo," 
can  be  considered  more  conveniently  in  connection  with  other  forms 
of  vertigo.  Here  only  the  derangements  of  the  auditory  function  of 
the  nerve  can  be  briefly  considered  in  their  medical  relations.  For  a 
fuller  description  of  the  symptoms  of  labyrinthine  affections  the  reader 
is  referred  to  special  works  on  Diseases  of  the  Eai\ 


Diminished  Function  ;   Nervous  Deafness. 

Causes. — Deafness  may  be  congenital,  as  in  80  per  cent,  of  deaf 
mutes ;  in  the  remaining  20  per  cent,  it  is  the  result  of  disease 
early  in  life.  The  mechanism  of  congenital  deafness  is  not  known. 
Inheritance  is  a  potent  cause,  especially  that  which  results  from  the 
marriage  of  relations  in  families  in  which  the  defect  exists  ;  rarely 
intermarriage  apart  from  the  defect  gives  rise  to  it.  As  an  instance 
of  inheritance,  one  family  in  the  United  States  has  had  thirty-four 
cases  in  four  generations,  another  twenty-one  in  three.  This  condi- 
tion, however,  does  not  come  within  the  subject  as  here  considered.f 
The  causes  of  "  nerve-deafness  "  may  be  thus  enumerated. 

(1)  By  far  the  most  common  is  disease  of  the  labyrinth,  either 
hindering  the  passage  of  the  vibrations  to  the  structures  in  which 
the  nerve-fibres  end,  or  else  damaging  those  structures  and  the  nerve- 
endings  themselves.  Such  disease  may  be  primary  in  the  labyi-inth, 
or  may  extend  to  it  from  the  middle  ear.  Our  knowledge  of  the 
nature  of  the  morbid  processes  is  limited  to  the  occurrence  of  acute 
inflammation,  chronic  inflammation,  syphilitic  disease,!  degenerative 
processes,  and  probably  hsemorrbage.  From  these  various  tissue 
changes,  fibrous  and  calcareous  formation  may  result.  Primary 
inflammation  is  sometimes  bilateral,  and  thus  causes  deafness  on  each 
side;  it  may  result  from  inherited  syphilis,  cold,  and  some  toxic 
blood-states.  It  occurs  also  in  purulent  meningitis  by  extension 
along  the  aqueduct  of  the  cochlea  and  along  the  auditory  nerve  itself, 
by  its  substance  or  outer  layer.  In  such  cases  the  labyrinth,  often  on 
both  sides,  contains  pus,  and  also  the  organisms  found  in  the  mem- 

*  'Zeitsch.  f.  Ohrenheilk.,'  xii,  p.  101. 

f  For  a  summary  of  facts  see  Warden,  '  Brit.  Med.  Journ.,'  1887. 
t  Moos,  *  Virchow's  Archiv,'  Bd.  lxix,  p.  313  (with  autopsy);  see  also  McBride, 
'  Glasgow  Med.  Journal,'  1885,  p.  172. 


262  CRANIAL    NERVES. 

branes  in  cerebro- spinal  meningitis  aud  in  tbe  tubercular  form.*  It 
is  probable  that  the  membrane  of  the  labyrinth,  in  the  old,  undergoes 
degenerative  changes,  since  these  may  be  observed  in  the  memurana 
tympani.  In  those  who  are  gouty,  symptoms  sometimes  suggest  that 
the  fibrous  tissues  of  the  internal  ear  may  be  the  seat  of  changes 
similar  to  those  met  with  elsewhere  in  this  condition. 

Certain  drugs  cause  deafness  having  the  characters  of  labyrinthine 
deafness,  and  probably  so  because  congestion  of  the  internal  ear 
has  been  found  to  accompany  the  symptoms.  A  loud  noise  has  been 
known  to  cause  permanent  deafness.  Lucae  suggests  that  the  mecha- 
nism may  be  a  haemorrhage  into  the  labyrinth,  since  he  has  found  an 
extravasation  in  the  middle  ear  from  this  cause. f 

(2)  Much  less  common  thau  disease  within  the  internal  ear  are 
lesions  of  the  nerve-trunk  in  the  internal  auditory  meatus  or  at  the 
base  of  the  brain.  The  nerve  suffers  chiefly  from  disease  commencing 
outside  it,  especially  morbid  growths  or  meningitis,  of  syphilitic  or 
other  nature,  and  aneurisms.  Inflammation  readily  invades  it,  on  ac- 
count of  the  slight  protection  afforded  by  its  sheath.  It  may  also  be 
compressed  in  consequence  of  thickening  of  the  cranial  bones  narrow- 
ing the  meatus.  Disease  arising  in  the  mrve  itself  is  rare  ;  tumours 
(neuromata),  interstitial  haemorrhage,  and  calcareous  nodules  have 
been  met  with.  Primary  inflammation  has  not  been  proved  to  occur, 
although  an  auditory  neuritis  analogous  to  ojrtic  neuritis  has  been 
suspected  in  cases  of  cerebral  tumour.  In  cases  described  as  rheu- 
matic neuritis  an  affection  of  the  labyrinth  is  more  probable. 

Primary  degeneration  of  the  nerve  occurs  occasionally  in  locomotor 
ataxy  (Erb,  "Wernicke).  A  case  is  mentioned  in  vol.  i  in  which  the 
progressive  limitation  of  the  range  of  hearing  made  such  atrophy  of 
the  auditory  nerve  highly  probable,  but  this  morbid  process  has 
certainly  been  sometimes  assumed  to  exist  without  sufficient  grounds, 
and  the  symptoms  of  simple  "  nervous  deafness  "  in  tabes  are  no  proof 
of  a  primary  atrophy.  Such  degeneration  has  also  been  met  with  as 
an  isolated  change,  chiefly  in  the  old,  as  in  a  woman  eighty-nine  years 
of  age  in  which  this  atrophy  was  found  by  Lucae.  Concretions  of 
phosphate  of  lime  have  also  been  observed  in  the  substance  of  the 
nerve  (Moos).  Long- continued  disease  of  the  nerve,  in  consequence 
of  disease  of  the  middle  ear,  has  been  supposed  to  lead  to  atrophy, 
but  the  evidence  is  inconclusive. 

(3)  The  nuclei  within  the  pons  may  be  damaged  by  haemorrhage, 
softening,  or  tumour,  but  seem  to  escape  more  frequently  than  other 
nuclei. 

(4)  Deafness  is  sometimes  produced  by  disease  above  the  nuclei. 
It  may  be  caused  (a.)  by  disease  which  damages  the  superficial  layer 

*  See  a  series  of  papers  by  Steinbrugge.  '  Zeitsebrift  f.  Ohrenb.,'  &c,  18S6-7-8, 
aud  Gradenigo,  '  Ann.  de  Mai.  de  l'Or./  1890. 

f  Lucae,  'Subjects.  Geliors-empfindungen,'  1884. 


AUDITORY  NERVE.  263 

of  the  tegmentum,  such  as  a  tumour  of  the  corpora  quadrigemiua;* 
(b)  by  disease  of  the  internal  capsule  ;  it  is  then  associated  with  hemi- 
ansesthesia  and  impairment  of  the  other  special  senses ;  (c)  by  disease 
of  the  cortex  in  the  upper  part  of  the  opposite  ternporo-sphenoidal 
lobe,  or  the  white  substance  within  it.f 

(5)  Loss  of  hearing  may  be  of  functional  origin.  In  hysteria  it  is 
common  as  part  of  hernianaesthesia.  In  anaemia  there  may  be  some 
loss  of  hearing,  which  may  pass  away  when  the  general  health  is  im- 
proved. Considerable  loss  of  blood  has  been  followed  by  absolute 
deafness,  analogous  perhaps  to  the  blindness  that  results  from  the 
same  cause  ;  after  death  no  morbid  condition  of  ear  or  nerve  has  been 
discovered. 

(6)  Lastly,  slight  persistent  defect,  having  the  characters  of  "  nerve- 
deafness,"  is  sometimes  congenital,  and  may  occur  in  several  members 
of  a  family  without  traceable  cause.  Some  defect  of  articulation 
may  accompany  it,  and  occasionally  general  mental  backwardness. 
The  condition  probably  depends  on  a  congenital  local  defect  of  the 
brain,  and  may  be  regarded  as  allied  to  that  of  congenital  deaf-mutism, 
which  is  apparently  analogous  in  nature  but  more  severe  in  degree. 

Symptoms. — Deafness,  the  indication  of  lessened  function  of  the 
auditory  nerves,  is  due  to  so  many  morbid  states  of  the  ear,  that  alone 
it  is  of  little  value  as  an  indication  of  an  affection  of  the  nerve.  For 
a  full  description  of  the  methods  of  examination  of  the  ear  the 
reader  is  referred  to  special  works.  J  Some  points  of  medical  import- 
ance may  be  here  mentioned.  When  the  deafness  is  due  to  obstruc- 
tion of  the  meatus,  or  to  disease  of  the  middle  ear,  i.  e.  whenever  there 
is  impaired  conduction  of  vibrations  to  the  internal  ear,  and  no  disease 
of  the  labyrinth  itself,  there  is  deafness  to  vibrations  that  reach  the 
ear  through  the  air,  while  those  that  are  conducted  through  the  bones 
of  the  skull  can  still  be  perceived.  A  vibrating  tuning-fork  held 
opposite  the  meatus  is  inaudible,  but  it  is  heard  at  once  if  placed  in 
contact  with  the  bone  of  the  skull.  In  cases  of  slighter  deafness,  in 
which  the  tuning-fork  can  be  heard  through  the  air,  defect  of  con- 
duction can  be  demonstrated  in  another  way.  Normally,  as  the 
vibrations  lessen,  they  can  be  heard  through  the  air  longer  than 
through  the  bone ;  when  the  fork  in  contact  with  the  skull  ceases  to 

*  See  chapter  on  "  Localisation." 

f  Deafness  in  the  left  ear,  with  left-sided  loss  of  sensation,  was  produced  by  a 
tumour  of  the  right  hemisphere  in  a  case  recorded  by  Strumpell,  'Neur.  Centralbl.  ' 
1882.  See  also  Sharkey's  case,  fig.  15,  p.  23.  In  a  man  of  seventy-nine  left- 
sided  deafness,  after  a  fall,  was  found  to  be  due  to  occlusion  of  the  right  posterior 
Sylvian  artery,  with  softening  of  the  region  adjacent  to  the  posterior  limb  of  the 
fissure  of  Sylvius,  the  ear  being  normal  (Kauffmann,  1886). 

X  An  examination  of  tbe  external  meatus  should,  of  course,  never  be  omitted,  and 
I  may,  in  passing,  mention  the  very  great  suitability  of  the  ophthalmoscope  fcr  this 
purpose.  A  three-inch  lens  should  be  held  over  the  speculum,  and  be  slightly  tilted 
to  get  rid  of  the  reflection.  The  lens  concentrates  the  light  on,  and  at  the  same 
time  magnifies,  the  membrana  tyinpani.     A  light  vulcanite  speculum  answers  best. 


264  CEAiNIAL    NERVES. 

be  heavd,  tbe  sound  can  still  be  perceived  if  the  instrument  is  held 
opposite  the  external  meatus  ("  Rinne's  test  ").  This  is  because  the 
receptive  mechanism  is  more  sensitive  to  vibrations  that  reach  it 
through  the  tympanum  and  chain  of  bones  than  to  those  which  it 
receives  from  the  bone  directly.  If  the  tuning-fork  cannot  be  beard 
longer  through  the  air  than  through  the  bone,  there  is  impaired  con- 
duction through  the  meatus  or  middle  ear.* 

Sounds  conducted  through  the  bone  are  intensified  by  closure  of  the 
external  meatus.  This  is  due  to  the  circumstances  that  vibrations 
escape  by  the  open  meatusf  (Mach),  and  that  the  closure  of  the 
meatus  intensifies  the  vibration  by  converting  the  cavity  into  a 
resonant  chamber  (Lucae).  The  intensification  shows  that  hearing 
through  the  bone  is  normal,  i.  e.  that  the  labyrinth  is  sensitive.  But 
it  is  a  less  convenient  test  than  simple  contact,  because  unobservant 
persons  often  fail  to  recognise  the  increase.  If  there  is  some  deafness 
to  sounds  through  the  air,  and  yet  the  tuning-fork  is  heard  longer 
through  the  air  than  through  the  bone,  i.  e.  the  hearing  through  air 
and  bone  have  their  normal  relation,  the  deafness  is  due  to  the  nerve 
or  labyrinth. 

Nerve-deafness  is  usually  greatest  for  sounds  of  high  pitch  and 
short  duration.  A  valuable  instrument  for  testing  the  audibility  of 
high-pitched  sounds  is  Galton's  whistle,  the  notes  of  which  reach  the 
limitation  of  hearing  and  extend  beyond  it. X  Deafness  to  all  its 
sounds  is  unquestionably  pathological,  and  inability  to  hear  the 
higher  notes  on  one  side  only  has  the  same  significance. 

The  high-pitched  short  sound  of  a  watch  furnishes  a  test  of  consi- 
derable value  and  delicacy  for  the  ability  to  hear  through  the  bone, 
but  caution  is  needed  in  drawing  inferences  from  the  results  obtained. 
The  best  method  of  using  it  is  to  close  the  meatus  by  pressing  back  the 
anti tragus,  and  first  to  hold  the  watch  near  but  not  in  contact  with 
the  root  of  the  zygoma,  and  then  to  press  it  firmly  against  the  bone. 
The  observation  may  be  repeated  against  the  mastoid  process.  If  the 
watch  is  heard  better  in  contact  than  when  not  in  contact,  the  func- 
tion of  the  labyrinth  is  not  impaired.  If  it  is  not  heard  better  in 
contact,  further  observations  may  be  made  with  the  tuning-fork.  If 
the  watch  is  heard  through  the  bone,  it  is  not  likely  that  the  tuning- 
fork  will  reveal  impairment.  If  the  sound  is  heard  through  the  bone 
but  not  so  loudly  as  normal,  we  cannot  infer  disease  of  the  labyrinth 

*  There  is  reason  to  believe  that  some  of  the  vibrations  reach  the  labyrinth  from 
the  hone  through  the  tympanum;  hut  that  vibrations  may  pass  to  the  labyrinth 
directly,  seems  proved  by  the  fact  (observed  by  Lucae)  that  when  the  membrane  and 
bones  of  the  tympanum  are  congenitally  absent,  sounds  can  still  be  heard  through 
the  bone. 

f  If  a  stethoscope  or  otoscope  is  applied  to  one  meatus,  sounds  entering  the  other 
ear  can  be  distinctly  heard;  the  old  adage,  "in  at  one  ear  and  out  at  the  other," 
having  thus  a  basis  of  literal  truth. 

J  A  cat  starts  up  when  a  note  is  (presumably)  sounded  which  is  quite  inaudible 
to  man. 


AUDITORY   NERVE.  265 

or  nerve,  "because  simple  anchylosis  of  the  stapes  will  reduce  bone 
conduction,  although  no  disease  of  the  middle  ear  will  extinguish  it 
(see  note  on  last  page).  But  during  the  degenerative  period  of  life, 
after  fifty  or  sixty  years  of  age,  it  is  very  common  for  the  watch  not 
to  be  heard  through  the  bone,  although  there  is  no  other  evidence  of 
impaired  function.  The  loss  apparently  depends  on  the  labyrinthine 
changes  incidental  to  age  already  mentioned.  During  the  first  half 
of  life  it  is  rare  to  find,  bone-deafness,  except  as  a  pathological  condi- 
tion, and  this  is  true  at  any  age  if  the  defect  exists  on  one  side  only. 
Even  after  middle  life  a  bilateral  loss  is  of  significance  if  associated 
with  deafness  to  Galton's  whistle  through  the  air. 

The  state  of  hearing  through  the  bone  is  of  special  importance  to 
the  physician,  because  it  indicates  the  functional  state  of  the  internal 
ear  and  nerve,  and  eliminates  the  morbid  states  of  the  conducting 
media,  the  meatus  and  tympanic  cavity.  It  is  assumed  that  the  vibra- 
tions pass  from  the  hone  directly  to  the  labyrinth  (see  note  on  pre- 
ceding page). 

Another  indication  of  impaired  function  of  the  nerve  is  an  altered 
electrical  reaction,  first  ascertained  by  Brenner,  and  since  studied  by 
Erb,  Gradenigo,  and  others.  But  this  is  little  employed  in  diagnosis. 
The  attempt  to  obtain  it  often  causes  vertigo ;  a  current  of  mode- 
rate strength  (10 — 16  niilliamperes)  gives  a  reaction  only  in  a  small 
percentage  of  normal  individuals,  and  the  order  of  response  is  vari- 
able ;  moreover  an  alteration  occurs  in  morbid  states  of  the  middle  ear 
as  well  as  in  affections  of  the  nerve,  and  in  the  latter  is  sometimes 
absent. 

We  have  no  means  of  distinguishing  between  disease  of  the  labyrinth 
and  nerve  except  by  the  associated  symptoms.  In  each  case  the 
deafness  is  the  same,  and  is  often  associated  with  symptoms  of  irrita- 
tion—  subjective  sounds.  If  the  facial  nerve  is  paralysed,  and  there 
is  no  disease  of  the  middle  ear  or  bone,  we  may  feel  sure  that  the 
nerves  are  affected  at  the  base  of  the  brain  or  in  the  internal  meatus.* 
A  basal  affection  is  also  probable  if  any  other  nerve  near  the  audi- 
tory (as  the  sixth)  suffers  with  it.  In  some  instances  the  auditory 
nerve  is  damaged  without  the  facial  at  the  base  of  the  brain  because 
the  resisting  power  of  the  'portio  mollis  is  less  than  that  of  the  portio 
dura.  This  is  especially  the  case  in  meningitis,  in  which  the  facial 
nerve  has  been  found  but  little  damaged,  while  the  auditory  was 
softened  and  infiltrated  with  the  products  of  inflammation  and  with 
extravasated  blood  (Gradenigo). 

*  If,  with  this  combination  of  symptoms,  there  is  also  disease  of  the  middle  ear, 
it  is  probable  that  the  facial  nerve  and  the  labyrinth  are  affected  by  extension  of 
disease  from  the  tympanum,  but  this  diagnosis  is  not  certain,  as  a  case  recorded  by 
Schwartze  shows.  In  spite  of  disease  of  the  middle  ear,  the  deafness  and  facial 
paralysis  were  found  to  depend  on  a  tubercular  tumour  springing  from  the  dura 
mater,  and  compressing  the  trunks  of  the  facial  and  auditory  nerve  ('  Beitrage  zur 
Path,  des  Ohres,'  1870). 


266  CRANIAL   NERVES. 

The  symptoms  of  disease  of  the  auditory  nuclei  in  the  medulla  are 
still  little  known.  In  several  recorded  cases,  disease  of  the  nuclei  on 
one  side  has  caused  deafness  in  the  ear  on  the  same  side.  But  we  do 
not  know  whether  this  relation  is  invariable,  whether  unilateral  dis- 
ease always  causes  deafness  on  the  same  side,  or  whether  the  connec- 
tion of  nucleus  and  ear  is  in  part  crossed.*  Moreover,  extensive 
damage  to  the  nuclei  has  been  found  when  no  deafness  was  noted. 
Nuclear  disease  may  be  suspected  if  deafness  comes  on  suddenly, 
together  with  other  symptoms  of  a  lesion  of  the  pons  or  medulla, 
especially  with  weakness  of  the  limbs  on  the  opposite  side.  Sudden 
deafness,  alone,  is  of  no  localising  significance,  because  either  the 
trunk  of  the  nerve  or  the  labyrinth  may  be  the  seat  of  sudden  haemor- 
rhage. Deafness  of  gradual  onset,  in  association  with  bulbar  sym- 
ptoms, is  also  of  little  significance  as  regards  disease  of  the  nucleus, 
since  it  is  more  frequently  due  to  pressure  on  the  nerve.  Deafness, 
with  hemianeesthesia  or  hemiplegia  on  the  same  side,  is  probably  due 
to  disease  of  the  cerebral  hemisphere. 

Bilateral  deafness  may  be  due  to  various  causes  : — (1)  Symmetrical 
disease  of  the  labyrinth,  which  is  common  ;  acute  inflammation  is 
sometimes,  and  chronic  degeneration  is  often,  bilateral.  Double  otitis 
interna  has  sometimes  been  mistaken  for  meningitis,  especially  in  the 
young,  in  whom  it  is  attended  with  fever,  and  sometimes  with  general 
cerebral  symptoms  and  even  convulsion.  It  may  cause  unsteadiness 
of  movement,  but  this  is  usually  transient  from  bilateral  disease.  (2) 
Symmetrical  lesions  of  the  two  auditory  nerves,  which  are  very  rare. 
(3)  Possibly  disease  of  the  medulla.  (4)  A  tumour  in  the  corpora 
quadrigemina,  damaging  the  crustae  of  the  crura  cerebri.  (5) 
Symmetrical  disease  of  each  temporo- sphenoidal  lobe ;  syphilitic 
gummata  caused  this  effect  in  a  case  recorded  by  Wernicke  and 
Friedlander. 

The  pathological  changes  in  disease  of  the  labyrinth  are  outside  our 
province.  Those  of  disease  of  the  nerve-trunk  are  multiform  and 
variable,  depending  on  the  nature  of  the  primary  lesion.  Evidence  of 
inflammation,  differing  in  extent  and  degree,  is  present  in  acute 
meningitis,  and  at  a  later  stage,  or  hi  chronic  processes,  degeneration 
of  the  fibres  is  found.  It  deserves  note,  however,  that  when  these 
have  been  destroyed  for  many  years  (e.  g.  by  meningitis)  the  cells  of 
the  auditory  nuclei  have  been  found  normal. f 

Tbeatmbnt. — For  a  description  of  the  little  that  can  be  done  in  the 
treatment  of  disease  of  the  labyrinth  the  reader  is  referred  to  special 
treatises.     The  treatment  of  disease  of  the  nerve-trunk  or  centres  is 

*  See  a  curious  ca;e  of  tumour  of  the  right  cerebellar  amygdala  (Wolf,  '  Ai  chiv 
f.  Ohrenheilk.,'  Bd.  xvi,  p.  157)  which  compressed  the  right  auditory  region,  and  is 
said  to  have  caused  deafness  of  the  left  ear  and  left  facial  paralysis.  The  latter, 
however,  might  have  been  due  to  a  tumour  that  existed  in  the  ascending  parietal 
convolution. 

t  Scliultze, «  Virchow's  Archiv,'  Bd.  cxix,  1890. 


AUDITORY    J^EKVE.  267 

for  the  most  part  that  of  the  morbid  process,  and  mnst  be  conducted 
on  the  same  principles  as  that  of  similar  lesions  in  the  other  cranial 
nerves.  In  cases  of  acute  deafness,  counter-irritation,  as  by  blisters, 
is  often  of  great  service,  and  even  in  chronic  cases  may  do  some  good. 
The  auditory  nerve  maj  be  stimulated  by  electricity'',  but  the  results 
obtained  by  most  of  those  who  have  employed  this  method  have  been 
slight  and  disappointing. 


Auditory  Hyperesthesia. 

The  term  is  applied  to  an  increased  or  perverted  action  of  the  audi- 
tory nerve  or  centres.  While  deafness  is  much  more  frequently  due 
to  diseases  of  the  ear  than  to  morbid  states  of  the  nerve,  the  opposite 
is  true  of  hypersesthesia,  which  is  commonly  due  to  altered  nerve- 
function. 

(1)  True  hypersesthesia,  increased  keenness  of  hearing,  "hyperacu- 
sis,"  is  a  rare  morbid  state  in  which  sounds  are  heard  with  undue 
loudness,  and  even  such  as  are  inaudible  to  other  persons  are  dis- 
tinctly perceived.  It  occurs  chiefly  in  hysteria,  usually  in  association 
with  augmented  acuteness  of  other  senses,  and  is  probably,  in  such 
cases,  of  central  origin.  It  has  also  been  observed  at  the  onset  of 
acute  cerebral  and  general  diseases,  and  may  co-exist  with  tinnitus  as 
a  consequence  of  the  same  cause.  The  changes  that  give  rise  to 
spontaneous  sounds  may  increase  the  intensity  of  those  that  are  heard, 
as  cutaneous  hyperaesthesia  occurs  in  neuralgia  and  superficial  tabetic 
pain.  The  hyperacusis  may  be  very  marked  for  the  high  notes  of 
Galton's  whistle. 

From  true  hyperaesthesia  we  must  distinguish  certain  forms  of 
hyperacusis  due  to  disorder  of  the  conducting  mechanism.  In  para- 
lysis of  the  stapedius  muscle,  from  disease  of  the  facial  nerve,  low 
notes  may  be  heard  with  undue  loudness. 

(2)  Auditory  Dysesthesia,  "  Dysacusis." — Sounds,  although  not 
heard  with  undue  loudness,  cause  discomfort.  This  is  common  in 
cerebral  affections,  functional  and  organic,  during  attacks  of  head- 
ache, in  many  cases  of  meningitis,  &c.  The  pain  in  the  head  seems 
to  be  intensified  by  the  noise.  There  is  no  evidence  that  irritation 
of  the  auditory  fibres  ever  produces  pain  directly.  Politzer  has  indeed 
recorded  a  case  of  labyrinthine  disease  in  which  chords  played  on  an 
harmonium  caused  a  distinct  sensation  of  pain,  while  single  notes  did 
not ;  but  the  case  stands  alone,  and  it  is  probable  that  the  pain  was 
produced  in  some  indirect  manner. 

The  treatment  of  these  forms  of  auditory  over-action  is  that  of  the 
morbid  state  with  which  they  are  connected,  and  the  nature  of  this  is 
usually  obvious.  If  direct  treatment  is  needed,  full  doses  of  bromide 
of  potassium  have  most  influence  in  diminishing  the  morbid  excita- 
bility. 


26S  CKAN1AL   NERVES. 

Irritation  of  the  Auditory  Nerve  ;  Tinnitus  Aurium. 

Subjective  souuds  are  of  vaiied  character  aud  still  more  varied 
origin.  Thej  constitute  a  common  ailment,  aud  one  that  is  often  most 
distressing  and  intractable,  which  disturbs  the  whole  nervous  system, 
and  thus  tends  to  become  worse.  Its  frequency  is  not  surprising. 
When  we  consider,  on  the  one  hand,  how  exquisitely  sensitive  the  organ 
of  hearing  is,  how  slight  a  vibration  will  affect  it,  and,  on  the  other 
hand,  the  facts  that  around,  and  even  within  it,  blood  is  in  constant 
and  muscle  in  frequent  motion,  and  that  all  parts  of  it  are  liable  to 
disease  of  various  nature,  the  marvel  is  rather  that  silence  is  habitual. 
It  has  indeed  been  thought,  with  reason,  that  the  apparent  silence  is 
due  to  cerebral  inattention,  and  not  to  peripheral  inactivity.  In  a 
quiet  room,  continuous  auditory  sensations  may  be  noticed,  of  which 
we  are  normally  unaware,  just  as  in  the  dark  the  field  of  vision  may 
be  found  full  of  moving  points  of  light,  or  sensations  may  be  per- 
ceived from  any  part  of  the  body. 

Almost  any  morbid  process  in  any  part  of  the  ear  may  cause  sub- 
jective sounds ;  they  may  result  also  from  sound-producing  processes 
in  and  about  a  normal  ear,  as  well  as  from  irritation  of  the  auditory 
nerve  and  centres  within  the  skull.  But  of  all  the  causes,  changes  in 
the  labyrinth  are  by  far  the  most  common  ;  evidence  of  "  nerve- deaf- 
ness," mostly  due  to  changes  in  the  internal  ear,  are  distinct  in  four 
fifths  of  the  cases  which  come  under  the  physician's  notice.  The 
experience  of  aural  surgeons  seems  to  furnish  a  large  proportion  of 
cases  of  disease  of  the  middle  ear,  but  for  this  there  may  be  special 
reasons.  -In  a  few  cases  the  symptoms  suggest  that  the  morbid  pro- 
cess is  wholly  in  the  auditory  centres,  the  nucleus  of  the  nerve  or 
cortical  structures. 

The  chief  predisposing  causes  are — (1)  those  that  lead  to  labyrin- 
thine disease,  among  which  gout  is  especially  frequent ;  and  (2)  a 
neurotic  disposition,  which  probably  acts  by  rendering  the  nerve- 
elements  prone  to  generate  impulses  when  diseased,  and  by  disposing 
the  centres  to  intensify  these  impulses,  and  even  to  produce  them  in 
some  cases  of  central  origin.  Many  sufferers  have  been  liable  to 
neuralgia  (with  which  tinnitus  presents  analogies),  to  periodical 
headaches,  to  typical  migraine,  or  to  cephalic  sensations  of  various 
character.  The  symptom  is  very  rare  in  the  young  ;  in  most  sufferers 
it  begins  after  middle  life,  and  it  is  common  in  the  old. 

The  more  direct  causes  may  be  thus  enumerated  : — (1)  The  blood- 
currents  within  and  near  the  ear,  which  normally  give  rise  to  no  sound, 
may  be  so  changed  that  they  cease  to  be  noiseless.  In  anaemia, 
vibrations  occur  in  the  blood  with  undue  readiness,  and  a  pulsating 
murmur  may  be  heard,  probably  produced  in  the  carotid  artery.  A 
similar  murmur  may  also  arise  in  an  intra-cranial  aneurism.  Vaso- 
motor paralysis  of  the  labyrinthine  vessels  has  probably  been  the 
cause  of  a  subjective  sound  observed  in  a  case  of  disease  of  the  cervical 


AUDITORY    NERVE.  269 

spiue,  pressing  on  the  vertebral  artery  along  which  the  sympathetic 
fibres  run.  A  similar  mechanism  may  have  been  effective  in  another 
case  in  which  there  was  enlargement  of  the  glands  of  the  neck  ad- 
jacent to  the  sympathetic ;  the  noise  ceased  when  the  glands  became 
small.*  Perhaps  dilatation  of  the  small  arteries  within  the  ear  may 
give  rise  to  a  similar  sound,  and  if  tinnitus  is  ever,  as  is  asserted,  of 
reflex  origin,  it  may  be  thus  produced.  Pulsating  sounds  are,  as  a  rule, 
arrested  or  lessened  by  compression  of  the  carotid  artery  in  the  neck. 

(2)  Tinnitus  may  attend  every  form  of  ear  disease — accumulation  of 
cerumen  or  growths  in  the  external  meatus;  inflammation  of  the  middle 
ear,  catarrhal,  plastic,  or  suppurative ;  spasmodic  contractions  of  the 
tympanic  muscles,  and  various  morbid  states  of  the  labyrinth.  The 
precise  mechanism  by  which  the  sounds  are  produced  is  a  matter  of 
conjecture  ;  vascular  congestion,  increased  labyrinthine  pressure,  and 
irritation  of  the  nerve-endings  or  the  structures  connected  with  them, 
have  all  been  assumed,  and  may  all  be  operative  in  different  cases. 

(3)  Organic  changes  that  irritate  the  fibres  of  the  auditory  nerve  or 
its  centres  may  cause  subjective  sensations  of  sound,  and  these  may 
therefore  be  present  as  a  symptom  of  any  of  the  morbid  states  already 
mentioned  as  affecting  these  parts,  and  producing  loss  of  hearing, 
degeneration,  concretions,  &c. 

(4)  Lasting  tinnitus  sometimes  follows  a  fall  in  which  the  head 
is  struck.  In  some  cases  there  are  signs  of  labyrinthine  deafness ; 
occasionally  there  is  hyperacusis  and  no  deafness. 

(5)  Intense  stimulation  of  the  auditory  nerve,  as  by  a  loud  railway 
whistle,  has  been  known  to  set  up  a  lasting  subjective  sound,  but  by 
what  mechanism  is  unknown.  Habitual  exposure  to  sounds  may 
cause  tinnitus,  usually  slight  in  degree ;  musicians,  piano  tuners, 
smiths,  &c,  are  said  to  suffer  occasionally  in  this  way. 

(6)  Subjective  sounds  are  certainly  sometimes  due  to  a  functional 
disturbance  of  the  auditory  centres,  and  probably  have  this  origin  in 
cases  in  which  we  cannot  feel  sure  of  the  fact.  In  migraine,  parox- 
ysmal sounds  sometimes  occur,  although  they  are  a  rare  symptom. 
Such  sounds  are  more  common  as  the  aura  of  an  epileptic  seizure ;  it 
is  probable  that  they  are  due  to  disturbance  in  the  cortical  auditory 
centre,  since  organic  disease  in  this  position  may  cause  such  a  sound 
as  the  warning  of  a  convulsion. f  That  continuous  tinnitus  some- 
times results  from  central  functional  disturbance  is  suggested  by 
the  elaboiute  character  of  the  sounds.  In  various  conditions  of 
nervous  exhaustion  and  excitability,  tinnitus  may  arise  without  im- 
pairment of  hearing.  Of  the  pathology  of  these  cases  nothing  is 
certainly  known,  but  it  is  probable  that  they  are  due  to  defective 
nutrition  of  the  nerve-elements,  central  or  peripheral. 

It  must  be  remembered  that  tinnitus  is  perceived  in  consequence 
of  the  activity  of  the  cortical  nerve-cells,  and  that  in  labyrinthine 

*  These  two  cases  are  recorded  by  Brandeis, '  Zeitsch.  f .  Ohrenbeilk.,'  xi,  1882,  p.  294. 
f  See  p.  24 ;  also  "  Localisation." 


270  C1UNIAL    NERVES. 

disease  there  must  be  an  intermediate  excitation  of  the  auditory 
nuclei.  The  susceptibility  of  the  nerve- cells  will  be  increased  by 
whatever  impairs  the  general  nutrition  of  the  nervous  system,  and 
hence  the  effect  of  ill-health,  mental  disturbance,  and  the  like,  in 
making  the  sounds  loudei','  can  be  understood.  Moreover,  the  sym- 
ptoms of  many  cases  suggest  that,  even  when  tinnitus  is  ultimately 
due  to  changes  in  the  ear,  it  may  be  increased,  maintained,  and 
modified  in  character  by  derangement  of  the  function  of  the  auditory 
centres.  Their  continuous  activity  must  entail  secondary  changes  in 
their  nutrition  and  function,  which  may  well  proceed  to  independent 
co-operation,  especially  in  those  predisposed  to  disturbance  of  the 
nervous  system.  On  this  hypothesis  many  facts,  otherwise  obscure, 
become  clear. 

Symptoms. — The  sounds  may  be  referred  to  one  or  both  ears,  or  to 
the  head,  either  behind  or  above  the  ear,  the  occiput  or  the  vertex. 
This  is  sometimes  called  "  tinnitus  capitis."  The  sounds  are  extremely 
various  in  character  and  intensity.  Slight  sounds  may  be  low-pitched, 
a  low  rumble  like  a  distant  waggon,  or  a  faint  murmur  such  as  may- 
be heard  when  a  shell  is  held  up  to  the  ear.  Louder  sounds  are 
rarely  low  in  tone.  They  may  be  humming,  hissing,  rushing,  or 
roaring  noises.  A  common  simile  is  that  of  an  engine  or  threshing 
machine,  or  the  hissing  of  a  kettle  or  a  gas  jet,  while  still  louder 
noises  are  compared  to  that  of  a  steam-engine  close  at  hand,  or  a 
waterfall,  or  to  a  room  full  of  machinery  in  motiou.  Others  again, 
less  common,  are  like  the  sound  of  a  bell,  or  of  many  bells  jangling 
at  a  distance,  while  still  more  elaborate  sensations  may  resemble 
music  or  voices.  Definite  words  are  seldom  heard,  except  in  cases  of 
insanity  or  epilepsy. 

It  is  common  for  sounds  to  vary  at  different  times.  In  a  case  of 
bilateral  nerve-deafness,  a  continuous  loud  rushing  sound,  referred 
to  the  head,  would  sometimes  stop  for  a  few  minutes,  and  begin 
ao-ain  as  a  whistle,  to  pass  presently  into  its  usual  form.  With  the 
same  condition,  another  patient  described  four  sounds,  hissing, 
whistling,  &c,  which  were  sometimes  successive  and  sometimes 
seemed  all  to  be  heard  at  once. 

An  important  difference  in  the  more  simple  sounds  is  their  con- 
linuity.  Some  are  rhythmical,  and  then  are  usually  synchronous 
with  the  pulse ;  others  are  continuous  and  unvarying.  The  signifi- 
cance of  the  synchronism  is  that  the  sound. is  due,  directly  or  indirectly, 
to  the  influence  of  arterial  pulsation,  but  its  ultimate  cause  may  be 
either  an  increase  of  this  pulsation  or  an  increased  sensitiveness  of 
the  nerve-structures.  Hence  the  sound  is  intermitting,  not  only  in 
aneurism,  but  in  anaemia,  and  also  in  many  diseases  of  the  middle 
ear,  and  in  some  labyrinthine  affections,  and  even  occasionally  in 
morbid  states  of  the  centre.*  Sounds  of  central  origin  are  generally 
*  That  intermittent  sounds  may  be  of  central  origin  is  certain,  from  the  facts  of 


AUDITORY    NERVE.  271 

continuous ;  but  continuous  sounds  are  also  often  clue  to  ear  disease, 
labyrinthine  or  tympanic,  and  even  to  accumulations  of  wax  in  the 
meatus.  In  one  case  of  slight  bilateral  labyrinthine  deafness,  a  con- 
tinuous sound,  referred  to  the  vertex  (sometimes  like  distant  bells) 
was  accompanied,  when  the  patient  was  tired,  by  a  pulsating  sound, 
in  one  ear.  In  another,  of  similar  character,  the  sound,  also  referred 
to  the  head,  was  sometimes  a  continuous  hiss,  sometimes  a  pulsating 
noise.  Thus  this  feature  of  tinnitus  affords  little  help  in  the  dia- 
gnosis of  its  cause.  Elaborate  sounds  are  generally  of  central  origin. 
A  lady,  for  twenty  years,  has  heard  the  sound  of  music;  no  actual 
tune  can  ever  be  distinguished,  but  she  states  tbat  were  it  not  for  its 
persistence  the  sound  would  be  pleasant :  no  affection  of  the  ear  can 
be  discovered.  Auditory  hallucinations  of  the  insane,  altbough  of 
cerebral  origin,  are  sometimes  determined  by  the  presence  of  ordinary 
tinnitus,  which  existed  before  the  onset  of  the  hallucinations.  The 
sounds  that  are  heard  in  epilepsy  may  be  simple  or  elaborate,  or  both. 
Thus,  before  severe  and  during  minor  attacks,  one  patient  heard  a 
noise  like  the  sea  waves  breaking,  and  with  this  a  distinct  sound  of 
the  voices  of  friends  ;  as  the  attack  was  passing  off  she  always  seemed 
to  hear  her  husband  telling  her  not  to  be  alarmed,  even  when  he  was 
not  present.  The  aura  of  tinnitus  may  also  be  accompanied  by  com- 
plete word-deafness,  a  complex  condition  combining  inhibition  and 
discharge  (see  "Epilepsy"). 

At  the  beginning  of  the  affection,  the  sound,  especially  if  slight  and 
of  a  familiar  character,  may  be  thought  to  have  an  actual  objective 
origin.  This  is  especially  the  case  when  the  sound  is  elaborate.  One 
patient  sent  a  message  to  his  next  door  neighbour,  asking  that  a 
clock  might  be  moved,  the  loud  striking  of  which  annoyed  him  ;  he 
had  no  idea  that  the  sound  was  subjective  until  informed  that  there 
was  not  a  striking  clock  in  his  neighbour's  house.  In  most  cases, 
however,  the  real  nature  of  the  sound  is  quickly  recognised.  The 
sound  is  usually  referred  by  the  patient  to  the  ear;  when  it  seems 
to  be  in  the  head  generally,  the  difference  depends  in  part  on  the 
loudness  of  the  sound  and  partly  on  its  bilateral  character,  on  its 
source,  and  also  on  conditions  we  do  not  yet  understand.  The  influ- 
ence of  intensity  was  shown  by  one  patieut  who  said  that  the  sound, 
as  a  rule,  seemed  to  be  in  the  ears,  but  when  it  became  more  intense 
it  seemed  to  be  within  the  skull.  The  effect  of  the  bilateral  character 
of  the  sound  on  its  apparent  seat  agrees  with  the  fact  that,  under 
normal  circumstances,  a  sound  conveyed  simultaneously  to  both  ears 
by  a  double  tube  is  referred  to  some  region  in  the  middle  line  of  the 
skull,  the  precise  locality  varying  in  different  persons.  But  sounds 
are  not  seldom  referred  to  the  head  when  there  is  nerve-deafness  on 

epilepsy.  I  have  elsewhere  recorded  a  case  in  which  part  of  the  aura  was  an  inter- 
mittent hissing,  evidently  synchronous  with  the  pulse,  and  succeeded  by  two  bright 
lights,  which  seemed  to  npproach  the  patient  by  jerks,  of  the  same  rhythm  as  the 
preceding  sounds  ('Epilepsy,  &c.,'  p.  67). 


272  CRANIAL    NERVES. 

one  side  only,  sometimes  to  some  pai*t  of  the  hinder  half  of  the  head 
on  that  side,  rarely  to  the  vertex. 

Why  sounds  should  ever  be  referred  to  the  head  may  seem  a  dif- 
ficult problem,  since  in  all  normal  stimulation  of  the  auditory  nerve 
the  cause  of  this  is  referred  to  an  external  source.  The  solution  of 
the  difficulty  is  perhaps  to  be  found  in  two  facts.  (1)  Vibi'ations 
that  reach  the  labyrinth  by  the  bones  of  the  skull  are  referred  to 
the  bone  ;  this  agrees  with  the  fact  (see  p.  264)  that  the  vibrations 
reach  the  labyrinth  directly,  and  must  influence  the  nerve-endings  in 
a  special  manner,  differing  from  that  produced  by  vibrations  that  pass 
through  the  chain  of  bones  in  the  middle  ear.  It  is  easy  to  under- 
stand that,  in  labyrinthine  disease,  the  irregular  irritation  of  the 
nerve-endings  should  correspond  to  the  former  rather  than  to  the 
latter  form  of  excitation,  and  that  a  similar  irregular  excitation 
should  occur  in  the  cells  of  the  cerebral  structures  in  some  cases  of 
tinnitus  produced  in  them.  (2)  Many  of  the  sounds  conducted 
through  the  middle  ear  are  elaborate  in  character,  and  when  such 
subjective  sounds  occur  they  are  usually  referr<  d  to  a  source  external 
to  the  body,  even  though  they  are  due  to  central  disturbance. 

The  sounds  may  vary  from  time  to  time  in  their  intensity.  Such 
variations  may  be  distinctly  dependent  on  the  general  health  of  the 
patient ;  the  sounds  may  lessen  or  even  cease  during  good  health,  and 
may  ii. crease  when  nervous  tone  or  general  strength  is  lowered. 
Occasionally  tinnitus  is  slight  or  absent  at  certain  periods  of  the 
day,  or  absent  on  one  day  and  loud  on  another,  without  any  obvious 
cause  for  the  variation.  It  may  be  at  first  paroxysmal,  afterwards  con- 
tinuous. A  sudden  increase  is  occasionally  met  with,  and  in  some 
cases  attacks  of  labyrinthine  vertigo  are  heralded  by  increasing  inten- 
sity of  sound,  compared  even  to  the  whistle  of  a  swiftly  passing  train. 

The  effect  of  external  noises  may  be  to  increase  or  lessen  the  sub- 
jective sound.  Either  condition  may  be  met  with  in  labyrinthine 
disease.  In  one  such  case  the  tinnitus  always  ceased  with  still- 
ness and  was  excited  by  sounds;  the  singing  in  church  (the  patient 
was  a  clergyman)  caused  distressing  noises.  But  it  is  more  common 
for  considerable  sounds  to  make  slight  tinnitus  inaudible  which  is 
always  perceived  when  there  is  no  noise,  and  hence  many  patients 
suffer  much  at  night.  Sounds  may  not  only  prevent  the  tinnitus 
being  noticed  ;  they  may  actually  arrest  it.  In  one  patient  in  whom 
the  tinnitus  probably  had  its  source  in  the  auditory  nucleus,  it  was  at 
once  stopped  if  she  sounded  even  a  soft  musical  note  with  her  own 
voice.  The  tinnitus  came  on  every  evening,  and  lasted  twelve  hours ;  it 
was  a  continuous  loud  rushing  noise,  referred  to  the  head  between  the 
ear  and  occiput,  with  no  trace  of  deafness,  but  with  other  indications 
of  central  disturbance,  e.  g.  attacks  of  numbness  in  the  night  in  one 
thigh.  In  rare  instances,  loud  noises  increase  the  sound  and  slight 
ones  lessen  it,  as  in  a  case  of  bilateral  tinnitus  with  impaired  nerve- 
hearing  on  one  side  only. 


AUDITORY    NERVE.  273 

The  state  of  hearing  presents  four  conditions  in  these  cases.  (1) 
As  we  have  seen,  nerve-deafness  is  common  on  one  or  both  sides.  It 
may  be  one-sided  when  sounds  are  referred  to  both  ears  ;  when  this 
deafness  exists,  the  morbid  process  that  irritates  the  auditory  nerve  also 
impairs  its  function,  or  hinders  the  passage  of  vibrations  through  the 
ear.  In  some  cases  of  progressive  disease,  the  deafness  gradually 
increases,  while  the  noises  become  less,  and  they  may  cease  altogether 
when  the  patient  is  entirely  deaf.  In  other  cases,  the  noises  continue 
in  spite  of  absolute  loss  of  hearing.  (2)  Hearing  may  be  perfectly 
normal  to  every  test.  (3)  The  tinnitus  seems  to  render  the  patient 
deaf  while  it  lasts,  as  we  haye  just  seen.  This  is  chiefly  met  with  when 
the  sounds  are  paroxysmal  in  existence  or  intensity.  The  patient 
may  have  "  to  strain  every  nerve  to  hear,"  and  in  rare  cases  there  is 
distinct  interference  with  the  action  of  the  auditory  centres.  In  one 
case,  the  paroxysms  coincided  with  darting  pain  through  the  base  of 
the  skull,  and  distinct  word-deafness;  words  were  heard  with  difficulty, 
and  their  meaning  could  not  be  made  out.  There  was  no  evidence  of 
ear  disease.  (4)  There  may  be  increased  sensitiveness,  hyperacusis, 
either  during  attacks  of  tinnitus  or  persistent. 

A  sound  produced  in  an  inti-a-cranial  aneurism  (of  the  internal 
carotid  or  vertebral)  may  be  heard  by  another  person  on  listening 
through  a  stethoscope  applied  to  the  skull.  In  extremely  rare  cases, 
sounds,  apparently  of  intra-aural  origin,  have  also  been  audible  on 
auscultation,  as  in  the  case  of  a  boy,  eight  years  of  age  (observed  by 
Greene*),  in  whom  an  aneurism  was  most  unlikely.  In  another  case,  a 
pulsating  sound,  resulting  from  some  effect  of  a  blow  two  weeks  before, 
could  be  heard  eight  inches  from  the  patient. f 

The  sound  of  muscular  contraction  within  the  ear  has  a  peculiar 
vibratory  character,  and  is  probably  usually  produced  by  the  stapedius 
muscle,  possibly  sometimes  by  the  tensor  tympani.  The  former  is  sup- 
plied by  the  facial  nerve,  audits  central  connections  are  l'elated  to  those 
for  the  orbicularis  palpebrarum,  so  that,  in  many  persons,  a  strong 
contraction  of  the  orbicularis  is  accompanied  by  this  peculiar  sound  in 
the  ear.  The  same  sound  may  accompany  facial  spasm  (see  p.  254). 
The  function  of  the  stapedius,  like  that  of  the  orbicularis,  is  to  guard 
the  sense-organ, — to  prevent  the  base  of  the  stapes  being  driven  too 
far  into  the  foramen  by  an  excessive  movement  of  the  membrana 
tympani.  The  tensor  tympani  may  have  been  involved  in  a  case  in 
which  a  "  fluttering "  in  the  ear,  for  five  or  ten  minutes  at  a  time, 
accompanied  attacks  of  pain  in  a  case  of  senile  degenerative  neuralgia. 
Clicking  sounds  are  probably  due  to  the  action  of  the  muscles  con- 
nected with  the  Eustachian  tube.  These  also  are  sometimes  audible  bv 
another  person.  J  In  one  case  clonic  spasm  of  the  levator  palati  gave 
rise  to  such  a  sound,  repeated  120  times  a  minute,  and  audible  twenty 

*  Greene,  'Trans.  American  Otolo°;ical  Society/  1878. 
f  Poosten,  'Monatsbl.  f.  Ohrenheilk./  1878,  No.  4. 
J  Backer,  '  Zeitschr.  f.  Ohrenheilk./  xiv,  1S85,  237. 
VOL.  II.  18 


274  CEANIAL   NERVES. 

feet  from  the  patient.  It  ceased  only  during  sleep*  As  already 
stated,  tinnitus  is  often  associated  with  neuralgia,  headache,  and 
various  manifestations  of  the  "nervous"  temperament.  The  last 
are  often  induced  by  the  affection,  which,  when  it  interferes  with 
sleep,  may  have  an  intensely  depressing  influence,  and  it  has 
been  known  more  than  once  to  induce  a  hopeless  sufferer  to  end  his 
life. 

Diagnosis. — The  characters  of  the  tinnitus  thus  afford  little  help  in 
diagnosis,  except  that,  in  the  rare  cases  in  which  the  sound  is  elaborate 
it  is  almost  certainly  of  central  origin.  An  aneurism  is  probable  if 
the  sound  is  audible  on  auscultation,  and  certain  if  this  coincides  with 
the  symptoms  of  a  basal  tumour.  But  in  all  cases  the  chief  indication 
of  the  cause  of  tinnitus  is  afforded  by  associated  symptoms.  The 
most  important  of  these  is  deafness,  which  is  present  in  the  majority 
of  cases.  The  cause  of  the  deafness  is,  as  a  rule,  the  cause  of  the 
tinnitus.  The  position  and  nature  of  the  disease  interfering  with 
hearing  must,  therefore,  be  ascertained  on  the  principles  already 
described.  If  must  be  remembered  that  disease  of  the  meatus  or 
middle  ear  can  only  cause  tinnitus  by  its  influence  on  the  labyrinth, 
either  by  increasing  the  labyrinthine  pressure  or  by  the  extension  of 
the  morbid  process.  If  there  is  evidence  of  disease,  not  of  the  middle 
ear  but  of  the  labyrinth  or  nerve-trunk,  we  can  only  distinguish 
between  these  by  associated  symptoms ;  if  they  are  absent  we  must  be 
guided  by  the  fact  that  disease  of  the  labyrinth  is  far  more  frequent, 
and  therefore  in  any  given  case  more  probable,  than  disease  of  the 
nerve,  and  that  this  is  especially  true  if  deafness  co-exists.  When 
tinnitus  is  due  to  organic  disease  of  the  centres,  other  definite  sym- 
ptoms are  rarely  absent,  and  indicate  its  seat  and  nature. 

But  the  questions  that  most  often  present  themselves  are — (1) 
whether  in  cases  of  labyrinthine  disease  the  auditory  centres  take  a 
share  in  producing  the  symptom  ;  (2)  when  there  is  no  deafness, 
whether  the  symptom  is  wholly  central,  or  (3)  is  due  to  irritation 
of  the  nerve-endings  that  does  not  lessen  their  function.  The  last 
is  suggested  only  when  deafness  has  existed  at  a  previous  time,  the 
first  when  elaborate  sounds  concur  with  evidence  of  labyrinthine 
deafness.  The  recognition  of  primary  central  tinnitus  presents  the 
greatest  difficulties.  It  is  only  justified  when  there  is  no  impairment 
of  hearing,  when  the  sounds  are  elaborate  in  character,  or  when 
simple  sounds,  referred  to  the  head,  occur  in  a  patient  who  suffers 
from  other  central  nerve  disturbances.  Instances  of  this  have  been 
already  mentioned  (as  the  case  of  neuralgic  tinnitus,  p.  273)  ;  it  was 
probable  in  a  young  man  who  suffered  from  headache,  head-pressure, 
and  varied  dyssesthesia,  in  whom  the  sound  was  a  continuous  "hiss- 
ing "  and  occasional  "  humming  "  or  "whistling,"  and  always  referred 
to  the  head. 

*  Williams,  '  Zcitsclir.  f .  Ohrenheilk.,'  xiii,  1884,  p.  99. 


AUDITORY    NERVE.  275 

Prognosis. — With  the  exception  of  the  cases  in  which  the  noise  is 
clue  to  removable  ear  disease  or  to  easily  remedied  constitutional  dis- 
turbance, the  prognosis  is  very  uncertain.  Iu  many  cases  the  noises 
persist  in  spite  of  all  treatment,  but  considerable  relief  is  sometimes 
obtained,  and  the  symptom  is  removed  not  unfrequently  if  the  condi- 
tions under  which  it  occurs  are  carefully  studied  and  treated. 

Treatment. — The  first  element  is  the  treatment  of  any  discover- 
able morbid  process  on  which  tinnitus  may  depend,  directly  or 
remotely.  This  causal  treatment  comprehends,  first,  the  removal,  as 
far  as  possible,  of  any  ear  disease  by  which  the  symptoms  may  have 
been  produced  ;  and,  secondly,  the  treatment  of  any  general  condition 
with  which  it  may  be  connected,  directly  or  indirectly, — anaemia,  defec- 
tive nerve-power,  gout,  syphilis.  Tinnitus  in  gouty  persons  is  often 
lessened  by  alkalies  and  free  purgation.  In  all  cases  the  general 
health  should  be  carefully  attended  to,  and  all  influences  that  increase 
the  noise  should  be  avoided.  Those  who  suffer  in  consequence  of 
habitual  exposure  to  sounds  should  obtain  rest  in  a  quiet  place,  and 
protect  themselves  by  obstructing  the  meatus.  If  snch  causes  are 
not  discoverable,  or  such  treatment  fails,  the  symptom  itself  must  be 
treated,  and  our  power  of  influencing  it  is  unfortunately  very  small. 

The  noise  is  sometimes  diminished  by  sedatives  that  lessen  nervous 
activity  and  over-activity.  Of  these  bromide  has  more  influence  than 
any  other  drug.  In  many  cases  its  effect  is  very  marked,  although  less 
than  on  the  giddiness  which  often  accompanies  the  noise.  It  should 
be  given  in  scruple  doses  two  or  three  times  a  day.  Hydrobromic  acid 
has  been  recommended,  but  seems  to  have  no  advantage  over  bromide, 
into  which  it  must  be  converted  as  soon  as  it  enters  the  alkaline  blood 
while  its  acidity  interferes  with  its  administration  in  adequate  doses.* 
The  effect  of  bromide  is  sometimes  increased  by  the  addition,  to  each 
dose,  of  tincture  of  belladonna  (n\x)  or  tincture  of  Indian  hemp 
(u\iij — v).  Morphia,  by  hypodermic  injection,  lessens  the  tinnitus  for 
a  time,  but  is  only  suitable  as  an  occasional  palliative  when  violent 
paroxysms  occur.  No  other  sedative  has  an  appreciable  effect  on  the 
noises. 

Counter-irritation  is  unquestionably  useful.  A  blister  behind  the 
ear  often  causes  the  sound  to  be  less  loud  for  a  week  or  ten  days  after 
the  application,  and  repeated  blisters  sometimes  produce  a  permanent 
diminution  in  the  intensity  of  tinnitus,  although  they  rarely  cause  it 
to  cease.  The  effect  is  manifest  in  cases  of  long  duration  as  well  as 
in  those  of  recent  origin,  and  cannot  therefore  be  ascribed  merely  to 
an  influence  on  inflammatory  processes. 

Drugs  that  are  known  to  interfere  with  the  functions  of  the  internal 
ear  have  been  given  in  the  endeavour  to  alter  the  morbid  action,  and 
in  the  hope  that  the  disturbance  produced  may  be  antagonistic  to  that 

*  The  dose  of  the  solution  of  hydrobromic  acid  usually  prescribed  is  20 — 60 
minims,  and  this  is  equal  only  to  3 — 8  grains  of  bromide  of  potassium. 


276  CEANIAL    NERVES. 

of  the  disease.  The  only  evidence  of  such  an  influence  is  the  produc- 
tion of  deafness,  tinnitus,  and  vertigo.  These  are  symptoms  common 
to  morbid  processes  of  varied  character  and  seat.  Politzer  noted  long 
ago  that  subjective  noise  "was  often  temporarily  reduced,  together  with 
hearing  power,  by  quinine.  Charcot  has  given  quinine  in  sufficient 
doses  to  produce  cinchonism,  and  found  that  in  some  cases,  when  the 
toxic  effect  had  passed  away,  the  noises  were  less.  I  have  tried  this 
and  also  salicylate  of  soda  (15  grains  three  times  a  day)  in  the  same 
way,  and  have  found  the  influence  of  the  latter  more  distinct  than 
that  of  quinine.  Of  course  it  is  only  in  chronic  and  stationary  cases 
that  this  treatment  is  admissible,  since  these  drugs  cause  actual  hyper- 
semia  of  the  labyrinth,  and  are  capable  of  increasing  acute  disease.* 
Lucae  has  advocated  the  treatment  of  tinnitus  (especially  when  the 
sound  has  a  musical  character)  by  exposing  the  patient  daily  for  a 
short  or  long  time,  according  to  circumstances,  to  a  sound  of  the 
opposite  character  to  that  which  he  hears, — to  a  high  tone  if  the 
subjective  tone  is  low,  and  vice  versa.  He  employs  a  tuning-fork,, 
acting  on  a  resonator  placed  in  the  meatus. f 


GLOSSO-PHABYNGEAL   NERVE. 

The  origin  of  the  glosso-pharyngeal  nerve  is  described  at  p.  45.  It 
leaves  the  surface  of  the  medulla  near  the  highest  fibres  of  the 
pneumogastric,  and  is  ultimately  distributed  to  the  back  part  of  the 
tongue,  the  soft  palate,  tonsils,  upper  part  of  the  pharynx  (mucous 
membrane  and  muscles),  to  the  Eustachian  tube,  and  to  the  tympanic 
cavity.  The  connections  of  the  nerve  are  important.  The  tympanic 
nerve  of  Jacobson  (arising  from  the  enlargement  on  the  glosso- 
pharyngeal termed  the  "petrosal  ganglion")  forms,  with  the  sym- 
pathetic, the  tympanic  plexus  in  the  wall  of  the  middle  ear,  and  gives 
two  branches,  one  to  the  large  superficial  petrosal  nerve  (from 
Meckel's  ganglion  to  the  facial  nerve),  and  the  other  (the  small 
petrosal  nerve)  to  the  otic  ganglion.  Thus  the  glosso-pharyngeal 
nerve  is  connected,  certainly  with  the  otic,  and  perhaps  also  with  the 

*  It  has  been  objected  that  this  treatment  is  homoeopathic.  It  is  not  more 
homoeopathic  than  the  treatment  of  psoriasis  by  irritants,  or  the  administration  of 
alcohol  to  reduce  the  rapid  pulse  of  fever,  or  the  application  of  an  alum  lotion  in 
conjunctivitis,  or  the  treatment  of  the  constipation  of  colic  by  opium.  Besides,  to 
make  the  production  of  like  symptoms  a  systematic  ground  of  rejection  of  treat- 
ment, is  only  less  irrational  than  to  make  it  a  systematic  ground  for  the  adoption  <>f 
treatment.  To  adopt  the  former  system  would  be  to  verify  the  epithet  of  "allo- 
path," at  present  an  untrue  name,  invented  to  conceal,  by  a  factitious  contrast,  a 
greater  absurdity. 

f  The  method  has  been  praised  also  by  Barr,  'Brit.  Med.  Journ.,'  1887,  ii,  454. 


GLUSSO-PHAEIXGEAL    NERVE.  277 

splieno-palatine  ganglion,  of  the  fifth  nerve.  Connections  with  the 
facial  nerve  are  effected  by  a  "branch  from  the  small  petrosal  nerve  to 
the  gangliform  enlargement  of  the  facial,  sometimes  also  by  a  filament 
to  the  trunk  of  the  nerve  from  the  digastric  branch  of  the  facial, 
possibly  by  the  connection  of  the  nerve  of  Jacobson  with  the  large 
superficial  petrosal.  It  is  connected  with  the  pneumogastric  at  the 
petrous  ganglion,  and  in  the  pharyngeal  plexus. 

Our  knowledge  of  the  functions  of  the  glossopharyngeal  nerve,  and 
of  the  symptoms  of  its  paralysis,  is  less  definite  than  with  regard  10 
any  other  cranial  nerve.  This  is  due  to  the  circumstances  that  the 
experimental  study  of  its  functions  in  animals  is  extremely  difficult, 
and  that  in  man  it  is  scarcely  ever  diseased  alone.  Heuce  its  func- 
tions have  to  be  inferred  from  its  anatomical  distribution,  and  the 
connection  with  other  nerves  lessens  considerably  the  value  of  con- 
clusions thus  reached,  because  the  functions  suggested  by  the  termi- 
nation of  its  fibres  may  be  in  part  due  to  its  connections,  and  may  not 
represent  the  functions  of  its  root. 

The  muscular  fibres  of  the  upper  part  of  the  pharynx  are  supplied 
by  the  pharyngeal  plexus,  and  opinion  is  divided  as  to  whether  the 
motor  fibres  come  from  the  glosso  pharyngeal  or  from  the  pneumo- 
gastric. The  glosso-pharyngeal  nucleus,  however,  contains  large 
nerve-cells,  motor  in  aspect,  a  fact  which  suggests  that  it  may  furnish 
the  fibres  for  these  muscles.  Most  anatomists  think  that  the  fibres  to 
the  stylo-pharyngeus  come  from  the  facial,  by  the  twig  from  the 
digastric  branch  of  the  latter.  "Whether  the  glosso-pharvngeal 
innervates  any  palatine  muscle  is  not  known.  It  is  probable  that  it 
supplies  sensory  fibres  to  the  upper  part  of  the  pharynx,  and  perhaps 
also  to  the  tympanic  cavity.  It  is  not  probable  that  it  is  the  sensory 
nerve  for  the  front  of  the  soft  palate,  palatine  arches,  or  back  of  the 
tongue,  since  these  are  rendered  anaesthetic  by  disease  of  the  root  of 
the  filth  nerve.  But  it  is  generally  believed  that  nausea  is  produced 
through  the  agency  of  this  nerve.  It  is  commonly  regarded  as  the 
nerve  of  taste  for  the  back  of  the  tongue,  palate,  and  the  fauces. 
Some  even  believe  that  it  subserves  taste  in  the  front  of  the  tongue, 
although  the  unquestionable  relation  of  this  to  the  chorda  tympani 
renders  it  necessary  to  assume  that  this  nerve  derives  its  taste-fibres 
front  the  glosso  pharyngeal  by  the  connection  between  the  large  and 
small  petrosal  nerves  (see  p.  227).  The  problem  of  the  nerves  of 
taste  has  been  already  considered.  The  fibres  of  the  glosso-pharyn- 
geal have  been  traced  to  the  circumvallate  papillae,  the  nerve-struc- 
tures in  which,  believed  to  subserve  taste,  undergo  degf-nerative 
changes  after  division  of  the  nerve-trunk.  But  there  is  no  instance 
on  record  of  loss  of  taste  at  the  back  of  the  tongue  from  disease  of  the 
roots  of  the  glosso-pharyngeal  nerve,  while  there  is  evidence  of  its 
persistence  in  spite  of  such  disease,  and  also  that  disease  of  the  root 
of  the  fifth  nerve  causes  loss  of  taste  on  the  back  as  well  as  the  front 
of  the  tongue,   and   on  the  palate  and    palatine  arch.     Hence  it  is 


278  CRANIAL   NERVES. 

impossible  to  resist  the  conclusion  that  if  some  of  the  terminal  fibres- 
of  the  glosso-pharyngeal  nerve  subserve  taste,  such  fibres  come  ulti- 
mately from  the  fifth  nerve.  Their  path  must  then  be  from  the  otic 
ganglion,  through  the  tympanic  plexus,  to  the  petrous  ganglion  of 
the  glosso-pharyngeal — a  circuitous  path,  but  scarcely  more  so  than 
that  which  the  taste-fibres  of  the  chorda  tympani  undoubtedly  take. 
This  view  is  supported  by  the  fact  that  taste  on  the  back  of  the 
tongue  may  be  lost  in  disease  of  the  middle  ear — a  fact  explicable  on 
no  other  hypothesis. 

The  nerve  may  be  diseased  by  any  of  the  intra-cranial  processes  that 
damage  the  nerve-roots — meningitis,  tumours,  &c,  and  its  motor  fibres 
participate  in  the  central  degenerations,  &c,  that  produce  labio-glossal 
paralysis.  It  is  probable  that  the  pharyngeal  symptoms  of  chronic 
and  acute  bulbar  paralysis  (labio-glosso-pharyngeal  paralysis)  are  due 
largely  to  interference  with  the  functions  of  this  nerve.  Of  the  sym- 
ptoms of  its  isolated  paralysis,  nothing  certain  is  known,  but  it  is- 
probable  that  the  upper  part  of  the  pharynx  is  rendered  insensitive 
and  weak,  so  that  deglutition  is  difficult,  but  both  nerves  may  have 
to  be  damaged  for  the  production  of  these  symptoms. 


PNEUMOGASTRIC   AND   ACCESSORY  NERVES. 

Of  all  the  cranial  nerves,  the  pneumogastric  has  the  most  extensive 
distribution,  supplying  the  pharynx,  larynx,  lungs,  heart,  oesophagus, 
and  stomach,  and  even,  in  part,  the  intestines  and  the  spleen.  In 
some  of  the  so-called  functional  diseases  of  the  organs  which  it  sup- 
plies, its  action  is  conspicuously  dei*anged.  The  symptoms  of  its 
disease  are  thus  very  extensive,  and  it  will  be  well  first  to  describe 
them  generally,  and  afterwards  to  consider  in  detail  those  that  merit 
separate  description. 

Some  of  the  functions  subserved  by  the  trunk  of  the  pneumogastric 
depend  on  the  fibres  which  it  derives  from  the  spinal  accessory  ;  but  it 
is  convenient  to  consider  disease  of  these  fibres  in  connection  with  that 
of  the  root  of  the  pneumogastric,  and  to  describe  separately  the 
derangement  of  the  spinal  fibres  of  the  accessory  nerve  which  supply 
the  muscles  of  the  neck. 

The  pneumogastric,  it  will  be  remembered,  arises  from  the  side  of 
the  medulla,  between  the  glosso-pharyngeal  above,  and  the  spinal 
accessory  below,  and  to  the  outer  side  of  the  hypoglossal.  Its  origin 
is  described  at  p.  45).  The  trunk  of  the  nerve,  after  receiving  fibres- 
fromthe  spinal  accessory,  and  giving  off  some  small  branches  (of  which 
the  most  important  is  one  to  the  external  ear),  passes  down  the  neck, 
behind  and  in  the  same  sheath  with  the  carotid  artery,  enters  the 


PNEUMOGASTRIC   NERVE.       »  279 

thoi*ax,  on  tbe  right  side  over  the  subclavian  artery,  and,  on  the  left, 
between  the  subclavian  and  the  carotid  ;  passes  through  the  thorax 
beside  the  cesphagus;  and  ends  in  branches  to  the  stomach,  spleen, 
and  intestines.  The  most  important  branches  are  the  phalangeal, 
which,  with  the  glosso-pharyngeal,  forms  the  plexus  of  the  same 
name  ;  the  superior  laryngeal ;  the  recurrent  laryngeal,  which  passes 
bach,  the  left  around  the  arch  of  the  aorta,  the  right  around  the  sub- 
clavian artery  ;  branches  to  the  cesophagus ;  pulmonary  branches 
which,  by  means  of  the  pulmonary  plexus,  supply  the  lung;  and 
branches  which  form  the  cardiac  plexus  for  the  heart. 

The  vagus  nerve,  besides  containing  motor  fibres  for  the  pharynx 
and  larynx,  is  the  chief  afferent  nerve  for  the  respiratory  centre.  It 
contains  accelerating  and  inhibitory  fibres  for  this  centre,  but  the 
former  preponderate,  so  that  exj)erimental  division  of  the  nerve  in  an 
animal  renders  the  respirations  less  frequent  but  deeper,  while  stimu- 
lation of  the  divided  (central)  end  quickens  the  inspiration,  and  the  ac- 
celeration may  even  proceed  to  tetanic  arrest.  The  inhibitory  fibres  are 
contained  chiefly  in  the  superior  laryngeal  nerve,  and  their  stimulation 
arrests  the  respiration,  the  muscles  being  relaxed.  It  is  the  inhibitory 
nerve  of  the  heart ;  slight  stimulation  increases  the  diastolic  periods, 
andsti-onger  stimulation  arrests  the  action  of  the  heart.  On  division 
of  the  nerve  the  cardiac  contractions  are  quickened.  It  has  been  said 
to  contain  trophic  fibres  for  the  heart  and  lungs,  but  this  is  not  certain. 
The  pneumogastric  is  an  afferent  nerve  for  the  vaso-motor  centre,  the 
action  of  which  is  lowered  by  its  stimulation,  so  that  the  arteries 
throughout  the  body  are  relaxed.  It  is  the  motor  and  sensory  nerve 
for  the  oesophagus,  the  sensory  nerve  for  the  stomach,  and  partly  also 
the  motor  nerve  for  the  stomach  and  intestines. 


Derangement  of  the  Pneumogastric  ,  generally. 

Causes. — The  deep  position  of  the  pneumogastric  and  its  branches 
preserves  it  from  some  forms  of  damage,  although  its  extensive  course 
renders  it  liable  to  suffer  from  many  causes.  The  nucleus  in  the 
medulla  may  be  affected  by  local  softening,  haemorrhage,  or  slow 
degeneration  ;  but  in  all  these  cases  other  adjacent  nuclei  suffer  also: 
The  nerve,  at  its  oi-igin  from  the  medulla,  may  be  compressed  by 
thickening  of  the  meninges,  growths  from  the  meninges  or  bones,  or 
aneurism  of  the  vertebral  artery.  Such  local  disease  is  often  due  to 
syphilis,  and  the  process  commonly  involves  other  adjacent  nerves  at 
the  same  time.  The  trunk  of  the  nerve  is  sometimes,  but  rarely,  im- 
plicated in  punctured  or  gunshot  wounds;  incised  and  lacerated  wounds 
in  its  position  are  usually  immediately  fatal  from  injury  to  the  large 
blood-vessels  to  which  it  is  contiguous.  In  surgical  operations  the 
trunk  and  branches  of  the  nerve  are  occasionally  damaged ;  the  trunk 
has  been  tied  in  ligature  of  the  carotid,  and  divided  in  the  removal  of 


280  .  CRANIAL    NERVES. 

deep-seated  tumours.  In  such  operations  in  the  lower  part  of  the  neck 
it  is  often  also  difficult  to  avoid  injury  to  the  recurrent  laryngeal.  In 
excision  of  an  enlarged  thyroid,  both  recurrent  laryngeals  have  been 
repeatedly  divided,  from  the  time  of  G-alen  down  to  the  present  day. 
Sarcomatous  and  other  tumours,  and  enlarged  glands,  may  compress 
or  involve  the  nerve  In  almost  any  part  of  its  course  ;  and  interference 
with  its  function  especially  occurs  from  such  disease  in  regions  limited 
l»y  rigid  structures,  as  in  the  upper  part  of  the  neck  near  the  skull, 
and  in  the  upper  part  of  the  thorax.  Aneurisms  may  compress 
the  nerve  or  its  branches ;  the  recurrent  laryngeals  suffer  from  this 
disease  with  especial  frequency.  Other  causes  of  interference  with  the 
recurrent  laryngeals  are  described  in  the  section  on  paralysis  of  the 
larynx.  The  vagus  is,  in  rare  cases,  the  seat  of  neuromata.  Neuritis 
of  the  trunk  of  the  nerve,  due  to  cold,  is  supposed  to  be  an  occasional 
cause  of  symptoms  ;  such  cases  are  extremely  rare,  but  in  some  acute 
forms  of  multiple  neuritis  this  nerve  has  certainly  been  involved, 
since  symptoms  of  its  derangement  are  occasionally  produced  by  toxic 
influences,  which  may  act  on  its  nucleus,  but  more  probably  produce 
neuritis.  The  vagus  may  thus  suffer  in  diphtheritic  paralysis,  in 
polyneuritis  due  to  cold,  septicaemia,  and  less  commonly  to  alcohol. 

Symptoms  due  to  paralysis  of  the  vagus  are  more  frequently  met 
with  than  those  which  result  from  its  irritation.  Occasionally  both 
are  combined.  Laryngeal  spasm  and  vomiting  are  the  irritative  sym- 
ptoms most  commonly  met  with,  but  occasionally  cardiac  inhibition 
occurs.  Czermak,  was  able  at  will  to  arrest  his  heart  for  a  few 
beats  by  pressing  a  small  tumour  of  the  neck  against  his  pneu- 
mogastric.  Concato  had  a  patient  in  whom  a  similar  inhibition  could 
be  caused  by  pressure  on  the  right  nerve.  The  increased  frequency  of 
pulse  which  corresponds  to  paralysis  of  the  vagus  has  been  several 
times  noted,  and  has  occasionally  been  associated  with  diminished 
frequency  of  respiration,  although  the  laryngeal  paralysis,  also  result- 
ing, has  usually  obscured  the  effect  on  the  respiratory  movements. 
Eoux  tied  the  trunk  of  the  vagus  with  the  left  carotid  ;  instantly 
respiration  was  arrested ;  the  pulse  was  also  retarded ;  although  the 
ligature  was  immediately  relaxed,  the  patient  died  in  half  an  hour. 
Robert  also  tied  the  nerve  with  the  carotid ;  the  patient,  who  was 
conscious,  immediately  called  out,  "  I  am  suffocated  !"  and  his  voice 
became  hoarse ;  he  recovered,  but  the  hoarseness  continued  for  six 
mouths.  An  instructive  example  of  interference  with  the  functions  of 
the  vagus  has  been  recorded  by  Gruttmann.  A  lad,  after  diphtheria, 
presented  paralysis  of  the  palate  and  of  one  sterno-mastoid.  His  re- 
spirations quickly  became  reduced  to  twelve  per  minute,  and  were  vei'y 
laboured,  while  his  pulse  rose  to  120,  and  he  died  in  a  few  hours.  In 
many  other  cases  a  similar  change  in  the  pulse  and  respiration  has 
been  noted,  and  even  a  pulse-rate  of  160—200.  In  the  face  of  these 
observations,  and  of  experiments  on  animals,  it  is  not  easy  to  under- 
stand a  fact  observed  by  Billroth,  who  excised  half  an  inch  of  one 


FNKUMOGASTRLC    NEKVE.  281 

pneumogastric,  -which  was  implicated  in  a  tumour,  without  any  result- 
ing symptoms,  unless  the  nerve  was  previously  degenerated. 

The  important  central  relations  of  the  vagus,  above  alluded  to, 
cause  derangement  of  its  function  to  form  part  of  many  so-called 
functional  disorders  of  the  central  nervous  system.  Its  nucleus  forms 
part  of,  or  is  connected  with,  the  respiratory  centre,  which  is  con- 
spicuously disturbed  in  hydrophobia  and  some  other  diseases.  The 
phenomena  of  "  Cheyne-Stokes  breathing,"  or  "respiration  of  ascend- 
ing and  descending  rhythm,"  are  probably  the  result  of  lowered 
action  of  the  respiratory  or  pneumogastric  centre  (see  p.  128).  The 
central  connections  of  the  vagus,  in  the  cerebral  hemispheres,  extend  to, 
•or  are  connected  with,  those  parts  which  are  concerned  in  emotion,  and 
it  is  apparently  through  the  agency  of  this  nerve  that  the  heart's  action 
is  affected  in  excitement  and  fear.  In  many  epileptic  fits,  the  central 
representation  of  the  nerve  is  the  part  through  which  consciousness 
is  first  affected,  and  hence  the  so-called  "  epigastric  aura." 

A  similar  disturbance  seems  to  be  the  cause  of  the  globus  hys- 
tericus and  of  the  laryngeal  spasm  which  are  conspicuous  in  some 
epileptic  and  hysteroid  seizures.  The  nerve  is  closely  connected  with 
the  centre  or  nerves  for  equilibration,  so  that  severe  vertigo,  on  what- 
ever dependent,  is  often  followed  by  vomiting.  The  nucleus  is 
contiguous  to  the  internal  auditory  nucleus,  and  part  of  the  auditory 
nerve,  that  which  comes  from  the  semicircular  canals,  is  known  to  be 
•concerned  in  the  process  of  regulating  the  maintenance  of  equilibrium. 
In  the  vertigo  that  results  from  disease  of  this  nerve  or  of  the  canals 
(labyrinthine  or  auditory  vertigo)  vomiting  is  very  common,  and  the 
nausea  and  retching  of  sea-sickness  are  probably  due  to  the  deranged 
action  of  the  semicircular  canals  in  consequence  of  the  motion  of  the 
endolymph,  which  acts  on  the  nerves  and  deranges  the  pneumogastric 
centre.  It  is  possible  that  the  connection  of  the  vagus  with  the 
equilibrial  nerves  is  by  means  of  the  cerebellum,  disease  of  which  so 
constantly  causes  vomiting,  although  this  connection  has  not  yet 
been  definitely  traced.  Conversely,  gastric  disturbance  of  the  vagus 
may  be  accompanied  by  vertigo,  especially  when  combined  with  pre 
existing  imperfect  action  of  the  fibres  from  the  semicircular  canals. 


Pharyngeal  Branches. 

Branches  of  the  pneumogastric  form,  with  the  glosso-pharyngeal, 
the  "  pharyngeal  plexus."  From  this  plexus  the  muscles  and  mucous 
membrane  of  the  pharynx  are  supplied.  The  special  distribution  of 
the  branches  of  each  constituent  nerve  is  not  known. 

The  most  common  cause  of  paralysis  of  the  pharynx  is  disease  of 
the  origin  of  the  nerve  in  the  medulla ;  such  disease  commonly  also 
involves  adjacent  nuclei.  Paralysis  may,  however,  result  from  menin- 
geal disease  outside  the  medulla,  and  from  disease  of  the  bones  of 


282  CRANIAL    NERVES. 

the  base  of  the  skull,  but  it  is  scarcely  ever  due  to  disease  outside  the 
skull.     It  occasionally  forms  part  of  diphtheritic  paralysis. 

Paralysis  of  the  pharynx  is  manifested  by  difficulty  of  swallow- 
ing ;  food,  entering  the  pharynx  from  the  mouth,  lodges  there  instead 
of  descending  to  the  oesophagus.  Small  particles  or  liquid  may  enter 
the  larynx,  and  cause  spasm  and  even  actual  choking.  Pulpy  food 
can  be  swallowed  better  than  solids  or  liquids.  If  the  paralysis  is 
limited  to  the  superior  constrictor,  liquids  may,  it  is  said,  be  forced 
into  the  nose  by  the  contraction  of  the  middle  constrictor,  but  it  is 
doubtful  whether  this  occurs  unless  the  soft  palate  is  also  paralysed. 
The  affection  of  the  nerves  on  one  side  causes  only  slight  difficulty  in 
deglutition,  no  doubt  on  account  of  the  circular  arrangement  of  the 
muscular  fibres. 

Paralysis  of  the  pharynx  can  be  confounded  with  other  conditions 
only  in  consequence  of  imperfect  observation.  I  have  known  the 
difficulty  in  swallowing  to  be  attributed  to  malignant  disease,  but 
such  a  mistake  ought  not  to  occur.  If  any  doubt  exists  as  to  whether 
dysphagia  is  due  to  paralysis  or  organic  obstruction,  the  passage  of  a 
sound  will  at  once  exclude  the  latter.  From  pharyngeal  spasm,  para- 
lysis is  distinguished  by  its  continuous  character. 

Spasm  of  the  pharynx  is  always  part  of  "  functional "  disturbance, 
and  does  not  result  from  organic  disease,  in  the  usual  sense  of  the 
word.  It  is  often  due  to  hysteria,  and  probably  occurs  in  the  more 
severe  form  of  hysterical  "  globus."  It  is  usually  associated  with 
other  hysterical  symptoms,  but  sometimes  occurs  alone.  As  an  in- 
stance may  be  mentioned  the  case  of  a  gifted  but  highly  nervous 
man,  who  for  many  years  could  only  swallow  food  when  alone ;  in 
the  presence  of  others,  spasm  of  the  pharynx  always  prevented  deglu- 
tition.    Similar  spasm  occurs  during  the  paroxysms  of  hydrophobia. 

Laryngeal  Branches. 

Paralysis  of  the  Larynx. — Paralysis  of  the  larynx  is  a  large  sub- 
ject, of  which  only  the  more  important  outlines  can  be  given  here. 
The  organ  is  innervated  by  two  branches  of  the  vagus.  (1)  The 
superior  laryngeal,  which  arises  high  up  in  the  neck.  It  is  the 
sensory  nerve  of  the  larynx  above  the  vocal  cords,  and  supplies  the 
crico-thyroid  muscle  and  the  deflectors  of  the  epiglottis.  (2)  The 
inferior  or  recurrent  laryngeal,  which  arises  in  the  upper  part  of  the 
thorax,  and  passes  up  to  the  larynx,  between  the  trachea  and 
oesophagus.  It  gives  sensibility  to  the  larynx  below  the  vocal  cords 
and  to  the  whole  trachea ;  and  it  supplies  all  the  muscles  of  the 
larynx  except  the  crico-thyroid  and  epiglottidean  muscles.  All  the 
motor  fibres  for  the  larynx  come  from  the  spinal  accessory  ;  only  the 
sensory  fibres  pass  to  the  medulla  by  the  roots  of  the  pneutnogastrie 
itself. 

In  order  to  understand  the  symptoms  of  laryngeal  paralysis  it  is 


PiMETJUOGASTRIO    NERVE.  283 

necessary  to  have  a  clear  conception  of  the  anatomy  of  the  larynx, 
and  of  the  action  of  its  muscles.  It  may  be  "well,  therefore,  first  to 
enumerate,  in  brief  outline,  the  facts  which  are  of  the  most  salient 
importance. 

The  glottis  is  opened  or  closed  by  the  movement  of  the  posterior 
extremities  of  the  cords  only  (the  anterior  remaining  always  fixed), 
and  this  movement  is  effected  chiefly  by  the  motion  of  the  arytenoid 
cartilages.  These  cartilages  are  attached  to  the  cricoid  cartilage  by 
an  articulation  that  permits  free  movement.  Each  has  the  form  of 
an  irregular  pyramid,  prolonged  at  the  base  into  two  processes,  an 
anterior  or  vocal  process,  from  which  the  vocal  cord  extends  to  the 
thyroid  cartilage,  and  an  external  or  muscular  process,  to  which  the 
muscles  are  chiefly  attached.  "When  the  latter,  which  is  at  right 
angles  to  the  vocal  process,  is  moved  back,  the  vocal  process  moves  out- 
wards, away  from  its  fellow ;  the  cord  is  abducted,  and  the  glottis 
opened.  When  the  muscular  process  is  moved  forwards,  the  vocal 
process  is  moved  inwards  towards  its  fellow ;  the  cord  is  adducted 
and  the  glottis  closed.  But  these  movements  of  the  cords  are  further 
aided  by  the  movement  of  the  arytsenoid  cartilages  away  from  or 
towards  each  other. 

The  most  important  muscles  of  the  larynx  and  the  effects  of  their 
palsy  may  be  briefly  described. 

Crico-thyroid. — The  fibres,  outside  the  thyroid  cartilage,  pass  down- 
wards  and  forwards  to  the  cricoid,  which  they  draw  back  and  slightly 
tilt,  lowering  the  posterior  part  of  the  cartilage  with  the  attached 
arytenoids,  and  thus  they  elongate  and  make  tense  the  vocal  cords. 
Isolated  paralysis  is  singularly  rare,  and  there  is  much  uncertainty 
about  its  exact  symptoms.  It  is  said  to  impair  the  production  of 
high  notes,  but  if  so,  it  is  probably  because,  without  the  influence  of 
the  crico-thyroid,  the  internal  thyro-ary  tsenoideus  cannot  act  with  effect. 
It  is  probable  that  paralysis  influences  the  height  of  the  cords  during 
the  production  of  high  notes,  but  this  effect  can  only  be  recognised 
when  the  paralysis  is  one-sided ;  the  arytenoid  cartilage  and  vocal 
cord  are  higher  on  the  paralysed  side  than  on  the  other,  on  account  of 
the  obliquity  of  the  cricoid  cartilage,  and  the  posterior  part  of  the 
glottis  is  displaced  towards  the  paralysed  side  (Eiegel). 

Thyro-arytsenoid. — The  fibres  pass  backwards,  from  the  posterior 
surface  of  the  front  of  the  thyroid  cartilage,  close  to  and  parallel  with 
the  vocal  cord.  The  inner  fibres  are  connected  with  the  cord,  and 
seem  to  influence  the  distribution  of  tension.  The  outer  fibres  pass 
to  the  muscular  process  of  the  arytsenoid,  and,  if  this  cartilage  is  free 
to  rotate,  they  draw  the  outer  process  forwards,  and  the  vocal  process 
inwards,  thus  adducting  the  cord.  The  inner  fibres,  and  also  the 
outer,  if  rotation  is  prevented,  shorten  the  cord.  Paralysis  of  the 
inner  fibres  renders  the  cord  atonic  with  a  concave  edge.  Paralysis  of 
the  outer  fibres  doubtless  lessens  the  power  of  adduction,  although  in 
a  degree  that  is  difficult  to  recognise. 


284,  CEANIAL    SERVES. 

Lateral  crico-arytasnoid. — The  fibres  pass  from,  the  side  of  the  cricoid 
backwards  and  upwards  to  the  outer  process  of  the  arytsenoid  cartilage, 
and,  drawing  this  forwards,  move  the  vocal  process  inwards  and  adduct 
the  cord.  It  is  the  chief  adductor.  Isolated  paralysis  is  very  rare, 
but  would  certainly  lessen  considerably  the  power  of  adduction  ;  it  is 
probable  that  tbe  cord  could  still  be  brought  to  the  middle  line  by  the 
thy  ro-arytaenoid,  unless  there  was  secondary  contracture  of  the  abductor. 

Arytsenoid. — This,  passing  between  the  arytenoid  cartilages  behind, 
draws  them  together  and  thus  adducts.  In  isolated  palsy  the  vocal 
cords  are  brought  together,  except  behind,  between  the  arytsenoid  carti- 
lages, where  a  small  triangular  space  remains. 

Posterior  crico-arytasnoid. — The  fibres  of  the  "  posticus  "  muscle  pass 
from  the  posterior  surface  of  the  cricoid  cartilage  outwards,  upwards, 
and  ultimately  forwards,  over  the  edge  of  the  cricoid  cartilage  to  the 
muscular  process  of  the  arytsenoid  cartilage.  They  draw  this  bach  and 
the  vocal  process  outwards,  and  thus  abduct  the  cords  and  open  the 
glottis.  It  is  the  only  special  abductor,  and  is  thus  a  muscle  of  great 
importance.  When  it  is  paralysed  alone,  abduction  is  impossible,  and 
the  vocal  cord  is  in  the  middle  line,  adducted  in  consequence  of  the 
unopposed  action  of  the  adductors. 

Thus  the  vocal  cord  is  abducted  chiefly  by  one  muscle,  but  the 
widening  is  increased  by  the  separation  of  the  arytaenoid  cartilages 
themselves,  effected  probably  by  the  simultaneous  action  of  the  poste- 
rior fibres  of  the  lateral  and  outer  fibres  of  the  posterior  crico-arytae- 
noids.  These  fibres  draw  the  arytaenoid  cartilage  downwards  and  out- 
wards on  its  convex  articular  surface.  The  cord  is  adducted,  and  the 
glottis  closed,  by  several  muscles — by  the  lateral  crico-arytaenoid  and 
the  outer  part  of  the  thyro-arytaenoid,  which  rotate  the  cartilage,  and 
by  the  arytenoids,  which  bring  the  cartilages  together.  The  vocal 
cords  are  lengthened  and  made  tense  by  the  crico-thyroid,  shortened  by 
the  thyro-arytaenoids,  and  made  either  lax  or  tense  in  parts,  according 
as  the  inner  fibres  of  this  muscle  are  inert  or  active. 

The  muscles  must,  however,  act  in  very  complex  combinations.  The 
different  fibres  of  each  muscle  have  not  all  the  same  direction,  and 
<jannot  have  the  same  action.  The  difference  may  even  be  such  that 
some  fibres  of  one  muscle  may  have  an  effect  opposed  to  that  of  the 
rest,  if  they  act  alone  or  with  fibres  of  another  muscle.  This  is  illus- 
trated by  the  fact,  already  mentioned,  that  the  posterior  fibres  of  the 
lateral  crico-arytaenoideus,  acting  with  the  outer  fibres  of  the  poste- 
rior crico-arytaenoideus,  may  aid  in  abduction  by  drawing  the  arytaenoid 
-cartilage  downwards.  On  the  other  hand,  if  the  other  glottis-closers 
are  acting  powerfully,  the  highest  (horizontal)  fibres  of  the  posterior 
crico-arytaenoideus,  the  chief  glottis-opener,  may  even  aid  closure  by 
helping  to  approximate  the  arytaenoid  cai'tilages.  If  the  action  may 
be  thus  complex  in  simple  opening  and  closing  the  glottis,  how  much 
more  complex  must  it  be  in  the  delicate  and  varied  actions  by  which 
is  produced  the  infinite  variety  of  vocal  sounds! 


PNEUMOGASTRIO    JSERVE.  285 

Causes. — Paralyses  of  the  larynx  fall  into  several  widely  different 
categories,  whether  they  are  considered  in  reference  to  their  symptoms 
or  to  their  causes.     The  chief  causes  are — 

(1)  Organic  disease  of  the  centres,  or  of  the  nerves  outside  the 
larynx.  According  to  the  seat  and  character  of  the  disease  the  palsy 
may  involve  one  or  another  group  of  muscles,  and  may  be  unilateral 
or  bilateral. 

(a)  A  rare  cause  is  disease  of  the  cortical  centre  for  the  larynx  in 
the  lowest  part  of  the  ascending  frontal  convolution  (Semon  and 
Horsley).  Such  disease,  to  be  effective,  must  be  bilateral,  because  the 
loss  of  function  of  one  centre  is  compensated  by  the  other;  "pseudo- 
bulbar paralysis  "  results  from  disease  on  both  sides,  with  the  sym- 
ptoms described  in  the  account  of  bulbar  paralysis.  Bilateral  disease 
of  the  conducting  tracts  in  the  hemispheres  is  equally  effective. 

(b)  The  most  frequent  central  cause  is  chronic  nuclear  degeneration, 
involving  the  cells  of  the  highest  part  of  the  spinal  accessory.  In  rare 
cases  the  lesion  is  acute  nuclear  softening.  In  either  case  the  sym- 
ptoms are  usually  associated  with  paralysis  of  the  tongue  and  lips,  as 
labio-glosso-laryngeal  paralysis,"  chronic  or  acute  ;  it  will  be  remem- 
bered that  the  highest  part  of  the  spinal  accessory  and  the  hypo- 
glossal nuclei  are  cqntiguous,  the  former  behind,  the  latter  in  front  of 
the  central  canal  of  the  cord.  Palsy  from  chronic  degeneration  is- 
often  associated  with  wasting  in  other  muscles.  Degenerative  para- 
lysis of  the  larynx  occurs  sometimes  in  disseminated  sclerosis,  in 
general  paralysis  of  the  insane,  and  especially  in  locomotor  ataxy. 
After  diphtheria,  also,  the  larynx  may  be  paralysed,  in  consequence 
of  central  changes  or  neuritis.  The  palsy  in  most  cases  is  bilateral, 
and  usually  abductor;  it  is  unilateral  only  in  rare  instances.  Some 
other  toxic  blood-states  have  a  similar  effect,  and  it  is  probably  by  this 
mechanism  that  such  paralysis  occurs  in  "acute  ascending  paralysis." 

(c)  Damage  to  the  roots  of  the  nerves  is  also  an  occasional  cause, 
commonly  of  syphilitic  origin,  sometimes  the  result  of  an  aneurism  or 
other  simple  tumour.  Paralysis  from  this  cause  is  usually  one-sided, 
and  often  affects  half  the  tongue  and  palate  as  well  as  the  Vocal  cord. 

(cZ)  The  long  course  of  the  nerve-trunks  exposes  them  to  damage 
from  many  morbid  processes  and  injuries,  which  have  been  enumerated 
in  the  section  on  general  causation,  and  to  these  must  be  added  the 
causes  of  multiple  neuritis,  in  which  the  laryngeal  nerves  are  occasion- 
ally involved,  early  or  late.  From  local  causes  the  superior  laryngeal 
nerve  is  in  general  (on  account  of  its  course)  less  liable  to  suffer  than 
the  recurrent.  Hence  disease  of  the  latter  is  the  most  frequent  cause 
of  such  laryngeal  palsy.  Aneurism  of  the  vessels,  round  which  the 
nerves  turn,  frequently  compresses  them  ;  and  the  left  suffers  from 
this  cause  more  frequently  than  the  right,  on  account  of  its  course 
round  the  aorta.  Other  causes  of  pressure  are  growths  and  enlarged 
glands  in  the  thorax,  cancer  of  the  cesophsgus,  and  enlargement  of 
the  thyroid.     Paralysis  has  been  met  with  in  some  cases  of  chronic 


286  CRANIAL    SERVES. 

lung  disease,  and  lias  probably  been  produced  through  the  agency  of 
enlargement  of  the  glands ;  the  paralysis  has  been  unilateral  or 
bilateral.  In  all  these  cases,  except  disease  of  the  superior  laryngeal, 
many  muscles  are  of  necessity  paralysed,  although  the  resulting  sym- 
ptoms ai'e  not  always  the  same. 

(2)  The  laryngeal  muscles  are  often  -weakened  by  processes  that, 
involving  no  organic  change  in  nerve  or  centre,  and  passing  away  com- 
pletely in  many  instances,  are  termed  "  functional."  The  morbid 
process  may  be  central  or  local  in  its  conspicuous  relations,  although 
■we  cannot  affirm  that  these  always  indicate  correctly  the  seat 
of  the  morbid  process.  The  chief  central  causes  are  hysteria,  and 
the  nervous  weakness  that  attends  anaemia  and  follows  prostrating 
maladies.  The  local  causes  are  congestion  and  inflammation  of 
the  mucous  membrane,  and  over-use  of  the  larynx,  especially  in  public 
speaking.  "We  cannot  altogether  separate  the  two  classes,  since 
local  and  central  disturbance  may  coincide  in  cases  that  appear  to  be 
of  local  origin ;  hysterical  aphonia,  for  instance,  is  frequently  excited 
by  a  transient  laryngeal  catarrh.  Moreover  some  cases,  now  regarded 
as  functional,  are  probably  due  to  slight  forms  of  polyneuritis,  some 
toxic  causes  which  have  more  tendency  to  affect  this  than  other  nerves. 
Paralysis  of  the  larynx  has  also  been  thought  to  be  occasionally  reflex 
in  origin.  Thus  abduction-palsy,  necessitating  tracheotomy,  has 
developed  without  traceable  cause  during  pregnancy,  and  has  passed 
away  after  delivery.* 

(3)  Paralysis  of  a  single  muscle  on  one  side  results  only  from 
local  disease  affecting  the  minute  branches  within  the  larynx. 
Laryngeal  growths,  cellulitis,  and  ulceration  of  the  cartilages  are 
occasional  causes  ;  but  palsy  of  this  nature  is  not  common.  Cold  has 
been  supposed  to  excite  a  rheumatic  neuritis  of  these  branches,  hut 
when  this  cause  is  effective  other  nerves  usually  suffer,  and  the  case 
comes  into  the  category  of  peripheral  polyneuritis. 

(4)  Lastly,  cases  of  laryngeal  palsy  are  sometimes  met  with  for 
which  no  adequate  or  probable  cause  can  be  discovered.  Such  cases 
will  doubtless  lessen  in  number  as  our  knowledge  increases. 

Symptoms. — The  larynx  is  the  organ  of  voice,  and  the  gate  of  the 
air-passages.  By  the  aid  of  the  laryngoscope  its  action  in  these  two 
functions  can  be  directly  observed.  The  evidence  of  paralysis  is 
correspondingly  threefold.  (1)  Voice  may  be  changed  or  lost ;  (2) 
the  entrance  of  air  in  respiration  may  be  impeded,  or  the  closure  of 
the  glottis  in  cough  may  be  impaired ;  (3)  the  defective  movement 
can  be,  in  part  at  least,  directly  observed.  The  phonic  and  respira- 
tory functions  are  subserved  by  the  same  muscles  and  the  same 
nerves,  but  by  centres  that  no  doubt  differ  in  anatomical  connection 
if  not  in  position. 

The  vocal  cords  assume,  after  death,  a  position  of  slight  abduction 
*  Aysaguer, '  L'Union  med./  March  31st,  1885. 


PNEUMOGASTEIC   NEltVE. 


287 


from  the  middle  line, — a  little  nearer  together  than  they  are  during 
ordinary  breathing.  This  position  must,  therefore,  be  regarded  as 
that  of  muscular  relaxation, — of  the  rest  that,  during  life,  they  may 
approximate,  but  never  actually  attain.  During  phonation  the  cords 
are  brought  together  and  made  tense ;  the  degree  of  approximation, 
and  tension  varies  according  to  the  note  produced.  In  breathing  the 
cords  are  separated  during  inspiration,  the  extent  of  abduction  being 
proportioned  to  the  force  of  the  inspiration ;  during  expiration  they 
are  brought  a  little  nearer  together  than  the  cadaveric  position. 

If  there  is  complete  paralysis  of  all  the  muscles,  or  (what  is  the 
common  condition)  of  all  except  the  crico-thyroids,  the  vocal  cords 
assume  the  cadaveric  position,  from  which  they  cannot  be  moved 
(Fig.  109).  They  are  not  approximated  on  an  attempt  to  phonate, 
nor  do  they  recede  on  deep  inspiration.  Hence  vocal  sounds  cannot 
be  produced.  In  deep  inspiration  the  current  of  air  may  bring  the 
cords  a  little  nearer  together  than  normal,  and  may  cause  slight 
stridor.  Instead  of  the  natural  explosive  cough  there  is  only  a  sudden 
rush  of  air  through  the  glottis.  If  only  one  cord  is  paralysed,  this 
cord  alone  is  motionless  in  the  "  cadaveric  position  "  (Fig.  110),  the 
other  moves  normally.  Some  phonation  may  still  be  possible,  because 
the  unaffected  cord  may  be  over-adducted  beyond  the  middle  line,  but 
the  voice  is  low-pitched,  and  often  hoarse.  The  abduction  of  the 
healthy  cord  during  inspiration  prevents  stridor.  But,  unless  the 
palsy  is  slight,  the  glottis  cannot  be  closed  with  sufficient  firmness  to 
effect  an  explosive  cough.  Complete  paralysis  is  met  with  in  central 
disease,  in  disease  of  the  trunk  of  the  vagus,  or  in  disease  of  the  re- 
current laryngeal.  The  escape  of  the  crico-thyroid  in  the  latter  case 
does  not  materially  modify  the  condition  of  the  larynx. 

Fio.  109. 


Fig.  109. — Total  palsy  of  both  cords.     Cadaveric  position. 
Fig.  110. — Similar  palsy  of  left  vocal  cord. 
Fig.  111. — Bilateral  abductor  paralysis. 


In  other  cases  of  paralysis,  instead  of  complete  loss  of  movement 
with  the  cords  in  the  cadaveric  position,  they  are  nearer  together  and 
cannot  be  abducted,  even  as  far  as  the  cadaveric  position  (Fig.  111). 
They  can  be  brought  closer  together  in  phonation  and  cough,  and 
when  the  effort  ceases  they  recede  a  little,  but  the  normal  wide  reces- 
sion during  inspiration  does  not  take  place.  This  indicates  paralysis 
of  the  abductors,  the  posterior  crico- arytenoids.  The  slight  recession 
that  may  occur  is  due  to  the  elasticity  of  the  attachments  of  the  cords 


288  CEANIAL    NERVES. 

The  position  of  the  cords,  and  the  amount  of  recession,  depend  on  the 
duration  of  the  paralysis..  The  adductors,  unopposed,  undergo  secon- 
dary contracture,  and  with  this  the  glottis  becomes  permanently 
narrower,  until  there  may  be  only,  at  widest,  a  narrow  chink  between 
the  cords.  The  tensors  are  still  active  as  well  as  the  adductors,  and 
hence  voice  is  little  affected.  The  cords  are  indeed  always  in  the 
position  for  phona/tion.  The  chief  symptom  is  the  effect  on  respira- 
tion.* The  normal  recession  of  the  cords  during  inspiration  does  not 
take  place,  and  they  are  even  brought  still  nearer  together  by  the 
pressure  of  the  inrushing  air.  Hence  inspiration  is  accompanied  by 
a  whistling  stridor,  often  very  loud  ;  the  hindrance  to  the  entrance  of 
air  brings  into  action  the  extraordinary  muscles  of  respiration,  and 
inspiration  occupies  a  longer  time  than  normal.  On  account  of  the 
shape  of  the  glottis  expiration  is  unimpeded;  the  current  of  air  even 
tends  to  separate  the  cords.  The  absence  of  any  affection  of  the  voice 
often  causes  an  error  in  diagnosis,  and  the  obstruction  is  referred  to  the 
trachea.  But  the  symptoms  differ  from  this  in  the  absence  of 
expiratory  stridor,  and  the  movement  of  the  larynx  up  and  down 
during  breathing  is  greater  than  is  ever  seen  in  tracheal  stenosis. 
The  symptoms  are  indeed  so  characteristic  that  the  diagnosis  can  be 
made  with  certainly,  even  without  the  aid  of  the  laryngoscope,  and 
they  ai*e  so  striking  that,  once  witnessed,  they  can  scarcely  be  mis- 
taken, and  cau  never  be  forgotten.  The  urgent  dyspnoea  and  loud 
stridor,  as  each  breath  is  drawn,  accompanied  as  they  may  be  with 
lividity  of  the  face,  and  coldness  of  the  extremities,  ai-e  alarming. 
The  danger  is  not  apparent  only  ;  the  slightest  catarrhal  swelling  of 
the  cords  suffices  to  occlude  the  narrowed  glottis,  and  prompt  laryn- 
gotomy  alone  may  save  the  patient  from  death  by  suffocation.  This 
account  is  true,  however,  only  of  bilateral  palsy.  If  the  paralysis  is- 
unilateral,  the  affected  cord  is  near  the  middle  line  and  motionless  ; 
the  other  recedes  during  respiration,  sometimes  to  a  greater  degree 
than  normal:  symptoms  are  slight,  and  may  even  be  absent.  The 
recession  of  the  unaffected  cord  prevents  both  stridor  and  dyspnoea. 

This  paralysis  of  abduction  may  be  due  to  central  disease  or  to 
local  causes.  It  has  been  known  to  follow  a  simple  laryngeal  catarrh. 
In  some  cases  its  etiology  is  uncertain.  Both  posterior  muscles  have 
been  found  destroyed  by  degeneration  when  all  the  other  laryngeal 
muscles  were  healthy.  It  is  possible  that  these  obscure  cases  are  also 
of  central  or  toxemic  origin.  But  a  similar  paralysis  of  abduction 
may  be  produced  by  disease  of  the  recurrent  laryngeal,  although  this 
nerve  contaius  fibres  for  the  adductors  as  well  as  the  abductors. 
Instead  of  the  cadaveric  position  of  the  cord,  and  the  complete  immo- 
bility found  in  many  cases  of  disease  of  the  recurrent,  the  cord  is 

*  Hence  this  palsy  was  termed  by  Tiirck  "respiratory  paralysis,"  as  distinguished 
from  "phouic  paralysis,"  in  which  the  voice  is  affected,  while  the  conditions  in 
which  both  functions  are  disturbed  have  been  termed  "mixed  paralysis."  This 
somewhat  loose  division  hardly  deserves  the  wide  adoption  it  has  obtained. 


PNEUMOGASTRIC    NERVE.  289 

near  the  middle  line  ;  fui'ther  adduction  is  still  possible,  but  there  is 
no  abduction,  and  if  both  nerves  are  affected  the  symptoms  above 
desmbed  are  present  in  characteristic  degree.  Much  ingenuity  has 
been  expended  in  attempting  to  explain  why  the  abductors  should 
suffer  chiefly  from  disease,  such  as  the  pressure  of  an  aneurism, 
which  presumably  affects  all  the  fibres  of  the  nerve.  Some  have 
suggested  that  the  adductors  must  be  supplied  also  by  the  superior 
laryngeal — an  hypothesis  unsupported  by  anatomy.  It  has  also  been 
suggested  that  the  fibres  for  the  abductors  may  be  superficial  in  the 
nerve,  and  so  suffer  first,  or  have  some  mysterious  special  proclivity 
to  disease.  Others  have  remarked  that  the  abductors  suffer  most, 
just  as  the  abductors  and  extensors  of  a  limb  suffer  more  in  hemi- 
plegia than  the  adductors  and  flexors — a  doubtful  analogy  which 
affords  no  explanation.* 

The  fact  that  disease  of  the  recurrent  laryngeal,  affecting  all  fibres 
apparently  equally,  may  influence  abduction  more  than  adduction, 
must  be  taken  in  connection  with  another  fact,  that  electrical  stimu- 
lation of  the  recurrent  nerve  causes  adduction  of  the  cord.  In  the 
former  case  we  are  justified  in  presuming  that  all  the  muscles  supplied 
under-act,  in  the  latter  case  it  is  certain  that  all  over-act ;  in  each 
case  there  is  adduction.  It  is  probable  that  the  explanation  will  be 
found  in  the  relative  bulk  and  arrangement  of  the  two  sets  of  fibres. 
The  adductors  are  more  numerous  than  the  abductors,  are  probably 
more  bulky,  are  certainly  more  varied  in  arrangement,  and  perhaps 
act  at  greater  mechanical  advantage.  The  direction  of  the  fibres  of 
the  posterior  crieo-arytsenoids  seems  less  favorable  to  their  action  on 
the  arytenoid  cartilages  than  that  of  the  lateral  muscles,  and  when 
the  cords  are  adducted  the  relative  disadvantage  of  the  posterior 
muscles  must  be  increased.  Thus  an  equal  reduction  of  absolute 
power  may  cause  a  far  greater  impairment  of  the  abductors  than  of 
the  adductors.  Hence  it  is  better  to  speak  of  this  condition  as  an 
impairment  or  loss  of  abduction,  rather  than  as  paralysis  of  the 
abductors.  The  abduction  palsy  with  narrow  glottis  probably  results 
from  damage  to  the  recurrent  nerves,  which  is  incomplete  in  degree 
although  not  necessarily  partial  in  distribution.  The  complete  palsy 
with  cadaveric  position  of  the  glottis  is  the  consequence  of  complete 
paralysis  of  the  nerve.  Thus  the  latter  has  been  observed  to  follow 
the  former  as  the  disease  progressed  (Schech,  jftosenbach). 

It  has  been  suggested  (first  by  Eiegel)  that  the  adduction  in  disease 
of  the  recurrent  might  be  the  result  of  secondary  contracture  in  the 
unopposed  crico-thyroid,  which,  as  a  tensor  and  elongatorof  the  cords, 
must  tend  to  bring  the  cord  and  vocal  process  into  a  straight  line. 
The  chief  difficulty  in  accepting  this  explanation  is  that  the  adduction 
is  not  invariable,  as  it  should  be  were  it  the  result  of  a  secondary  con- 
tracture of  the  unopposed  crico-thyroid.  Nevertheless  secondary  con- 
tracture may  play  a  part  in  the  phenomena  of  some  cases.     If  the 

*  See  Semon,  'Arch,  of  Laryngol.,'  18S1 ;  and  Russell,  *  Proc.  Roy.  Soc.,'  1892. 
VOL.  II.  19 


290  CRANIAL    NERVES. 

narrow  glottis  ever  persists  after  palsy  lias  become  complete,  it  may 
"be  from  secondary  contracture  and  shortening  of  the  adductors,  per- 
petuated "by  tissue  chauges  in  them.* 

Disease  of  one  recurrent  nerve  usually  affects  only  the  corresponding 
vocal  cord.  Paralysis  of  both  cords,  when  produced  by  an  organic 
lesion,  is  generally  due  to  disease  of  both  recurrent  nerves  or  to 
central  changes.  But  three  cases  are  on  record  in  which  both  cords 
were  paralysed,  although  only  one  recurrent  nerve  was  found  to  be 
compressed  or  otherwise  diseased. f  In  two  cases  the  paralysis  was 
greater  on  the  side  of  the  lesion  than  on  the  other.  The  paralysis 
of  the  opposite  cord  is  supposed  to  be  due  to  an  influence  on  the 
centre. 

Paralysis  of  abduction  also  occurs  in  hysteria,  although  rarely;  it 
is  then  always  bilateral.  The  characteristic  symptoms  are  present— 
inspiratory  stridor,  often  intense,  with  unimpaired  phonation.  Most 
recorded  cases  have  recovered,  but  the  inspiratory  dyspnoea  may  be 
alarming  in  its  intensity,  and  it  is  probable  that  death  has  occurred 
in  more  than  one  instance.  In  a  case  of  morphia  habit  and  hysteria  J 
the  patient  suffered  from  loud  inspiratory  stridor,  absent  during 
expiration,  not  interfering  with  phonation,  and  due  to  abductor 
paralysis.  It  disappeared  entirely  while  the  patient  was  under  the 
influence  of  morphia,  but  reached  an  alarming  intensity  when 
morphia  had  been  withheld  for  twelve  hours,  the  stridor  being  audible 
all  over  the  house.  Amaurosis  and  some  mental  derangement  coincided 
with  the  stridor.  She  recovered  rapidly  under  treatment,  which 
consisted  in  a  modification  of  the  Weir-Mitchell  system,  the  gradual 
withdrawal  of  morphia,  and  the  hypodermic  injection  of  strychnine. 
The  abductor  paralysis  has  been  mistaken  for  spasm,  on  account  of 
the  stridor  that  accompanies  it ;  but  the  circumstances  that  expiration 
is  noiseless  or  nearly  so,  and  speech  unaffected,  effectually  distinguish 
it  from  spasm.  It  is  probable  that  many  cases  of  so-called  hysterical 
spasm,  of  the  glottis  have  been  really  abductor  palsy. 

In  adductor  paralysis  the  cords  ai'e  apart  and  cannot  be  brought 
together.  The  state  in  which  the  cords  are  in  the  cadaveric  position, 
and  cannot  be  moved,  should  not  be  spoken  of  as  adductor  paralysis, 
because,  although  the  adductors  are  paralysed,  all  the  other  muscles 
are  paralysed  also.  The  term  should  be  applied  only  to  the  cases  in 
which  there  is  still  the  power  of  abduction  on  deep  inspiration,  but  no 
power  of  bringing  the  cords  nearer  together  than  the  cadaveric  posi- 
tion.    Thus  defined,  adductor  paralysis  is  rarely  due  to  organic  disease 

*  "Wagner  attributes  the  cadaveric  position  to  the  crico-thyroid,  because  it  is 
assumed  when  the  superior  laryngeal  nerve  is  divided  alter  the  inferior  ('  Virch. 
Arch.,'  Bd.  cxx,  p.  437,  1890). 

f  Baumler,  Johnson,  Sommerbrcdt.  The  case  of  Sornmerbrodt  was  one  of  trau- 
matic damage. 

%  Seen  with  Mr.  "W.  L.  Winterbotham,  of  Bridgwater.  The  diagnosis  of  the 
laryngeal  condition  was  afterwards  confirmed  by  Sir  Morell  Mackenzie. 


PNEUMOGASTBIC    KEBVE. 


291 


of  the  nerves  or  centres.*  It  is  most  common  as  a  partial  paralysis  ; 
the  cords  are  not  brought  together  in  phonation,  and  the  patient  is 
therefore  voiceless,  but  they  can  be  brought  together  in  coughino-. 
Hence  this  has  been  termed  "phonic  paralysis"  (Turck).  It  is 
common  in  hysteria,  in  which  it  causes  the  so-called  "  hysterical 
aphonia,"  and  it  results  also  from  over-use  of  the  voice  and  from  catar- 
rhal laryngitis.  It  is  also  said  sometimes  to  result  from  cold  without 
laryngitis  (Bose).  In  hysterical  aphonia  tbe  patient  is  sometimes  able 
to  sing,  although  she  can  only  speak  in  a  whisper  (v.  Bruns). 

Another  form  of  partial  adductor  palsy  is  due  to  loss  of  power 
in  the  arytaenoideus  ;  the  result  is  defective  closure  of  the  posterior  part 
of  the  glottis  and  hoarseness  or  loss  of  voice.  Little  is  known  of  the 
symptoms  and  causes  of  paralysis  of  the  tensors  of  the  vocal  cords, 
beyond  the  fact  that  palsy  of  the  internal  fibres  of  the  thy  ro- arytaenoideus 
causes  the  edge  of  the  cord  to  be  concave.  The  effect  on  the  voice  is 
similar  to  that  of  the  preceding  palsy,  and  the  two  are  sometimes 
associated. 

For  the  exact  diagnosis  of  these  laryngeal  palsies  an  examination 
by  means  of  the  laryngoscope  is  essential.  But  it  may  be  useful  to 
compare  the  symptoms  presented  by  the  chief  forms  of  paralysis, 
since  they  often  suggest  very  clearly  the  nature  of  the  affection. 
In  the  following  table  the  symptoms  are  enumerated  in  the  first 
column,  the  condition  seen  with  the  laryngoscope  in  the  second, 
and  the  form  of  paralysis  in  the  third.  The  inability  to  effect  an 
explosive  cough  is  of  great  significance  as  evidence  of  a  palsy  of 
organic  origin,  in  the  absence,  of  course,  of  local  organic  disease. 
Entire  loss  of  voice,  as  well  as  of  cough,  suggests  bilateral  palsy  of 
grave  organic  nature,  but  without  loss  of  cough  it  indicates  unimpor- 
tant adduction  palsy.  Loss  of  cough  without  loss  of  voice  suggests 
paralysis  of  one  cord.  Loud  inspiratory  stridor  without  loss  of  voice 
means  abduction  paralysis. 


Symptoms. 


Signs. 


Lesion. 


No  voice;    no  cough;    stridor  Both   cords  moderately  abducted  and  Total  bilateral 
only  on  deep  inspiration.  motionless.  palsy. 


Voice  low-pitched  and  hoarse ; 
no  cough ;  stridor  absent  or 
slight  on  deep  breathing. 


One    cord    moderately   abducted   and         Total 
motionless,  the  other  moving  freely,      unilateral 
and  even  beyond  the  middle  line  in 
phonation. 


Voice   little   changed ;    cough  Both  cords  near  together,  and  during         Total 
normal;    inspiration   difficult    inspiration    not    separated,   but  even!      abductor 
and  long,  with  loud  stridor,    j  drawn  nearer  together.  palsy. 


*  Navratil,  '  Berlin,  klin.  Wochenschrift,'  1869,  Nos.  36  and  37.     The  same  fact 
has  been  recently  emphasised  by  Dr.  Semon,  'Arch,  of  Laryngology,'  loc.  cifc. 


292 


CEANIAL    NERVES. 


Symptoms. 

Signs. 

Lesion. 

Symptoms  inconclusive;  little 
affection  of  voice  or  cough. 

No  voice;  perfect  cough;  no 
stridor  or  dyspnoea. 

One   cord   near  the   middle   line,  not 
moving  during  inspiration  ;  the  other 
normal. 

Cords  normal  in  position  and  moving 
normally  in  respiration, hut  not  brought 
together  on  an  attempt  at  phonation. 

Unilateral 

abductor 

palsy. 

Adductor 

palsy. 

Ansesthesia  of  the  larynx  is  rare.  It  results  from  disease  of  the 
superior  laryngeal  nerve,  or  the  roots  of  the  vagus ;  it  is  occasionally 
met  with  in  degenerations  of  the  medulla,  but  is  then  usually 
incomplete.  It  may  form  part  of  heniianaesthesia  of  hysterical  or 
cerebral  origin.  In  the  latter  cases  reflex  action  is  unimpaired;  in 
disease  of  the  nerve  or  medulla  it  is  lost.  General  ansesthesia  about 
the  entrance  to  the  larynx  is  said  to  have  been  met  with  in  hysterical 
aphonia. 


Spasm  of  the  Larynx 

The  common  form  of  spasm  of  the  laryngeal  muscles  is  that  of  the 
adductors.  The  muscles  that  close  the  glottis  are  more  powerful  than 
those  that  open  it,  no  doubt  because  firm  closure  is  necessary  for  the 
process  of  coughing,  and  in  order  to  fix  the  thorax  during  muscular 
effort.  Moreover  the  reflex  mechanism  is  connected  chiefly  with  the 
glottis-closers,  doubtless  to  protect  the  air-passages  from  foreign 
bodies,  or  to  aid  in  the  expulsion,  by  coughing,  of  any  irritant  sub- 
stances that  have  gained  an  entrance.  Hence  any  nerve  irritation, 
direct,  central,  or  reflex,  causes  closure ;  and  it  is  not  surprising  that' 
spasm  accompanies  a  large  number  of  laryngeal  diseases,  varying  in 
its  prominence  according  to  the  irritative  nature  of  the  disease  and 
the  excitability  of  the  reflex  mechanism.  The  latter  is  far  more 
intense  in  children  than  in  adults,  and  hence  in  thrin  the  slightest 
laryngeal  catarrh  gives  rise  to  spasm.  Attacks  occur  especially  at 
night,  when  the  reflex  mechanism,  released  by  sleep  from  the  control 
of  the  higher  centres,  is  in  its  most  active  state.  Spasm  may  occur 
from  irritation,  not  only  of  the  superior  laryngeal  nerve,  but  also  of 
the  vagus  below,  as  when  the  latter  is  compressed  by  a  tumour  in  the 
upper  part  of  the  chest ;  the  afferent  impression  is  due  to  irritation  of 
the  sensory  fibres  from  the  trachea.  Reflex  spasm  is  always  bilateral. 
Direct  spasm  from  irritation  of  one  recurrent  laryngeal  usually  in- 
volves only  one  vocal  cord,  but  in  a  few  cases  spasm,  so  excited,  has 
been  bilateral.  This  may  be  explained  either  by  the  irritation  of  some 
afferent  fibres,  or  (according  to  Krishaber)  by  spasm  of  the  arytaenoi- 
deus,  which  is  a  bilateral  muscle. 

Simple    spasm   occurs    in   rickety  children,  in  whom  the  nervous 


PNETJMOGASTRIC   NERVE.  293 

system  is  in  a  condition  of  excessive  i-eflex  excitability.  In  this  form, 
which  is  termed  "laryngismus  stridulus,"  the  vaso-niotor  and  cardiac 
centres  of  the  medulla  are  also  deranged ;  the  child  on  some  exciting 
cause,  as  a  start,  a  peripheral  impression,  or  even  without  apparent 
cause,  suddenly  turns  pale,  is  unable  to  get  its  breath  for  a  few- 
seconds,  and  then,  the  spasm  relaxing,  air  is  drawn  through  the 
slowly  opening  glottis  with  a  crowing  noise.  Paroxysmal  attacks  of 
laryngeal  spasm  sometimes  occur  in  adults,  usually  in  the  night. 
They  are  apparently  analogous  to  attacks  of  asthma,  the  spasm 
affecting  the  larynx  instead  of  the  bronchial  tubes.  The  sufferer 
wakes  up  with  a  feeling  of  suffocation,  intense  difficulty  of  breathing, 
and  loud  laryngeal  stridor,  which  after  a  few  minutes  passes  away. 
During  the  spasm  the  distress  may  be  extreme,  the  patient  tears 
open  his  clothes,  and  may  seem  at  the  point  of  death.  Such  occa- 
sional attacks  have  been  known  to  recur  from  time  to  time  during 
many  years.  They  have  been  known  to  replace  attacks  of  migraine 
(Liveing),  and  are  occasionally  met  with  in  the  subjects  of  locomotor 
ataxy,  in  whom  they  have  been  termed  "  laryngeal  crises  "  (see  vol.  i). 
The  paroxysms  of  laryngismus  stridulus  probably  differ  only  in 
degree  from  the  general  convulsions  that  are  also  common  in  rickety 
children.  In  most  epileptic  convulsions  there  is  laryngeal  spasm, 
which  causes  the  initial  "  epileptic  cry."  During  the  paroxysms  of 
hydrophobia  there  is  also  spasm  of  the  glottis. 

Lastly,  spasm  of  the  larynx  is  met  with  in  certain  general  neuroses,. 
in  tetany*  rarely,  in  hysteria  occasionally.  In  the  latter  it  may  occur 
in  paroxysmal  or  more  continuous  form.  The  paroxysmal  form  con- 
stitutes one  variety  of  hysteroid  convulsion.  Instances  of  this  are 
described  in  the  chapter  on  hysteria.  The  continuous  form  is  very 
rare.  There  is  stridor  with  inspiration  and  expiration,  the  voice  is 
feeble,  and  there  may  be  hysterical  rapid  breathing.  The  diagnosis 
from  hysterical  abduction-paralysis  rests  on  the  fact  that  the  stridor 
in  spasm  accompanies  inspiration  as  well  as  expiration,  and  the  voice 
is  more  altered  than  in  abduction-palsy,  in  which  also  the  loud 
whistling  inspiration  contrasts  with  the  almost  noiseless  expiration. 
The  laryngeal  symptoms  usually  partake  of  the  character  of  the  other 
disturbances  that  may  be  present;  the  spasm  is  accompanied  by  other 
spasmodic  or  convulsive  symptoms  ;  the  paralysis,  by  loss  of  power  or 
of  sensibility.  It  is  probable  that  some  cases  of  supposed  spasm  have 
been  really  instances  of  abduction-jjaralysis. 

A  rare  condition  of  functional  spasm  has  been  described/)"  in  which 
spasm  is  excited  by  attempts  to  speak.  It  is,  so  to  speak,  the  con- 
verse of  phonic  paralysis.  In  the  latter  the  cords  cannot  be  brought 
together  in  speaking ;  in  the  functional  spasm  they  are  brought 
together  too  forcibly.  Either  the  patient  cannot  speak  or  speaks  at 
first  in  an  altered  voice,  which  ceases  altogether  when  a  greater  effort 
*  Killian,  «  Monatssclir.  f.  Ohrenkr.,  &c.,'  1884. 
f  Schnitzler  (1875),  Schech  (1879),  Nothnagel  (1881),  Fritsche,  Jurasz  (1880). 


294  CRANIAL   NEKVES. 

is  made,  on  account  of  the  increased  spasm  that  the  effort  induces. 
Apart  from  attempts  to  speak  there  is  no  laryngeal  disturbance.  It 
has  been  terinnied  "  spastic  aphonia"  or  "  phonic  laryngeal  spasm" 
by  Schnitzler,  "spastic  dysphonia"  by  Sehech,  and  '-'co-ordinated 
laryngeal  spasm  "  by  Nothnagel,  because  he  observed  it  to  accompany 
other  voluntary  movements  of  the  larynx  besides  those  of  speech, 
while  it  was  absent  in  all  involuntary  and  automatic  movements. 
The  spasm  may  be  attended  Avith  pain  in  the  larynx  and  even  in 
the  upper  part  of  the  thorax  (Jurasz).  The  affection  has  been  com- 
pared to  writers'  cramp,  but  differs  from  this  in  its  general  etiological 
relations,  and  in  its  greater  amenability  to  treatment.  A  closer 
analogy  to  writers'  cramp  was  presented  by  a  case  recorded  by 
Gerhardt,  in  which  the  patient  had  actually  suffered  from  writers' 
cramp,  and,  at  the  age  of  fifty,  learned  to  play  the  flute.  The  act  of 
blowing  the  flute  brought  on  laryngeal  spasm  and  an  unintended 
voice-sound,  accompanied  by  muscular  contractions  in  the  arm  and 
angle  of  the  mouth. 

Various  forms  of  cough  occur  as  isolated  symptoms,  but  scarcely 
come  into  the  province  of  this  book.  One  form,  however,  deserves 
special  mention,  the  barking  cough  which  occurs  in  boys  about  the 
time  of  puberty,  which  is  a  source  of  great  annoyance  to  the  friends 
of  the  patient.  It  is  generally  the  result  of  the  habit  of  masturba- 
tion, and  a  knowledge  of  this  enables  a  case  which  has  gone  on  for 
months  to  be  quickly  cured. 


Pulmonary  Branches. 

The  influence  of  general  disturbance  of  the  pneumogastric  on  the 
respiratory  movements,  and  the  spasm  that  results  from  irritation  of 
the  afferent  pulmonary  nerves,  have  been  already  described.  The 
muscular  fibres  of  the  bronchi  are  supplied  by  this  nerve,  and  their 
paroxysmal  contraction  in  asthma  has  been  thought  to  be  produced 
through  its  agency.  It  has  also  been  asserted  that  the  plain  muscu- 
lar fibres  said  to  exist  in  the  pulmonary  tissue  are  supplied  by  the 
pneumogastric  (G-erlach),  and  their  contraction  has  been  assumed  to 
explain  a  peculiar  form  of  emphysema  observed  in  a  case  of  compres- 
sion of  the  pneumogastric  (Tuczek)  ;  but  the  compression  caused  also 
deep  breathing  of  a  costo-superior  type,  and  the  emphysema  may 
have  been  merely  the  result  of  the  energetic  movement  consequent  on 
the  stimulation  of  the  respiratory  centre.  The  pneumogastric  is 
commonly  believed  to  contain  vaso-motor  fibres  for  the  vessels  of  the 
lungs,  but  Brown- Sequard  and  Franck  have  separately  shown  that 
these  fibres  are  contained,  not  iu  the  vagus,  but  in  the  sympathetic. 
Vascular  lesions  of  the  lungs  have,  however,  been  observed  after 
section  of  the  vagus.  Alichaelson  noted  rapid  congestion  and  hemor- 
rhage ;  it  is  possible  that  this  may  have  been  of  reflex  origin,  pro- 


PNEUMOGASTBIC   NEBVE.  295 

duced  through,  the  agency  of  the  sympathetic.  But  in  man,  acute 
lesions  of  the  pons  sometimes  cause  rapid  vascular  changes  in  the 
lungs ;  in  one  case  of  haemorrhage  into  the  pons,  fatal  in  two  hours, 
I  found  intense  congestion  with  extravasation  into  the  left  lung,  and 
haemorrhages  in  the  left  extremity  of  the  stomach.  After  section  of 
the  vagus,  animals  die  from  chronic  pneumonia,  and  hence  the  va<ms 
has  been  supposed  to  be  a  trophic  nerve  for  the  lungs.  Such  changes 
have  also  been  accounted  for  by  the  entrance  of  food  from  the 
pharynx  into  the  bronchi,  in  consequence  of  paralysis  of  the  oeso- 
phagus and  the  paralysis  of  the  larynx  (Traube,  Steiner).  All 
admit  that  this  is  one  cause  of  the  pulmonary  affection,  but  opinions 
differ  as  to  the  extent  of  its  influence. 

It  is  possible  that  the  curious  phenomena  of  hiccough  may  be 
connected  with  the  affections  of  this  nerve,  as  they  certainly  are  with 
the  respiratory  centre.  Other  paroxysmal  attacks  of  varied  and 
various  char-acter  are  also  met  with.  Thus  a  man  aged  thirty- seven, 
whose  family  was  liable  to  asthma  in  the  last  generation,  suffered 
for  One  and  a  half  years,  at  intervals  of  four  days  to  a  week,  from 
peculiar  attacks  lasting  from  twelve  to  twenty-four  hours,  and 
characterised  by  prostration,  weakness  of  the  limbs,  and  pallor  of  the 
face  with  muscular  "  working  "  in  the  chest,  followed  by  a  copious 
flow  of  saliva,  such  as  precedes  vomiting,  and  then  an  intense  sense 
of  suffocation. 

Cardiac  Branches. 

The  inhibitory  effect  of  irritation,  and  the  acceleration  of  the  heart's 
action  that  results  from  lessened  action  of  the  vagus,  have  been  before 
alluded  to.  Increased  frequency  has  been  several  times  observed 
in  cases  of  local  disease  of  the  vagus  in  the  thorax,  compression  by 
mediastinal  tumours,  &c.  In  a  case  of  phthisis,  for  instance,  in  which 
the  pulse  was  unduly  frequent  (130—148),  at  first  occasionally,  and 
afterwards  constantly,  Meixner  found  the  left  vagus  enclosed  in  a  mass 
of  enlarged  glands  in  the  upper  opening  of  the  thorax.  The  vagus  is 
also  the  afferent  nerve  from  the  heart ;  and  although  we  are  normally 
unconscious  of  the  cardiac  action,  some  of  the  disordered  sensations 
of  disease  are  apparently  produced  through  its  agency.  In  certain 
anginal  attacks  the  heart's  action  is,  for  a  time,  arrested  or  retarded, 
and  in  a  few  cases  these  symptoms  have  been  found  associated  with 
organic  disease  of  the  cardiac  plexus.  Thus  in  a  case  in  which,  durino- 
paroxysms  of  intense  anginal  anguish,  the  heart's  action  was  arrested 
for  four  or  six  pulsations,  Heine  found  a  tumour  involving  the 
cardiac  plexus.  In  a  case  recorded  by  Blandin,  anginal  attacks  were 
associated  with  a  small  tumour  of  the  vagus.  Pseudo-anginal  sym- 
ptoms have  been  supposed  to  be  associated  with  neuritis  of  one  vagus 
nerve.*  Further,  there  are  afferent  fibres  from  the  heart,  inhibiting 
*  See  Obolensky,  'Berlin,  klin.  YVocheiischr./  No.  52,  1889. 


296  CRANIAL    NERVES. 

the  action  of  the  vaso-motor  centre,  and,  these  are  probably  disturbed 
in  some  anginal  seizures. 

The  inhibitory  fibres  also  for  the  heart  seem  to  be  sometimes  stimu- 
lated from  the  centre,  e.  g.  by  toxic  blood-states  having  a  special 
influence  on  this  part.  But  they  are  occasionally  disordered  in  parox- 
ysms which  seem  to  be  related  to  those  of  migraine,  and  like  mi- 
graine, may  be  remotely  connected  with  inherited  gout,  which  is  a  po- 
tent cause  of  functional  nerve  derangement.* 

After  disease  or  injury  of  the  vagus  the  heart  has  been  found  in  a 
state  of  fatty  degeneration,  and  hence  it  has  been  thought  that  the 
vagus  contains  trophic  fibres  for  the  cardiac  substance. 

Gastric  Branches. 

The  branches  to  the  oesophagus  are  rarely  diseased  except  in  cases 
of  affection  of  the  nerve-trunk  or  of  the  centre.  In  very  rare  cases, 
such  disease  has  caused  difficulty  in  swallowing,  simulating  stricture. 
Spasm  of  the  oesophagus  is  far  more  frequent.  The  vagus  is  the 
sensory  nerve  for  the  stomach.  Its  fibres  are  very  sensitive  to  any 
local  irritation,  and  not  rarely  the  seat  of  spontaneous  neuralgia. 
Hunger  is  generally  believed  to  be  a  pneumogastric  sensation,  and 
complete  loss  of  the  sensations  of  hunger  and  thirst  was  noted  in  a, 
case  of  softening  of  the  root  of  the  vagus  from  an  aneurism  of  the 
vertebral  artery  (Johnson).  Appetite,  however,  is  not  always  lost  in 
animals  when  the  pneumogastrics  have  been  divided  (Eeid).  In  some 
cases  of  disease  of  the  nerve,  excessive  appetite  has  been  present.  This 
symptom,  for  instance,  was  noted  in  one  case,  in  conjunction  with 
dyspnoea,  noisy  breathing,  and  vomiting  of  unaltered  food;  post 
mortem  both  pneumogastrics  were  found  atrophied  (Swan).  In 
another  case  of  insatiable  appetite,  small  neuromata  were  found  on 
the  nerve.  It  is  possible  that  the  symptom  may  be  partly  the  result 
of  the  defective  digestion  of  food. 

The  pneumogastric  is  also  in  part  the  motor  nerve  of  the  stomach  ; 
after  its  section  the  contractions  of  the  organ  are  lessened,  although 
not  altogether  arrested.  Yomiting  is  probably  produced  through  its 
agency,  by  varied  reflex  and  central  irritation.  In  the  latter  case  (as 
in  meningitis)  the  vomiting  is  sometimes  extremely  lapid.  I  have 
known  paroxysmal  vomiting  to  result  from  the  intermitting  pressure 
of  a  tumour  on  the  vagus  ;  and  Boinet,  having  exposed  the  vagus  in 
an  operation  in  the  neck,  noted  that  whenever  he  touched  the  nerve 
the  patient  vomited. 

*  A  woman,  in  the  course  of  five  years,  had  six  attacks,  in  which  there  was  a 
peculiar  cedematous  erythema  in  the  region  supplied  by  the  first  division  of  the  fifth 
nerve  on  both  sides,  followed  by  prolonged  retardation  of  the  heart  down  to  22  and 
32  a  minute  for  weeks  together,  in  consequence  of  prolongation  of  the  systole. 
During  the  first  few  days  of  each  attack  the  temperature  was  raised  to  102,5°. 
There  was  a  family  history  of  gout,  and  the  patient  had  formerly  suffered  from 
distinct  migraine. 


PNEUMOGASTBIO   NERVE.  297 

The  vagus  accelerates  the  contraction  of   the  intestines,  but  no 
intestinal  symptoms  have  been  observed  from  its  disease. 


Prognosis. — The  prognosis  in  every  case  depends  chiefly  upon  the 
nature  of  the  disease  that  interferes  with  the  function  of  the  nerve. 
It  is  good  only  when  the  disturbance  is  not  due  to  organic  mischief. 
In  the  diseases  in  which  the  local  symptoms  form  part  of  a  wider 
functional  disturbance,  as  in  hysteria  and  multiple  neuritis,  the 
prognosis  is  described  in  the  account  of  those  diseases. 

Diagnosis. — The  chief  symptoms  on  which  the  diagnosis  of  disease 
of  the  vagus,  in  any  given  case,  depends,  are  the  laryngeal  paralysis, 
retarded  respiration,  accelerated  or  retarded  action  of  the  heart,  and 
vomiting.  The  diagnosis  of  the  seat  of  the  disease  rests  upon  the 
distribution  of  the  symptoms,  and  on  the  associated  disturbance.  It 
is  especially  important  to  remember  that  this  nerve  suffers  in  poly- 
neuritis. Disease  of  the  trunk  of  the  vagus  is  much  less  common 
than  disease  of  its  branches  or  roots.  Paralysis  of  one  vocal  cord, 
for  instance,  is  almost  always  the  result  of  pressure,  either  on  the 
recurrent  laryngeal  or  on  the  roots  of  the  spinal  accessory  at  the 
medulla.  In  the  former  case  there  are  indications  of  disease  in  the 
thorax ;  in  the  latter,  other  nerves  suffer,  especially  the  hypoglossal. 
Bilateral  paralysis  of  the  larynx,  if  considerable,  suggests  central 
disease — degeneration  of  the  nuclei  in  the  medulla  ;  if  slight,  it  may 
be  of  local  origin  and  independent  of  a  lesion  of  the  nerve  itself,  as 
in  the  case  of  the  "  phonic "  adduction-palsy.  Disease  of  both 
recurrent  laryngeals  is  very  rare,  but  it  must  b*  remembered  that 
disease  of  one  recurrent  has  been  known  to  influence  both  cords.  In 
most  cases  of  pressure  on  the  nerve  the  compressing  disease  causes 
other  obtrusive  indications  of  its  presence  and  position,  the  chief 
exception  being  deeply  seated  tumours  of  the  thorax. 

Treatment. — The  chief  element  in  treatment  is  to  remove  the 
morbid  process  by  which  the  damage  to  the  nerve  is  produced;  the 
measures  to  be  employed  must  vary  according  to  the  nature  of  the 
process,  and  have  been  already  fully  described  in  connection  with  the 
other  cranial  nerves.  The  frequency  with  which  a  lesion  of  the  nerve- 
roots  is  due  to  syphilis  must  be  especially  remembered.  Central 
degenerative  processes  are,  for  the  most  part,  beyond  the  influence 
of  drugs  ;  their  treatment,  as  far  as  it  is  practicable,  is  described  in 
the  section  on  bulbar  paralysis. 

The  chief  division  of  the  pneumogastric  for  which  special  treatment 
may  be  necessary  is  that  for  the  larynx.  The  causes  of  organic 
damage  to  the  recurrent  nerves  are  generally  grave  progressive  diseases, 
such  as  cancer  or  aneurism,  beyond  the  effective  range  of  medicine  or 
surgery.  The  fact  that  scrofulous  enlargement  of  lymphatic  glands  is 
an  occasional  cause  of  compression  of  the  recurrent  nerves  should  be 


298  CRANIAL   NERVES. 

remembered  ;  and  cod-liver  oil,  iodide  of  potassium,  and  arsenic  should 
be  given  whenever  it  is  probable  or  even  possible  that  the  disease  is  of 
this  nature.     Moreover,  here  also  syphilis  may  be  at  work. 

In  paralysis  secondary  to  inflammation  of  the  larynx  or  to  cold,  the 
appropriate  treatment  for  the  laryngeal  disease  should  be  combined 
with  stimulating  applications  or  blisters  to  the  exterior  of  the  larynx. 
The  insufflation  of  strychnine  has  been  recommended,  but  the  amount 
absorbed  is  uncertain  and  variable,  and  dangerous  symptoms  have 
ensued.  It  is  probable  that  all  the  good  which  strychnia  can  accom- 
plish is  to  be  obtained  from  its  administration  by  the  stomach  or  the 
skin.  Hypodermic  injections  are  unquestionably  useful  in  laryngeal 
palsy  ;  gr.  -^ — -Jl.  0f  the  nitrate  may  be  injected  daily.  It  is  of  especial 
value  in  hysterical  paralysis,  in  phonic  paralysis,  and  in  diphtheritic 
palsy. 

Electricity  has  been  used  in  various  ways.  (1)  One  electrode  has 
been  introduced  into  the  laiynx  and  placed  near  the  paralysed  muscle, 
with  the  guidance  of  the  laryngoscopic  mirror,  the  other  electrode  being 
placed  outside  the  larynx.  (2)  A  double  laryngeal  electrode  has  been 
used,  with  two  small  rheophores  close  together.  (3)  One  electrode 
has  been  placed  in  the  pharynx  at  the  back  of  the  larynx,  the  other 
outside.  (4)  Both  poles  have  been  placed  outside  the  larynx,  and  the 
current  passed  through  it.  The  intra-laryngeal  application,  even  in 
the  most  skilful  hands,  is  not  pleasant  to  the  patient,  and  can  only  be 
borne  for  a  few  seconds  at  a  time.  The  percutaneous  method  is  pain- 
ful, although  far  less  so  than  the  other ;  a  stronger  current  can  be 
borne  and  for  a  longer  time,  and,  if  the  current  cannot  be  localised 
with  the  same  precision,  the  muscles  can  be  more  effectually  stimu- 
lated. The  positive  rheophore  may  be  pressed  behind  the  jaw,  and 
the  negative  pressed  firmly  and  moved  down  the  side  of  the  larynx 
aud  trachea.  In  thin  persons  at  least,  the  superior  and  inferior 
nerves  may  be  thus  directly  stimulated.  Either  faradism  or  voltaism 
may  be  applied  externally  ;  in  organic  disease  of  the  nerve  the  latter 
only  will  influence  the  muscles.  But  the  value  of  electricity  in  organic 
disease  of  the  nerves  is  probably  not  great.  In  functional  palsy, 
phonic  paralysis,  and  the  like,  the  nerves  not  being  degenerated,  fara- 
dism can  be  employed,  aud  is  often  distinctly  useful.  It  is  highly 
probable  that  the  chief  results  obtained  by  electricity  are  due  to  the 
stimulation  of  the  sensory  nerves,  and  to  the  indirect  influence  thus 
exerted  on  the  centres. 

In  the  gravest  form  of  laryngeal  palsy,  paralysis  of  the  postici,  tho 
utility  of  electricity  is  practically  limited  to  hysterical  cases,  and  even 
in  them  it  must  be  employed  with  some  caution.  The  separate 
stimulation  of  the  postici  can  only  be  effected  by  the  intra-pharyngeal 
method,  the  electrode  being  placed  at  the  back  of  the  cartilage,  a  little 
on  one  side  of  the  middle  line.  Any  other  method  of  application 
will  stimulate  the  adductors  far  more  than  the  abductors,  and  so 
increase  the   perilous  constriction  of  the  glottis.     Even  the  intra- 


SPINAL    ACCESSORY    NERVE.  299 

pharyngeal  method  is  not' free  from  this  danger.  All  stimulation  of 
the  sensory  nerves  has  a  reflex  action  chiefly  on  the  adductors,  by 
virtue  of  the  central  reflex  mechanism  for  guarding  the  air-passages 
against  the  entrance  of  foreign  bodies.  Hence  even  the  intra-pharyn- 
geal  application  is  in  danger  of  doing  more  harm  indirectly  than  good 
directly. 

In  some  cases  of  phonic  paralysis,  careful  laryngeal  gymnastics 
have  been  found  of  service,  as  in  making  the  patient  utter  or  sin» 
certain  simple  vowel  sounds  without  complicating  articulation.  Treat- 
ment by  manipulation  of  the  larynx  was  proposed  some  years  a^o 
by  Oliver,*  and  has  been  found  useful  by  G-erhardt  and  others.  It 
consists  in  pressing  firmly  with  the  thumb  and  forefinger  on  each 
side  of  the  thyroid  cartilage,  at  the  upper  and  hinder  part.  Durino* 
the  compression  the  patient  is  made  to  utter  a  simple  sound,  and  then 
is  often  able  to  speak,  at  first  in  a  weak,  and  afterwards  in  a  stronger 
voice.  Vocalisation  once  effected,  the  patient  is  often  able  to  continue 
to  speak.  Laryngoscopic  examination  during  the  compression  shows 
that  the  manipulation  approximates  the  arytenoid  cartilages  and  the 
vocal  cords,  and  at  the  same  time  makes  them  tense.  The  treatment 
of  hysterical  aphonia  is  described  in  the  chapter  on  that  disease. 

In  the  treatment  of  laryngeal  spasm  the  most  important  thine  is  the 
removal  of  the  condition  on  which  it  depends,  by  the  treatment  of  any 
local  laryngeal  irritation  and  of  any  diathetic  state  which  exalts  the 
irritability  of  the  central  nervous  system.  Bromide  of  potassium  or 
ammonium  at  once  lessens  the  irritability,  and  cocaine  applied  as  a 
spray  has  a  like  action,  but  these  are  in  most  instances  palliative  only. 
Useful  as  they  are  in  removing  spasm  for  a  time,  it  is  necessary  also 
to  strengthen  the  nerve-centres  by  tonics  in  order  to  prevent  a  recur- 
rence. The  spasm  is  usually  removed  for  a  time  by  the  inhalation  of 
chloroform,  and  often  by  nitrite  of  amyl.  Ten-grain  doses  of  chloral 
have  been  recommended  by  Johnson  as  a  substitute  for  chloroform 
but  chloral  is,  as  a  rule,  inferior  to  bromide.  Spasm  due  to  local 
laryngeal  irritation  is  often  relieved  by  a  necklet  of  ice  ;  a  long  narrow 
tube  is  made  with  gutta-percha  tissue,  the  edges  being  stuck  together 
by  means  of  chloroform,  and  this  is  filled  with  small  pieces  of  ice  and 
placed  round  the  neck. 


SPINAL   ACCESSORY   NEEVE. 

(external  part.) 

Of  the  two  parts  of  which  the  spinal  accessory  nerve  consists,  the 

"  accessory  "  part    (which  arises  from  the   medulla    oblongata,  and, 

joining  the  pneumogastric,  supplies  the  laryngeal  muscles)  has  been 

already  described.     The  "  spinal "  portion,  as  it  is  termed  from  its 

*  '  American  Journal  of  Med.  Scrence/  April,  1870,  p.  305. 


-300  CEAXIAL    KEKVES. 

origin,  or"  external  portion,"  as  it  is  sometimes  called  from  its  distri- 
bution, is  virtually  a  series  of  fibres  of  the  motor  cervical  nerves, 
that  have  the  unusual  course  of  ascending  to  the  cranial  cavity  and 
leaving  it  again  with  one  of  the  cranial  nerves  to  be  distributed  to 
the  cervical  muscles.  The  root-fibres  arise  from  the  middle  of  the 
lateral  column  of  the  cord,  but  the  fibres  pass  through  this,  and 
spring  from  the  nerve-cells  of  the  anterior  cornu,  just  as  do  the  ante- 
rior roots  of  the  cervical  nerves.  As  the  fibres  have  the  same  origin 
as  the  motor  cervical  nerves,  so  they  have  the  same  distribution — to 
two  cervical  muscles,  the  sterno-mastoid  and  trapezius,  which  are  sup- 
plied in  part  by  this  nerve  and  in  part  by  the  cervical  nerves.  The 
nerve  usually  perforates  the  sterno-mastoid,  and  supplies  this  muscle 
almost  entirely,  the  other  nerves  to  it  being  unimportant  branches 
from  the  second  and  third  cervical  pairs.  The  fibres  can  be  traced 
almost  down  to  the  lower  border  of  the  trapezius,  but  this  muscle 
receives  a  larger  supply  from  the  cervical  and  upper  dorsal  nerves. 
Only  paralysis  of  the  nerve  is  here  described.  The  muscles  supplied 
by  it  are  frequently  the  seat  of  spasm,  which  produces  the  condition 
known  as  "  torticollis."  But  the  spasm  often  passes  beyond  the 
distribution  of  this  nerve,  and  is  therefore  more  conveniently  con- 
sidered, in  connection  with  other  forms  of  spasm,  at  a  later  page. 

Causes. — The  nuclear  grey  matter  from  which  the  neiwe  arises  may 
participate  in  central  degeneration,  causing  wasting  in  these  muscles, 
associated  with  more  extensive  muscular  atrophy  (see  vol.  i,  p.  483). 
The  nerve  may  be  damaged  in  the  neighbourhood  of  the  foramen 
magnum  by  local  meningitis  and  compression,  and  both  nerves  may  be 
thus  affected.  At  the  side  of  the  medulla,  moreover,  the  external  part 
may  suffer  with  the  hypoglossal,  and  with  the  fibres  for  the  larynx. 
Outside  the  skull  it  may  be  damaged  by  wounds,  by  deep-seated 
tumours,  by  caries  of  the  higher  cervical  vertebra,  and  by  abscesses 
springing  from  the  cervical  glands,  and  sometimes,  although  rarely, 
by  rheumatic  neuritis. 

Symptoms. — The  effect  of  disease  of  the  nerve  is  paralysis  of  the 
muscles  supplied  by  it.  If  the  trunk  of  the  nerve  is  diseased,  the 
sterno-mastoid  suffers  much  more  than  the  trapezius,  and  the  latter 
chiefly  in  its  higher  parts.  "Wasting  almost  always  accompanies  the 
loss  of  power.  The  paralysis  of  the  sterno-mastoid  is  shown  by  an 
absence  of  the  normal  prominence  of  the  muscle  in  movements  of  the 
head,  and  by  defective  power  of  rotation  of  the  head  to  the  side  oppo- 
site to  the  paralysis.  Paralysis  of  one  sterno-mastoid  does  not  cause 
any  deviation  of  the  head  when  at  rest,  but  such  deviation  may  arise 
from  secondary  contraction  of  the  unopposed  muscle  on  the  other  side. 
There  is  no  such  thing  as  a  pure  paralytic  torticollis. 

The  only  part  of  the  trapezius  that  is  completely  paralysed  by 
disease  of  the  spinal  accessory  nerve  is  the  highest  portion,  which 


SPINAL    ACCESSORY    NERVE.  301 

descends  from  the  occipital  bone  to  the  acromion.  Instead  of  the 
nearly  straight  contour  which  this  muscle  gives  to  the  outer  side  of 
the  neck  in  the  normal  condition,  the  neck  presents  a  concave  curve, 
and  the  difference  between  the  two  sides  is  bi-ought  out  strongly  by  a 
deep  inspiration,  the  action  in  which  this  muscle  is  chiefly  employed. 
The  weakening  of  the  second  part  of  the  trapezius  allows  the  shoulder 
to  fall  a  little  ;  the  scapula  recedes  from  the  spine,  and  is  rotated,  the 
lower  angle  inwards,  in  cousequence  of  the  unopposed  action  of  the 
rhomboids  and  the  levator  anguli  scapulae.  Elevation  of  the  arm  is 
also  impaired,  because  the  deltoid  has  lost  some  of  the  support  from 
which  it  acts.  But  the  middle  part  of  the  trapezius  is  never  com- 
pletely paralysed  from  disease  limited  to  the  accessory  nerve,  by 
reason  of  the  additional  innervation  from  the  spinal  nerves. 

In  bilateral  paralysis  of  these  muscles  the  power  of  supporting  the 
head  in  the  upright  posture  is  impaired.  If  both  sterno-mastoids  are 
affected,  the  head  tends  to  fall  backwai'ds ;  if  both  trapezii,  it  readily 
sinks  forwards,  so  that  the  chin  rests  on  the  sternum.  Such  defective 
power  of  support  of  the  head  is  not  uncommon  in  children  in  conse- 
quence of  chronic  meningitis  about  the  foramen  magnum,  damaoino- 
both  spinal  accessory  nerves ;  and  it  is  conspicuous  in  many  cases  of 
progressive  muscular  atrophy  (vol.  i,  fig.  136).  In  recent  cases  of 
injury  to  the  nerve  the  muscles  present  the  characteristic  reaction  of 
nerve  degeneration.  In  central  disease  the  reaction  varies,  as  it  does 
elsewhere  in  progressive  muscular  atrophy. 

The  distribution  of  the  symptoms  differs  according  to  the  seat  of 
the  disease.  When  this  is  in  the  central  grey  matter  other  muscles 
are  always  involved,  and  the  distribution  of  the  paralysis  in  the  region 
of  the  spinal  accessory  varies  much.  As  a  rule,  the  highest  part  of 
the  trapezius  suffers  later  than  the  rest  of  the  muscle,  and  for  this 
reason  Duchenne  called  it  the  ultimum  moriens.  But  this  rule  is  not 
invariable;  I  have  known  this  part  to  be  the  first  to  suffer.  In 
disease  of  the  trunk  of  the  nerve  all  parts  are  involved.  Not  infre- 
quently the  nerve  is  damaged,  by  local  disease  or  injury,  after  it  has 
passed  through  the  sterno-mastoid,  and  then  this  muscle  escapes 
and  the  trapezius  alone  suffers.  When  the  lesion  involves  the  intra- 
cranial part  of  the  nerve,  it  is  common  for  the  internal  or  accessory 
portion  to  be  likewise  affected,  and  there  is  then  paralysis  of  the  vocal 
cord  on  the  same  side.  If  the  lesion  is  within  the  skull  the  hypo- 
glossal is  frequently  damaged  also,  and  sometimes  the  palate. 

Tbeatment. — The  treatment  of  paralysis  of  the  external  part  of  the 
spinal  accessory  is,  first,  that  of  the  morbid  process  by  which  it  has 
been  damaged ;  and  secondly,  the  stimulation  of  the  paralysed  muscles 
by  electricity  for  the  purpose  of  maintaining  or  improving  their 
nutrition  during  the  recovery  of  the  nerve.  The  form  must  be  used 
to  which  the  muscles  most  readily  respond. 


302  CRANIAL    NERVES. 


HYPOGLOSSAL   NERVE. 

The  hypoglossal  nerve  is  the  motor  nerve  for  the  tongue,  for  the 
depressors  of  the  hyoid  hone,  and  for  some  of  the  elevators  (hyo- 
glossus  and  genio-kyoid)  ;  it  arises  from  the  medulla  oblongata  beside 
the  olivary  body.  Its  origin  has  been  already  described  (p.  44).  The 
fibres  within  the  skull  are  close  to  those  of  the  spinal  accessory  and 
pneumogastric,  a  relation  that  is  resumed  for  a  short  distance  in  the 
upper  part  of  the  neck,  after  the  passage  of  the  nerve  through  a 
separate  foramen  in  the  occipital  bone.  The  nerve,  however,  soon 
leaves  its  deep  position  to  course  forward  to  its  distribution.  Its  most 
important  connection  is  with  the  petrous  ganglion  of  the  pneumo- 
gastric, and  with  the  loop  joining  the  first  two  cervical  nerves,  from 
which,  and  not  from  the  hypoglossal  nucleus,  the  fibres  are  apparently 
derived  which  supply  the  depressors  of  the  hyoid  bone  (Horsley  and 
Beevor). 

Paralysis. 

Causes. — (1)  Nuclear  disease  which  is  usually  degeneration,  rarely 
sudden  softening  from  vascular  occlusion,  or  an  acute  process  from 
inflammation.  It  forms  part  of  bulbar  paralysis,  acute  and  chronic, 
and  has  occurred  in  rare  cases  of  locomotor  ataxy.  The  affection  is 
almost  always  bilateral,  the  two  nuclei  being  so  near  together  that 
even  an  acute  lesion  scarcely  ever  affects  one  only,  although  this  has 
been  observed  when  the  onset  was  sudden,*  and  very  rarely  in  chronic 
degeneration,  as  in  tabest  and  general  paralysis.  The  lips  and 
other  parts  almost  always  suffer  as  well.  (2)  Supra-nuclear  disease, 
involving  the  motor  tract  anywhere  between  the  medulla  and  the 
lowest  part  of  the  ascending  frontal  convolution  or  the  root  of  the 
third  frontal, J  and  of  any  nature,  may  paralyse  the  tongue  on  the 
opposite  side.  (3)  Infra-nuclear  disease:  (a)  within  the  medulla, 
the  root-fibres  are  occasionally  damaged  by  softening  or  by  a  tumour, 
usually  in  association  with  the  contiguous  motor  tract  of  the  opposite 
limbs  ;  (&)  outside  the  pons,  the  fibres  of  origin  are  damaged  ty 
meningitis,  simple  or  syphilitic. §  and  by  growths.  In  thickening  of 
tbe  bones  of  the  skull  the  nerve  may  be  compressed  within  its  foramen. 
In  its  course  outside  the  skull  the  nerve  is  occasionally  damaged  by 
deep-seated  tumours,  by  local  cellulitis,  by  mischief  communicated 

*  Hirt,  '  Berl.  kl.  Wochenschr./  1885,  No.  26. 

f  Raymond  and  Artaud,  '  Arch,  de  Phys.,'  No.  3,  1884.  The  degeneration  was 
proved  post  mortem.  Many  similar  instances  of  tabetic  palsy  have  been  since 
observed. 

J  Beneath  which  a  small  focus  of  softening  has  affected  the  tongue  only  (Edinger, 
« Deut.  med.  VVochenschr.,'  1886). 

§  A  good  example  of  damage  by  chronic  meningitis  is  recorded  by  Hayem  and 
Giraudeau  ('  Rev.  dc  Med.,'  March,  1883). 


HYPOGLOSSAL   NERVE. 


303 


from  cai-ies  of  the  highest  cervical  vertebrae,  or  is  injured  by 
penetrating  wounds.  In  this  position  the  spinal  accessory  often 
suffers  with  it,  and  paralysis  of  the  palate,  occasionally  of  the  vocal 
cord,  results,  with  or  without  some  wasting  in  the  trapezius  and 
sterno-mastoid.  The  hypoglossal  nerve  is  rarely  the  seat  of  isolated 
neuritis.*  Hemiatrophy  of  the  tongue  is  sometimes  associated  with 
that  of  the  face  (q.  v.),  but  is  pro- 
bably independent  of  the  hypoglossal 
nerve. 

Symptoms. — The  effects  of  disease 
of  the  hypoglossal  nerve  are  motor 
only;  no  loss  of  sensation  results. 
In  paralysis  of  one  hypoglossal  nerve 
the  tongue  at  rest  is  in  its  normal 
position  in  the  mouth,  but  its  root  is 
higher  on  the  paralysed  than  on  the 
unparalysed  side,  in.  consequence  of 
the  loss  of  the  tonic  contraction  of 
the  posterior  fibres  of  the  hyo-glossus. 
Within  the  mouth  the  movement  is 
deficient  towards  the  paralysed  side. 
When  protruded  (Fig.  112),  how- 
ever, the  tongue  deviates  towards  the 
affected,  and  from  the  unaffected  side, 
because,  in  protrusion,  the  tongue  is 
pushed  out  by  the  fibres  of  the  genio- 

glossus  and  is  pushed  towards  the  weaker  side.  The  point  of  the 
tongue  is  often  curved  towards  the  affected  half.  In  complete 
bilateral  paralysis  the  tongue  lies  motionless  within  the  mouth,  and 
cannot  be  protruded.  Articulation  is  always  impaired  in  bilateral 
paralysis,  but  one-sided  palsy,  even  considerable,  interferes  very  little 
with  speech,  chewing,  or  swallowing.  Mastication  is  hindered  because 
the  tongue  fails  to  keep  the  food  between  the  teeth,  and  the  loss  of 
the  propelling  power  of  the  tongue  may  make  it  difficult  for  the 
patient  to  get  the  food  into  the  throat.  The  nutrition  of  the  tongue 
varies  according  to  the  seat  of  the  disease :  when  above  the  nucleus 
wasting  is  absent  or  insignificant;  but  when  the  nucleus  or  nerve- 
fibres  are  diseased,  the  tongue  wastes  and  shrinks.  The  wasting  is  of 
the  muscular  tissue ;  the  mucous  membrane  is  thrown  into  con- 
spicuous irregular  folds,  prominent  rugse  with  deep  furrows  between 
them.  Sensation  is  not  impaired,  nor  is  taste  except  in  slight  decree 
in  consequence  of  inability  to  move  sapid  substances  about  in  the 
mouth. 

*  A  case  of  isolated  affection  of  this  nerve  in  a  lad  aged  thirteen,  possibly  a 
rheumatic  neuritis,  has  been  recorded  by  Erb  ('Deut.  Arch.  f.  kl.  Med./  xxxvii, 
p.  265). 


Fig.  112. — Paralysis  and  wasting  of 
the  right  half  of  the  tongue,  due 
to  disease  of  the  hypoglossal  nerve. 


304  CRANIAL    NERVES. 

Diagnosis. — The  position  of  the  lesion  is  indicated  by  the  associa- 
tions of  the  paralysis.  If  the  disease  is  in  the  motor  tract  above  the 
nucleus  (pons,  crus,  or  hemisphere),  there  is  almost  always  hemiplegic 
weakness  on  the  side  of  the  paralysis  of  the  tongue.  In  disease  of 
the  nucleus  the  paralysis  is  commonly  bilateral,  is  associated  with 
paralysis  of  the  lips  and  throat,  and  there  is  usually  wasting.  Disease 
of  the  fibres  of  origin  within  the  medulla  is  associated  with  paralysis 
of  the  opposite  limbs,  so  that  the  tongue  deviates  from  the  paralysed 
side.  When  the  disease  is  at  the  surface  of  the  medulla  the  paralysis 
is  commonly  unilateral,  and  is  associated  with  paralysis  of  the  cor- 
responding half  of  the  palate  and  vocal  cord  ;  aud  this  is  also  true 
when  the  disease  is  outside  the  skull,  although  the  associated  palsy  is 
often  incomplete  and  irregular  (see  p.  285).  There  are  commonly 
other  indications  of  a  morbid  process  in  this  situation.  In  disease 
of  the  fibres  of  origin  within  or  outside  the  medulla  there  is  com- 
monly wasting.  The  diagnosis  of  the  pathological  cause  of  the 
paralysis  rests  on  the  course  of  the  affection,  and  on  the  presence  of 
any  causal  and  associated  condition. 

Prognosis. — This  is  usually  unfavorable,  on  account  of  the  cha- 
racter o>f  the  disease,  which  damages  the  nerve  or  centre.  Even  in 
syphilitic  cases  recovery  is  often  incomplete. 

Treatment. — The  treatment  of  paralysis  of  the  hypoglossal  nerve 
is  that  of  the  causal  disease.  Tonics,  counter-irritation,  iodide  of 
potassium,  and  mercury,  with  occasionally  the  application  of  electricity 
to  the  tongue,  are  the  most  important  remedies  to  be  employed 
according  to  the  etiological  indication.  The  most  convenient  method 
of  applying  electricity  is  by  means  of  a  tongue  depressor  in  a  wooden 
handle,  the  blade  being  insulated  by  a  coating  of  sealing-wax  where  it 
comes  in  contact  with  the  lips. 


Spasm  of  the  Tongue. 

The  tongue  participates  in  certain  forms  of  general  spasm,  such  a3 
those  of  epilepsy  and  chorea.  The  tongue-biting  in  epileptic  attacks 
is  due  to  the  organ  being  jerked  between  the  teeth  by  the  genio-glossus, 
when  the  jaws  are  brought  together  by  the  spasm  in  the  masseters. 
Spasm  occurs  also  in  some  forms  of  stuttering.  A  peculiar  affection, 
allied  to  stuttering,  in  which  an  attempt  to  speak  brought  on  spasm 
in  the  tongue  and  muscles  attached  to  the  hyoid  bone,  was  described 
by  Fleury*  under  the  name  "  aphthongia."  It  is  especially  excited  by 
emotion,  and  has  been  compared  to  writers'  cramo. 

*  Fleury,  *  Gaz.  hebd.,'  1865,  No.  16.  The  case  (in  a  man)  was  complicated  by 
convulsions  and  other  indications  of  cerebral  disturbance.  It  is  possible  that  the 
symptoms  were  of  functional  origin,  as  similar  spasm  certainly  was  in  cases  (of 


\ 


HYPOGLOSSAL    NERVE.  30$ 

The  tongue  is  a  not  infrequent  seat  of  spasm  in  hysteria,  in  which 
protrusion  may  occur  during  paroxysmal  convulsive  attacks,  or  rarely 
without  spasm  elsewhere.  More  frequent  in  this  disease  is  spasmodic 
deviation  of  the  tongue  when  it  is  put  out.  I  have  seen  this  as  an 
isolated  symptom  in  a  child,  continuing  for  some  weeks,  and  also  in 
association  with  some  forms  of  hysterical  spasm  about  the  face.  Thus 
in  the  case  of  hysterical  ptosis,  shown  in  Fig.  102,  the  tongue  deviated 
to  the  left  on  protrusion,  and  continued  to  do  so  as  long  as  the  affec- 
tion of  the  eyelids  lasted.  In  another  case,  in  a  young  woman,  similar 
deviation  to  the  left  was  associated  with  persistent  tonic  spasm,  by 
which  the  left  angle  of  the  mouth  and  the  lower  lip  were  drawn  down- 
wards and  outward.  It  is  probable  that  some  other  cases  of  spasm 
of  the  tongue,  recorded  as  idiopathic,  were  due  to  the  same  disease. 
A  girl,*  aged  nine,  suffered  for  some  months  from  attacks,  recurring 
every  ten  minutes,  and  sometimes  during  sleep,  in  which  the  tongue 
was  protruded  in  tonic  spasm,  and  towards  the  end  of  the  attack  the 
tip  was  turned  upwards ;  if  the  mouth  was  shut  at  the  time,  the 
tongue  was  finnly  pressed  against  the  teeth.  Her  own  explanation 
was  that  she  felt  an  irresistible  desire  to  protrude  the  tongue.  A 
young  man,  during  two  years,  had  from  fifteen  to  thirty  attacks  daily 
of  cramp-like  protrusion  of  the  tongue,  accompanied  with  pain  in  the 
muscles  connecting  it  with  the  hyoid  bone.f  In  another  instance  of 
a  girl  suffering  from  peculiar  hallucinations,  whenever  the  tongue 
was  protruded  it  presented  very  rapid  movements  of  protrusion  and 
retraction. J  An  allied  condition  probably  caused  clonic  spasm  (also 
in  the  stylo-  and  genio-hyoid)  which  existed  during  puerperal  melan- 
cholia^ » 

Spasm  in  the  tongue  seems  to  be  sometimes  caused  by  irritation  of 
the  fifth  nerve.  In  one  instance,  it  existed  during  each  paroxysm  of 
neuralgia  in  the  lingual  nerve.  ||  In  another  case,  dental  caries  with 
ulceration  of  the  gums  seemed  to  be  the  cause  of  attacks  of  spasm,  in 
which  the  tongue  was  as  hard  as  a  piece  of  wood,  and  was  curved  up- 
wards, with  the  tip  toward  the  palate.  The  spasm  afterwards  spread 
to  the  face,  neck,  and  arm,  and  ceased  on  the  removal  of  the  teeth.^f 

Paroxysmal  clonic  spasm  in  the  tongue  has  been  occasionally  met 
with,  especially  as  a  functional  affection,  as  which  it  may  accompany 
similar  spasm  in  the  face,  or  may  occur  alone.  Constant  clonic  spasm 
on  one  side,  involving  also  the  stylo-glossus  and  genio-glossus,  coin- 
cided with  puerperal  melancholia,. and  ceased  with  it,  in  one  recorded 

children)  recorded  by  Pantliel  (( Deut.  Klinik.,'  1S55)  and  Vallin  fGaz.  Hebd.,' 
1S65,  No.  17). 

*  Dochmann,  'Berl.  Id.  Wochensch./  1883,  No.  1. 

t  Personali,  '  Acad,  di  Med.  di  Torino,5  liii,  1891. 

X  Erb,  'Krank.  der  Peri  ph.  Nerv.,'  2  Aufl.,  1876.  p  296. 

§  Sepelli,  '  Riv.  Sper.,'  1886. 

||   Romberg,  « Lehrbuch,'  3  Auf.,  1857,  p.  388. 
f  Mitchell, '  Med.-Chir.  Trans.,'  vol.  iv,  p.  75. 

vol.  ii.  20 


306  CRANIAL    NERVES. 

case.*  More  frequently  the  spasm  lias  "been  paroxysmal,  and  has 
accompanied  facial  spasm  (q.  v.).  A  man,  aged  thirty-three,  was 
liable  to  attacks  of  protrusion  of  the  tongue,  which  was  pushed  out 
fortv  or  fifty  times  a  minute.  Each  attack  was  preceded  and  accom- 
panied by  peculiar  sensations  in  the  left  side  of  the  tongue  and 
adjacent  gums.  The  spasm  seemed  to  be  greatest  in  the  left  half  of 
the  tongue,  and  it  spread  to  the  left  side  of  the  face,  where  there 
was  slight  loss  of  power.  Mastication  excited  the  spasm  ;  speaking 
did  not.  Eemak,  who  recorded  the  case.t  thought  the  spasm  was 
probably  of  cortical  origin,  and  the  contiguity  of  the  facial  and 
lingual  centres  gives  support  to  the  opinion.  The  attacks  ceased 
under  iodide  of  potassium  and  electrical  treatment.  Somewhat 
similar  paroxysms  of  clonic  spasm  were  limited  to  the  tongue  in  a  case 
described  by  Berger.J  A  sense  of  tension  in  the  organ  preceded 
each  attack,  which  lasted  one  or  two  minutes.  The  attacks  occurred 
duriug  sleep  as  well  as  by  day,  and  continued  during  a  year  and  a 
half.  The  patient  was  a  woman  aged  twenty-eight ;  she  was  anaemic, 
and  recovered  when  treated  with  iron  and  change  of  air.  In  another 
case  a  man,  aged  forty,  had  suffered  for  two  years  from  attacks  in 
which  the  tongue  was  pushed  out  and  drawn  back  more  deliberately. 
The  intervals  between  the  attacks  varied  from  a  few  hours  to  several 
weeks. § 

It  seems  clear,  from  these  meagre  facts,  that  spasm  in  the  tongue  is 
generally  paroxysmal,  and  dependent  on  functional  states  of  the 
nervous  system  that  are  removable  by  tonic  treatment.  It  thus 
differs  essentially  from  spasm  in  the  face  and  neck. 

Lingual  Dysesthesia  is  also  met  with,  sometimes  as  an  obstinate  and 
obtrusive  malady,  givicg  rise  to  the  impression  that  the  patient  has 
organic  disease  of  the  organ,  especially  cancer.  But  the  symptom  is 
allied  to  neuralgia,  in  connection  with  which  it  is  described. 


Paealysis  of  the  Palate. 

The  movement  of  the  palate  that  is  of  chief  medical  importance  is 
its  elevation,  which  is  best  seen  when  the  patient  utters  a  long  "  Ah  ;" 
the  base  of  the  palate  is  then  dr'awn  up.  so  that  a  depression  is  formed 
in  the  middle  line  of  the  upper  half  of  the  palate.  It  is  probable 
that  this  movement  is  produced  chi  fly  by  the  levators,  each  of  which 
spreads  out  towards  the  middle  line,  and  there  blends  with  its  fellow. 
If  this  movement  is  lost  on  one  side,  when  the  patient  utters  the  sound 
the  middle  of  the  soft  palate  is  drawn  a  little  towards  the  unaffected 
side,  and   a   depression  is  formed  on  this   side  of  the  middle  line, 

*  Sepelli,  '  Riv.  Sper.  di  Frcn.,'  18S6. 

t  *Berl.  klin.  Wochensclir.,'  1S83,  No.  34. 

X  '  Near.  Centralbl.,'  1882,  p.  49. 

§  Ibid. 


HYPOGLOSSAL    NERVE.  307 

instead  of  in  the  middle  line  itself.  The  difference  between  the  height 
of  the  edge  of  the  palate  on  each  side,  at  rest,  is  of  little  significance, 
since  a  difference  is  very  common  in  health  :  loss  of  action  of  one  side  of 
the  azygos  uvulae  is  also  seldom  to  he  recognised  in  cases  of  unques- 
tionable paralysis  of  the  palate.  In  bilateral  palsy,  however,  the 
palate  hangs  lower  than  normal,  and  the  uvula  is  long  and  flaccid. 
The  effect  of  palsy  of  the  palate  is  to  permit  the  regurgitation  of 
liquids  from  the  throat  into  the  nbse,  and  to  interfere  with  speech  bv 
causing  a  persistent  nasal  resonance,  and  by  preventing  the  compres- 
sion of  air  necessary  for  the  articulation  of  the  explosive  labial  con- 
sonants. Paralysis  of  one  side  of  the  palate  does  not  usually  cause 
symptoms,  and  is  only  discovered  by  an  examination  of  the  throat. 

The  origin  of  the  nerve  supply  to  the  palate  is  one  of  the  most 
obscure  questions  connected  with  the  anatomy  of  the  cranial  nerves. 
The  levator  palati  and  azygos  uvulae  are  said  to  be  supplied  from  the 
Vidian  nerve,  and  the  tensor  palati  from  the  otic  gangliou  of  the 
fifth.  The  fibres  from  the  Vidian  are  commonly  thought  to  be  de- 
rived from  the  facial  nerve,  but  we  have  already  seen  reason  to  doubt 
the  truth  of  this  opinion.  It  is  certain  that  the  movement  of  the 
palate  just  described,  of  which  the  one  sided  loss  is  the  most  definite 
and  frequent,  is  innervated  from  one  of  the  nerves  that  arise  from  the 
medulla  oblongata.  Whenever  disease  at  the  surface  of  the  medulla 
damages  the  hypoglossal  and  spinal  accessory  nerves  so  as  to  paralyse 
the  tongue  and  vocal  cord  on  the  same  side,  it  will  almost  always  be 
found  that  this  movement  of  the  palate  is  lost.*  It  is  certain,  there- 
fore, that  it  depends  on  one  of  these  nerves,  as  was  pointed  out,  from 
experimental  results,  by  John  Eeid  in  1838,  by  Bischoff  in  1842,  and 
afterwards  by  Stilling,  Wagner,  Bernard,  and  others.f  That  the 
innervation  is  really  from  the  spinal  accessory  has  been  conclusively 
proved  by  Beevor  and  Horsley,  who  found  that  the  palato  remained, 
still  when  the  facial  or  glossopharyngeal  was  stimulated  within  the 
skull,  but  moved  when  the  spinal  accessory  was  stimulated.  J  Fibres 
from  this  nerve  may  pass  to  the  palate  by  the  branch  that  the  pneu- 
mogastric  gives  to  the  pharyngeal  plexus.  In  some  cases  of  this 
paralysis  the  external  muscles  supplied  by  the  spinal  accessory  a:e 
wasted.  The  same  combination  of  palsy  of  tongue,  palate,  and  larynx 
occurs  also  from  disease  within  the  medulla,  damaging  the  bulbar 
nuclei,  and  is  considered  in  another  section.  The  causation  and  treat- 
ment of  unilateral  paralysis  of  the  palate  are  the  same  as  of  disease 
of  the  tongue,  already  described. 

*  The  frequency  of  this  fact  was  first  pointed  out  by  Hughlings  Jackson  (« London 
Hosp.  Rep.,'  vol.  i,  1864). 

t  See  an  instructive  paper  by  W.  A.  Turner,  'Journal  of  Anat.  and  Pbys.,'  1889. 

%  '  Proc.  Royal  Society.'  That  the  spinal  accessory  is  tbe  nerve  for  tbi-i  movement 
of  tbe  palate  was  suggested  by  S.  Mackenzie  (r  British  Med.  Journal,'  March  3rd, 
1883),  and  also  in  tbe  first  edition  of  this  work. 


oOS  LOCALISATION    OF    CEKEBKAL    DL>EASF. 


LOCALISATION   OF   CEREBRAL   DISEASE. 

(relation  of  locality  to  symptoms.) 

The  chief  facts  regarding  the  relation  of  symptoms  to  locality  of 
lesion  have  been  already  incidently  described  in  the  account  of  the 
functions  of  the  brain  and  of  the  symptoms  themselves.  Reference 
must  be  made  to  this  when  the  object  is  to  ascertain  the  position 
of  a  lesion  from  the  symptoms  it  produces.  It  is  convenient,  however, 
to  recapitulate  the  various  effects,  regarded  from  the  side  of  locality, 
that  are  caused  by  disease  in  the  several  parts  of  the  brain,  so  far  as 
these  are  known,  and  are  of  importance  in  diagnosis.  The  variations 
that  depend  upon  the  nature  of  the  lesion  will  be  described  in  the 
account  of  the  special  diseases.  The  chief  precautions  that  have  to  be 
observed  in  drawing  conclusions  from  observed  facts  have  been  men- 
tioned on  p.  15.*  It  should  be  remembered  that  the  symptoms, 
nnd  their  combination  constitute  the  evidence  as  to  the  seat  of  the 
disease.  The  mode  of  onset  and  course  indicate  its  nature,  which 
is  only  of  localising  significance  in  so  far  as  some  lesions  are  more 
common  than  others  in  certain  parts. 

Cerebral  Cortex. — It  is  convenient  to  consider  seriatim  the 
several  regions  into  which  the  cortex  is  commonly  divided,  beginning 
with  that  in  which  disease  most  frequently  causes  conspicuous 
symptoms. 

Central  Region,  i.  e.  the  ascending  frontal  and  parietal,  anterior 
two  thirds  of  superior  parietal  lobule,  and  paracentral  lobule  on  the 
inner  surface.  Destruction  causes  hemiplegia  on  the  opposite  side, 
permanent,  with  secondary  degeneration  of  the  pyramidal  tract, 
and  rigidity  of  the  limbs;  a  partial  lesion  affects  face,  arm,  or  leg, 
according  to  its  position  (see  p.  80).  Partial  lesions  are  very  common, 
first,  on  account  of  the  wide  extent  of  the  central  region  ;  and  secondly, 
because  the  region  is  supplied  by  different  arterial  branches,  and  sof  ten- 
iug  from  their  occlusion  is  frequent.  Partial  palsy,  "  monoplegia,"  is 
far  more  common  from  disease  of  the  cortex  than  from  disease  more 
deeplv  seated  :  hence  it  always  suggests  a  cortical  les;on,  but  does  not 
prove  it,  because  it  may  be  due  to  a  deeper  lesion .  The  leg  is  probably 
affected   alone   only  in   disease    of   the   medial    cortex    (paracentral 

*  The  most  important  writings  on  the  subject  of  cerebral  localisations  are  by  Xoth- 
nagel,  in  his  admirable  and  exhaustive  'Topische  Diagnostik  der  Gehirnkr.,'  1879 
Ferrier, '  Gulstonian  Lectures  on  Localisation  of  Cerebral  Disease,'  London,  2nd  ed. ; 
Charcot  and  Pitres,  '  Revue  de  Med.,'  1877,  1878,  1S79,  and  1883,  and  Allen  Starr, 
numerous  collections  of  facts  published  chiefly  in  the  '  Ainer.  Journ.  of  Med. 
Science'  since  1884. 


LOCALISATION    Of    CEREBRAL    DISEASE. 


309 


lobule),  or  when  disease  of  the  outer  surface  is  close  to  the  lon- 
gitudinal fissure.  Disease  between  the  longitudinal  fissure  and  the 
level  of  the  lower  frontal  sulcus,  paralyses  the  arm,*  which  is  affected 
alone  if  the  lesion  is  limited  to  the  middle  third  of  the  convolutions 
(Fig.  113).  Probably  disease  at  the  junction  of  the  ascending  frontal 
and  highest  frontal  paralyses  the  foot  more  than  the  rest  of  the  leg. 
and  a  lesion  in  the  highest  part  of  the  arm-region  affects  the  shoulder 
more  than  the  arm.  In  drawing  conclusions  from  the  preponderant 
palsy  of  the  extremity  of  either  limb,  great  care  is  necessary,  because 
this  part  is  less  represented  in  the  other  hemisphere  than  are  the 
muscles  of  the  upper  parts  of  the  limbs,  and  the  latter  recover  some 
power  by  compensation  (see  p.  80).  Disease  of  the  ascending 
frontal,  opposite  the  upper  half  of  the  inferior  frontal,  causes  paralysis 
of  the  lower  part  of  the  face,  except  the  lips,  which  suffer,  with  the 
tongue,  in  disease  of  the  lowest  part  of  the  ascending  frontal  (Fig. 
114).  But  the  bilatei'al  representation  of  the  lips  renders  the  effect 
of  one-sided  disease  inconspicuous.  Disease  in  the  same  region 
sometimes  causes  transient  weakness  of  the  opposite  masseter  ;  that  of 
the  lowest  part,  in  front,  paralyses  the  opposite  vocal  cord  (see  p.  14). 
On  the  whole,  the  paralysing  effects  of  limited  lesions  of  the  central 
region  correspond  very  closely  in  different  cases.  Apparent  excep- 
tions are  sometimes  due  to  the  depth  to  which  the  disease  penetrates. 
Lesions  are  seldom  confined  to  the  grey  substance,  and  if  they  extend 
deeply  into  the  white  substance  they  may  interrupt  the  fibres  from 
another  region  of  the  cortex  that  is  not  diseased. 


Fig.  114. 


Fig.  113. —  Posiiion  of  a  tumour  in  the  middle  of  the  ceuiiul  convolu- 
tion which  caused  convulsions  beginning  in  the  left  arm,  and  afterwards 
paralysis  of  the  arm  without  implication  of  leg  or  face.  (Miiller,  '  Trans. 
Int.  Med.  Congress'  London,  1881.) 

Fig.  114. — Position  of  a  small  haemorrhage  which  caused  paralysis  of 
the  tongue  and  lower  part  of  the  face.  (Ballet,  'Prog.  Med.,5  18S0, 
p.  762.) 


Irritating  disease  in  the  central  cortex,  and  also  stationary  partial 
lesions  cause  convulsion,  which  begins  locally  in  the  leg,  arm,  or  face, 
as  the  disease  is  in  or  near  the  region  destruction  of  which  causes 
palsy  of  the  part.     Thus  disease  of  the  middle  third  of  the  central 

*  Yet  the  arm  has  been  paralysed  by  a  lesion  only  a  few  millimetres  from  the 
longitudinal  fissure. 


310  LOCALISATION    OF    CEREBRAL    DISEASE. 

convolutions  often  causes  convulsions  "beginning  in  the  band. 
According  to  its  degree,  tbe  resulting  convulsion  may  be  confined  to 
tbe  part  whose  centre  is  irritated,  or  may  spread  through  the  whole 
side,  or  may  be  bilateral ;  the  second  side  being  affected  after  the 
first  (see  p.  90).  This  local  commencement  is  the  great  characteristic 
of  convulsions  from  cortical  disease.  Rarely  a  legion  elsewhere,  either 
an  acute  lesion  or  chronic  irritating  disease,  such  as  tumour,  causes 
such  convulsions.  But  a  stationary  legion,  of  acute  onset,  never  causes 
recurring  convulsions  uuless  it  is  in  the  cortex.  Hence  initial  con- 
vulsions of  this  character  suggest  cortical  disease,  but  recurring 
convulsions  from  a  stationary  lesion  in  adult  life  prove  it.  They  may 
follow  a  lesion  of  the  internal  capsule  in  childhood.  Such  convulsions 
are  thus  of  great  general  significance,  but  the  indication  they  afford 
as  to  the  exact  seat  of  the  disease  is  not  always  precise ;  it  is,  less 
precise  than  is  paralysis,  because  cortical  disease  causing  local  palsy 
must  involve  the  centre  concerned,  hut  such  disease  causing  local 
convulsion  may  be  only  near  the  centre.  The  convulsion  may  begin 
by  a  sensation  or  by  spasm,  the  significant  indication  is  the  part  in 
which  the  discharge  commences,  irr.  spective  of  its  nature.  Thus,  if 
the  fit  begins  with  tingling  in  the  foot,  aud  the  sensation  seems  to 
pass  up  the  leg  and  side,  and  down  the  arm,  and  then  the  hand  begins 
to  twitch  in  spasm,  the  phenomena  indicate  disease  in  or  near  the  leg 
centre,  as  certainly  as  if  it  began  by  motor  spasm.  Further,  certain 
centres  seem  to  be  more  readily  discharged  than  others,  and  an 
influence  that  exalts  irritability  in  a  considerable  area  may  be  first 
manifested  in  these  centres,  not  because  the  morbid  state  is  greater 
in  them  than  elsewhere,  but  because  they  respond  to  it  more  readily. 
The  centre  that  influences  the  movement  of  the  head  and  eyes  to  one 
side,  is  apparently  the  most  sensitive  of  all  the  cortical  motor  centres. 
The  fits  of  idiopathic  epilepsy  commonly  begin  by  this  movement; 
hence  such  commencement  of  a  convulsion  due  to  organic  disease  is 
of  little  localising  significance.  Persistent  tonic  or  clonic  spasm  is 
seldom  met  with  from  cortical  lesions,  but  a  few  instances  are  on 
record.  Clonic  spasm  in  the  face  resulted  from  the  small  lesion 
shown  in  Fig.  107.  A  lesion  beneath  the  lower  part  of  the  ascending 
frontal  caused  trismus  during  the  two  days  the  patient  lived,*  and 
convulsive  spasm  in  the  shoulder  muscles  was  due  to  a  tumour  at  the 
root  of  the  second  frontal.f 

Besides  the  motor  palsy,  disease  of  the  central  cortex  often  causes 
loss  of  the  sense  of  posture  in  the  part  paralysed,  but  as  this  loss  also 
occurs  in  disease  of  the  motor  path  in  the  internal  capsule  its 
diagnostic  significance  is  not  great.  Cutaneous  sensibility  may  also 
be  impaired  by  disease  of  the  central  region,  and  the  sensory  paralysis 
corresponds  in  seat  to  tbe  motor  palsy,  but  it  is  always  very  much 
slighter  in  degree,   and  is  chiefly  marked  at  the   extremity  of   the 

*  '  Revue  de  Med.,'  Oct.,  1882. 

t  Putnam,  'New  York  lied.  Asioc.,'  1S91. 


LOCALISATION    OF    CElilfi-BflAL    DISEASE. 


811 


Fig.  115. — Extensive  softening  of  cortex  of 
left  prefrontal  lobe  which  caused  no  motor 
or  sensory  symptoms. 


affected  liinb.f  It  may  be  absent,  and  hciniansesthcsia  never  results 
from  disease  limited  to  this  part.  Tactile  sensibility  is  more 
impaired  than  is  sensibility  to  pain.  There  are  commonly  no  definite 
mental  symptoms. 

Prefrontal  Lobe. — A  lesion  at  the  posterior  extremity  of  the  upper 
frontal  convolution,  at  its  junction  with  the  ascendiugfrontal,  may  cause 
paralysis  of  the  foots  or  convul- 
sion beginning  in  the  foot;  but 
with  this  exception  no  perma- 
nent motor  paralysis  res  ults  from 
disease  of  this  region,  even  when 
it  extends  up  to  the  ascending 
frontal.  The  extensive  lesion 
shown  in  Fig.  115  produced  no 
palsy.  If  the  movement  of  the 
head  and  eyes  to  one  side  is 
represented  in  this  region,  as  is 
suspected  from  the  results  ob- 
tained   by    experiments     upon 

auimals,  the  loss  in  man  is  quickly  compensated  by  the  other  hemi- 
sphere, and  disappears.  Exceptions  are,  indeed,  sometimes  seen,  in 
which  hemiplegia  is  accompanied  by  prolonged  deviation  of  the  head 
and  eyes,  but  the  seat  of  disease  causing  this  has  not  been  ascertained. 
Unsteadiness  on  walking,  like  that  of  cerebellar  disease,  has  been 
described  as  frequent  in  prefrontal  growths. f  It  is  distinguished  by 
associated  hemiplegia,  and  the  local  headache  and  tenderness  on  percus- 
sion. J  Local  convulsions  are  sometimes  caused  by  irritating  disease 
adjacent  to  the  ascending  frontal.  Disease  of  the  third  frontal,  on  the 
left  side,  impairs  voluntary  speech  in  the  manner  already  described 
(p.  114),  and  a  similar  effect  is  produced  by  disease  of  the  correspond- 
ing region  on  the  right  side  in  left-handed  persons,  and  in  those  who 
have  recovered  speech  after  destruction  of  the  left  motor  speech 
region.  No  sensory  symptoms  are  caused  by  disease  in  the  pre- 
frontal lobe,  but  in  some  cases  considerable  mental  change  has  been 
observed,  various  in  character,  but  sufficiently  frequent  and  consider- 
able to  be  of  significance. §     A  very  large  number  of  cases  are  on 

*  Deferences  to  tlie  evidence  of  this  will  be  found  in  the  chapter  on  thefunclions 
of  the  cortex.  A  series  of  cases  of  disease  of  the  central  region  with  loss  of  sensa- 
tion is  recorded  by  Petrina,  '  Prag.  Zeitschr.  f.  Heilk.,'  ii,  1887,  No.  5. 

t  Bruns,  '  Deut.  med.  Wochenschr./  1892. 

X  The  experiments  of  Feriier,  Mutt,  and  Schafer  suggest  that  the  centre  for 
movement  of  the  head  is  at  the  root  of  the  second  frontal,  and  that  for  the  eyes  in 
front  of  this;  that  for  a  downward  and  lateral  movement  being  in  the  upper  and 
for  an  upward  and  lateral  movement  in  the  lower  part  of  the  centre.  Extirpation 
of  the  opposite  centres  restrict  movements  (on  stimulation)  to  the  opposite  e$e. 

§  A  familiar  instance  is  the  American  "  crowbar  case,"  in  which  a  crowbar  was 
driven  through  the  left  frontal  lobe,  from  the  eye  to  the  coronal  suture,  and  the 
patient  lived  for  thirteen  years,  with  only  a  childish  mental  state  and  epileptic  (its. 


312  LOCALISATION    OF    CEREBRAL    DISEASE. 

record  of  disease  and  injury  of  various  kinds  in  this  part,  in  which 
psychical  disturbance  was  the  only  symptom.  It  is  greatest  when 
both  frontal  lobes  are  diseased,  and  sometimes  passes  away  (by  com- 
pensation; when  the  lesion  is  unilateral. 

Parietal  Lobe. — The  symptoms  produced  by  disease  of  the  ascending 
parietal  and  the  superior  parietal  lobule  have  been  mentioned  already. 
The  posterior  extremity  of  the  latter,  adjacent  to  the  parieto-occipital 
fissure  has  been  found  diseased  when  no  motor  or  sensory  symptoms 
have  been  observed.  Ptosis,  on  the  opposite  side,  has  been  observed 
in  many  casei  of  disease  (see  p.  19)  of  the  lower  parietal  lobule. 
Disease  of  the  posterior  part  of  the  inferior  lobule  probably  causes 
"  crossed  amblyopia,"  and  on  the  left  side  interferes  with  the  visual 
perception  of  words,  and  may  apparently  cause  "  agraphia"  from  the 
loss  of  the  images  of  written  characters  ;  if  bilateral,  it  perhaps  causes 
mind-blindness.  On  one  side  it  may  be  associated  with  hemianopia  from 
the  disease  passing  inwards  to  the  "  optic  radiation."  Extensive  disease 
of  the  whole  parietal  lobe  seems  to  lessen  sensibility  in  the  trunk  and 
limbs  on  the  opposite  side.  Such  an  isolated  effect  has  not  been 
observed,  but  it  is  certain  that  disease  involving  the  parietal  as  well 
as  the  central  cortex  causes  greater  sensory  loss  than  does  a  lesion 
that  is  confined  to  the  central  region. 

Occipital  Lobe. — Disease  of  the  apical  region,  and  especially  of  the 
cuneus,  causes  lateral  hemianopia,  and  a  partial  lesion  causes  loss  of 
part  of  the  half-field,  a  quadi*antic  or  sectional  defect,  which,  when 
above,  indicates  a  lesion  in  the  upper  part  of  the  cuneus,  when  below, 
in  the  lower  part.  Lesions  of  the  outer  part  of  the  apex  have  been 
associated  with  hemianopia,  but  the  readiness  with  which  the  fibres 
from  the  cuneus  may  be  reached  must  be  remembered.  A  lesion  of 
both  occipital  lobes  causes  complete  loss  of  sight,  and  is  the  probable 
cause  of  this  when  it  is  sudden  in  onset.*  The  loss  of  the  second  half- 
fields  may  be  transient,  due  to  inhibition  by  the  the  primary  lesion. 
As  a  sequel  to  apoplectic  coma,  it  is  mentioned  later  (p.  317). 
If  the  onset  is  deliberate  and  consciousness  retained,  the  primary  and 
permanent  hemianopia  may  precede  the  secondary  and  transient  loss.f 

Possibly  disease  of  the  anterior  part  of  this  lobe  causes  colour 
hemianopia.  No  motor  or  other  sensory  symptoms  are  known  to  be 
produced  by  disease  elsewhere  in  this  lobe.  Conjugate  deviation  of 
the  eyes  occurs  from  the  side  of  the  disease,  sometimes  in  irritating 
lesions,  aud  is  doubtless  a  reflex  subserved  by  the  fibres  that  pa^s 
forward  to  the  prefrontal  lobe. 

Temporo-sphenoidal  Lobe. — Only  auditory  symptoms  are  caused  by 

*  Sudden  complete  blindness,  except  perception  of  a  bright  light  in  the  outer 
ansrle  of  the  left  field,  in  a  man  of  sixty,  was  found  to  be  due  to  softening  of  the 
whole  of  the  left  occipital  lobe  and  of  the  right  angular  gyrus,  &c,  and  sub- 
jacent white  substance,  involving  the  fibres  of  the  "optic  radiati  >n "  (Sioli, 
'Ver^a.P.  Psych.  Vereins  Karlsruhe,'  November,  1892). 

Case  of  Noyes,  '  Journ.  Nerv.  aud  Meut.  Disea-es/  1889. 


LOCALISATION    OP    CEREBKAL    DISEASE.  313 

disease  of  the  outer  aspect :  deafness  in  the  opposite  ear  when  the 
disease  involves  the  hinder  half  or  third  of  the  first,  or  first  and 
second  convolutions,  and  an  auditory  aura,  if  convulsions  are  caused 
by  a  lesion  in  or  near  this  part.  Such  an  aura,  with  other  symptoms 
of  a  stationary  or  progressive  lesion,  justifies  the  diagnosis  of  disease 
of  this  part.  A  tumour  caused  convulsions  preceded  by  the  sound  of 
bells ;  in  another  case  of  tumour  in  this  situation,  recorded  by 
Fergusson,*  the  diagnosis  was  curiously  complicated  by  old  ostitis 
on  the  opposite  side.  The  deafness  is  not  permanent,  but  if,  as  in 
Mills'  case,  there  is  a  second  lesion  in  the  corresponding  region  of  the 
other  hemisphere,  total  deafness  results.  Conjugate  deviation  of  the 
eyes  has  been  observed  as  in  disease  of  the  occipital  lobe ;  it  is  pro- 
bably reflex,  and  due  to  the  auditory  impression.  The  auditory  region 
is  said  to  be  more  extensive  on  the  left  side,  and  disease  of  the 
posterior  third  of  the  first  temporal  causes  word-deafness  and  the 
"paraphasia"  that  results  from  the  loss  of  the  leading  element  in 
the  subjective  revival  of  words,  and  consequent  "  verbal  amnesia." 
Disease  of  the  highest  (uncinate)  convolution  on  the  medial  surface, 
near  the  apex  of  the  lobe,  may  disturb  the  seuse  of  smell  on  the  same 
side  (see  p.  20). 

Extensive  lesions  of  the  cortex  around  the  fissure  of  Sylvius, 
extending  over  a  considerable  area  of  the  ceutral,  parietal,  and  temporal 
lobes  (such  as  is  shown  in  Fig.  15,  p.  23)  may  cause  hemiplegia  and 
hemiansesthesia  involving  all  the  special  senses,  the  opposite  eye  being 
the  more  affected. 

Lastly,  transient  bilateral  symptoms  may,  as  we  have  seen,  result 
from  irritative  inhibition  of  the  corresponding  centres  in  the  oj)posite 
hemispheres.  It  occurs  in  disease  both  of  the  cortex  and  white 
substance  if  so  placed  as  to  influence  the  fibres  of  the  corpus- 
callosum. 

White  Substance  of  the  Hemisphere  ;  Centrum  Ovale. — 
Disease  of  the  white  substance  causes  symptoms  resembling,  on  the  one 
hand,  those  of  disease  of  the  cortex,  and  on  the  other  of:  the  internal 
capsule,  according  as  the  seat  of  the  lesion  approaches  one  or  the 
other  of  these  structures.  Thus  a  lesion  beneath  a  given  part  of  the 
central  convolutions  produces  paralysis  similar  in  distribution  to  that 
which  is  caused  by  disease  of  the  corresponding  region  of  the  cortex. 
Hemiplegia  is  pioduced  by  lesions  that  interrupt  the  fibres  which 
converge  from  the  central  region  to  the  motor  part  of  the  internal 
capsule.  One  important  difference,  however,  exists  :  the  local  con- 
vulsions, that  are  so  frequent  and  characteristic  a  symptom  of  a  cor- 
tical lesion,  are  met  with  in  disease  of  the  white  substance  only  when 
an  irritating  lesion  is  situated  just  leneath  the  grey  substance  so  as 
to  irritate  this  directly.  General  couvulsion3  are  rare,  and  occur 
chiefly  in  disease  that  increases  intra  cranial  pressure.  The  loss  of 
*  '  Jouru.  of  Anat.  and  Phys.,'  1891. 


314  LOCALISATION    01'    CEh'EEEAL    DISEASE. 

speech  that  results  from  disease  of  the  fibres  passing  from  the  third 
frontal  convolution,  to  the  internal  capsule  is  transient,  unless  the 
lesion  is  just  beneath  the  cortex.  Its  various  characters  have  been 
described  at  p.  114.  Anaesthesia  occurs  chiefly  from  extensive  lesions 
beneath  tbe  parietal  and  central  regions,  but  in  most  cases  in  which 
considerable  hemi anaesthesia  results  from  disease  of  the  white  sub- 
stance, this  extends  down  to  the  neighbourhood  of  the  posterior  part 
of  tbe  internal  capsule.  Hemianopia  may  be  caused  by  disease  of 
tbe  white  substance  of  the  occipital  lobe,  anywhere  between  the  optic 
thalamus  and  the  extremities  of  the  hemisphere. 

Corpus  Callosum. — The  chief  lesion  that  occurs  in  the  corpus 
callosum  is  tumour,  but  this  almost  always  extends  into  one  or  both 
hemispheres.  Mental  dulness  and  stupor,  with  weakness  in  the 
limbs,  greater  on  one  side,  have  been  present  in  many  cases,  and  in 
some  there  has  been  disturbance  of  speech  and  locomotion  ;  but  it 
is  probable  that  these  symptoms  (with  the  possible  exception  of  the 
mental  dulness)  are  due  to  the  pressure  on,  or  extension  into,  the 
cerebral  hemispheres.  We  do  not  yet  know  of  any  symptoms  that 
are  the  result  of  the  damage  to  the  callosal  fibres  ;  it  is  certain  that 
the  symptoms  that  have  been  present  are  indistinguishable  from  those 
produced  by  multiple  tumours,*  and  that  their  complete  interruption 
(by  softening  from  embolism)  has  caused  no  symptoms. f 

Central  Ganglia  and  Internal  Capsule.— Internal  Capsule. — 
Disease  limited  to  the  anterior  part  of  the  capsule,  between  the  caudate 
nucleus  and  the  anterior  extremity  of  the  lenticular  nucleus — so  as  not 
to  involve  the  "  an.le,"  at  the  junction  of  the  two  parts — is  very  rare, 
and  we  do  not  yet  know  whether  it  causes  definite  symptoms.  J  Dis- 
ease of  the  angle  and  posterior  segment  causes  hemiplegia  of  the  com- 
mon type,  the  lower  part  of  the  face,  the  tongue,  the  arm,  and  the  leg 
being  all  involved,  and  if  the  disease  is  on  the  left  side  there  may  be, 
at  first,  defect  of"  speech.  The  latter  is  transient ;  the  hemiplegia  is 
permanent  if  the  lesion  continues  (except  only  such  recovery  as  may 
occur  by  compensation),  and  the  paralysed  liml  s  are  the  seat  of  late 
rigidity.  At  tbe  onset  there  may  be  deviation  of  the  head  and  eyes, 
but  there  is  no  permanent  and  complete  palsy  of  any  cranial  nerve. 

*  Some  interesting  cases  of  tumour  of  the  corpus  callosum  have  been  publ'slud 
by  Bristowe,  '  Brain,'  1884,  p.  315,  but  the  diagnostic  indications  formulated  by  liiui 
are  no  exception  to  the  statement  in  the  text.  A  remarkable  case  of  extensive 
haemorrhage  into  the  corpus  callosum  has  been  recorded  by  Erb  ('Virch.  Arch.,' 
B  J.  xcvii,  329),  but  the  haemorrhage  occurred  apparently  during  the  course  of  cerebro- 
spinal meningitis,  in  the  symptoms  of  which  any  effects  of  the  callosal  haemorrhage- 
were  lost.  The  history  hardly  seems  to  warrant  the  conclusion  that  no  symptoms 
were  produced. 

■j-  Kaufi'mann,  'Arch.  f.  Psych.,'  xviii. 

J  Raymond  and  Artaud  believe  that  the  speech-path  is  in  the  anterior  segment 
('Arch,  de  Neur-logie,'  1884),  but  it  is  doubtful  whether  this  path  is  separate  from 
that  for  the  tongue  and  lips  in  the  angle  of  the  capsule 


LOCALISATION    OF    CEREBRAL    DISEASE.  315 

Convulsions  may  attend  the  onset  of  an  acute  lesion,  but  are  infre- 
quent, and,  as  in  other  parts  except  the  cortex,  they  do  not  recur  after 
the  disease  has  reached  a  stationary  stage.  The  palsy  is  thus  the 
typical,  common  form,  the  details  of  which  have  been  described  at 
p.  75.  Most  cases  of  simple  hemiplegia  are  due  to  disease  of  this 
part,  and  we  must  therefore  assume  that  this  region  is  diseased,  un- 
less there  are  other  symptoms  to  indicate  a  different  seat  of  the  dis- 
ease. But  hemiplegia  from  disease  of  the  capsule  is  not  always  com- 
plete ;  we  have  seen  (p.  29)  that  the  path  for  the  face  and  tongue 
seems  to  pass  chiefly  at  the  angle,  that  for  the  arm  in  the  anterior, 
and  that  for  the  leg  in  the  middle  third  of  the  posterior  limb.  Small 
lesions  may  therefore  affect  chiefly  one  or  the  other  of  these  parts ; 
there  is  seldom  an  actual  limitation  of  the  palsy,  although  isolated 
facial  hemiplegia  has  been  observed  from  disease  at  the  bend,  and  a 
bilateral  lesion  further  back  has  apparently  caused  phonic  laryngeal 
palsy.*  Hemianaasthesia  may  accompany  the  hemiplegia,  from  impli- 
cation of  the  separate  sensory  path  in  the  hinder  third ;  such  sensory 
loss  sometimes  accompanies  hemiplegic  weakness  in  which  the  leg 
suffers  most,  a  fact  which  is  explained  by  the  contiguity  of  the  fibres 
for  the  leg  and  the  sensory  path.  The  hemiansesthesia  produced  by 
a  considerable  lesion  of  the  path  in  the  capsule  may  be  complete, 
and  involve  the  special  senses  as  well  as  the  skin  and  the  muscles ; 
the  loss  of  vision  is  hemianopia,  as  before  explained.  Smell  may  also 
be  lost  on  the  anaesthetic  side.  This  region  is  the  "  sensory  crossway  " 
of  Charcot.  But  the  special  senses  may  escape,  even  when  the 
cutaneous  loss  is  great.  At  the  deliberate  onset  of  an  acute  lesion, 
tingling  and  other  sensations  are  far  more  common  than  they  are  when 
the  disease  is  limited  to  the  motor  part  of  the  capsule.  If  the  hemi- 
anesthesia is  partial,  from  incomplete  disease,  pains  are  often  felt  in 
the  affected  limbs,  sometimes  most  persistent  from  the  irritation  of 
the  slightly  damaged  sensory  fibres  of  the  internal  capsule,  while  if 
the  lesion  is  so  placed  as  to  influence  in  like  manner  the  motor  fibres, 
there  may  be  permanent  rigidity  of  the  limbs  of  the  opposite  side. 

Corpus  Striatum. — Acute  lesions  of  either  caudate  or  lenticular 
nucleus  generally  cause  hemiplegia,  but  this  is  permanent  only  if  the 
internal  capsule  is  directly  damaged.  If  the  lesion  is  confined  to  the 
grey  substauce  of  either  nucleus,  there  are  usually  no  persistent  sym- 
ptoms, motor  or  sensory.  If  the  lesion  is  small,  and  is  at  a  distance 
from  the  white  fibres  of  the  capsule,  there  may  even  be  no  initial 
hemiplegia.  I  have  seen  a  narrow  vertical  band  of  central  softenj.no-, 
extending  from  the  anterior  to  the  posterior  extremity  of  the  lenti- 
cular nucleus,  when  no  trace  of  hemiplegia  could  be  detected  before 
death,  and  a  careful  history  had  elicited  no  account  of  any  previous 
paralysis.  Even  a  quite  recent  haemorrhage  into  the  lenticular  nucleus 
has  caused  no  symptoms.  Chi'onic  lesions,  such  as  tumour,  often 
develop  in  the  grey  nuclei  without  causing  paralysis.     From  these 

*  Eisenlokr. 


316  LOCALISATION    OF    CEEEBRAL    DISEASE. 

facts  it  is  probable  that  no  sensory  or  motor  palsy  is  produced  by 
disease  of  the  grey  matter,  and  that  the  symptoms  which  occur  at  the 
onset  of  acute  lesions  are  due  to  the  interference  •with  the  fibres  of  the 
internal  capsule,  which  have  been  already  described.  In  a  few  cases* 
mobile  spasm  (choreoid  movement)  has  been  observed  when  the 
lesion  involved  the  posterior  part  of  the  lenticular  nucleus,  but  in 
most  cases  the  internal  capsule  was  also  damaged.  Disease  of  the 
grey  matter  of  this  or  the  thalamus  has  been  associated  with  brief 
increased  temperature  (Hale-White)  both  in  experiments  and  also 
as  a  result  of  disease  in  man. 

Optic  Thalamus. — Slight  hemiplegia  has  been  observed  when  the 
disease  has  been  in  the  middle  third  of  the  thalamus,  but  is  absent 
if  the  lesion  is  small  or  near  the  ventricular  surface ;  hence  there  is 
a  strong  presumption  that  the  loss  of  power  is  due  to  interference 
with  the  motor  part  of  the  internal  capsule,  which  is  adjacent  to  the 
middle  third.  In  disease  of  this  part  of  the  thalamus  another  motor 
symptom  has  been  occasionally  observed,  mobile  spasm  and  inco- 
ordination on  the  opposite  side,  chiefly  in  the  hand.  The  symptom 
usually  succeeds  transient  hemiplegia.  In  one  such  case  (in  an  adult) 
I  found  a  small  cicatrix  of  old  softening,  limited  to  the  thalamus,f  and 
several  other  similar  cases  are  on  record.  In  one  there  was  softening 
in  the  lower  part  of  the  thalamus,  adjacent  to  the  crus.J  It  seems 
probable  that  the  initial  hemiplegia  is  due  to  the  interference  with  the 
capsular  fibres,  and  that  the  subsequent  spasm  is  in  some  way  the 
direct  result  of  the  disease  of  the  thalamus.  Disturbance  of  farial 
expression  has  been  ascribed  to  a  lesion  in  the  posterior  part  of  each 
thalamus. §  Sensation  is  not  impaired  by  lesions  limited  to  the  thalamus. 
A  special  relation  to  the  impulses  from  the  muscles  has  been  suggested,  || 
but  has  not  received  the  confirmation  reasonably  to  be  expected, 
although  it  would  agree  with  many  facts  and  hypothetical  explanations 
of  symptoms,  as  athetosis,  cerebellar  disease,  &c.  Hemianesthesia 
occurs  only  when  the  disease  extends  into  the  internal  capsule  outside 
the  pulvinar.  In  such  cases  there  may  also  be  hemianopia,  and 
this  symptom  may,  apparently  be  caused  by  disease  limited  to  the 
posterior  part  of  the  thalamus  itself.  I  have  seen  two  cases  in  which 
there  was  no  other  lesion  that  could  be  associated  with  the  hemi- 
anopia which  existed  during  life,  and  the  pulvinar  has  been  found 
atrophied  with  the  occipital  lobe  (and  also  the  anterior  corpus  quadii- 
geminum,  the  external  corpus  geuiculatum,  and  the  optic  tract), %  and 
partial  degeneration  of  the  optic  tract  has  been  traced  to  it  (Noyes). 

It  has  been  thought  that  muscular  sensibility  is  specially  impaired 

*   Demange,  '  Revue  de  Med.,'  May,  1883. 
t  f  Med.-Chir.  Trans.,'  1876,  p.' 318. 

\  Greiff,  '  Arch.  f.  Psyeli.,'  Bd.  xiv,  p.  598.  Choreoid  movements  set  in  suddenlv, 
with  transient  hemiplegia  and  hyperesthesia.  §    Eisenlohr. 

|j    From  the  symptoms  of  a  tumour  (Kiritzew,  '  Neur.  Cent.,'  1891). 
%  Eisenlohr,  1890;  Stanffer,  1890. 


LOCALISATION    OP    CEREBRAL    DISEASE.  317 

by  thalamic  lesions  (Meynert),  but  the  evidence  does  not  satisfactorily 
exclude  the  adjacent  capsule.  Diminution  of  reflex  action  has  been 
thought  to  be  another  effect,  but  it  is  met  with  in  disease  of  other 
parts  of  the  brain.     Vaso-motor  symptoms  do  not  seem  to  result. 

Coepoea  Quadeigemina. — Lesions  whose  influence  is  confined  to 
tbe  corpora  quadrigemina  are  so  rare  that  there  is  considerable  doubt 
;is  to  tbe  symptoms  produced.  It  has  been  thought  that  disease  of 
tbe  anterior  pair  causes  loss  of  sight  and  loss  of  action  of  tbe  pupils, 
but  in  most  of  tbe  cases  on  which  tbe  opinion  is  based  the  disease  was 
a  tumour,  and  optic  neuritis  co-existed.*  Ataxy  of  movement  has 
been  present  in  some  cases  of  disease  of  the  posterior  tubercles,  but  it 
resembled  closely  that  due  to  disease  of  the  middle  lobe  of  the  cere- 
bellum, implicatian  of  which  (or  of  fibres  passing  from  the  cerebellum 
to  the  brain)  may  possibly  have  been  tbe  cause  of  the  symptoms. 
Loss  of  the  upward  movement  of  the  eyes  was  produced,  in  one  case 
under  my  care,  by  a  small  growth  at  the  junction  of  the  hinder 
tubercles  with  the  valve  of  Vieussens,  and  experiment  also  suggests  a 
connection  between  the  grey  matter  of  these  with  this  movement  of 
the  eyes.  But  in  most  cases  of  disease  of  the  tubercula,  causing  palsy 
of  the  ocular  movements,  the  lesion  has  extended  so  deeply  as  to 
involve  the  nuclei  of  the  third  nerves.  A  combination  of  the  above 
symptoms,  however,  justifies  a  suspicion  of  disease  of  these  structures. 
If  acute,  contraction  of  the  pupils  showing  irritation  of  these  centres 
adds  to  the  probability  of  the  lesion. 

Cetts  Ceeebei. — Tbe  characteristic  symptom  is  hemiplegia,  involv- 
ing the  lower  part  of  tbe  face  as  well  as  the  limbs,  and  accompanied 
by  palsy  of  tbe  third  nerve  on  the  opposite  side,  i.  e.  on  the  side  of  the 
lesion,  the  two  symptoms  coming  on  at  the  same  time.  The  affection 
of  the  third  nerve  is  usually  complete,  but  now  and  then  is  partial ; 
sometimes  the  fibres  for  the  internal  ocular  muscles  have  escaped. 
Convulsions  are  seldom  met  with,  but  some  spasm  has  been  observed 
in  cases  of  tumour.  Loss  of  sensation  acconrpanies  the  motor  palsy 
when  the  lesion  extends  into  the  upper  region  of  the  crus,  and  is 
sometimes  accompanied  by  tingling  and  other  signs  of  sensory  irrita- 
tion. Vaso-motor  disturbance  is  occasionally  conspicuous  in  the 
paralysed  limbs.     Hemianopia  is  much  less  common  than  might  be 

*  One  case  of  acute  lesion  causing  these  symptoms  has  heen  recorded  hy  Dr.  Bns- 
tian,  and  I  have  seen  one  similar  case.  Haemorrhage  in  hoth  occipital  lobes  is  the 
most  likely  cause.  Bilateral  lesions  are  sometimes  simultaneous  and  symmetrical; 
probably  tbat  on  one  side  can  disturb  the  circulation  on  the  other.  A  woman  was 
unconscious  for  several  days,  evidently  from  cerebral  haemorrhage.  On  regaining 
consciousness  she  was  quite  blind.  In  a  few  days  more  vision  returned  in  the 
lateral  half-fields  on  the  left  side,  but  remained  permanently  absent  in  them  on  the 
right.  It  would  seem  that  a  haemorrhage  in  the  left  occipital  lobe  had  inhibited 
for  a  time  the  corresponding  half-vision  centres  on  the  other  hemisphere.  Such  an 
effect  may  readily  be  attended  by  disturbance  of  the  circulation,  facilitating  another 
haemorrhage.     Atheroma  also  is  sometimes  symmetrical. 


318  LOCALISATION    OF    CEKISBRAL    DISEASE. 

expected  from  the  contiguity  of  the  optic  tract,  and  has  been  met  with 
chiefly  in  cases  of  tumour. 

Partial  lesions  in  or  near  the  middle  line,  beneath  the  corpora 
.quadrig<jmina,  may  cause  the  symptoms  of  acute  nuclear  ophthalmo- 
plegia described  at  p.  198.  The  paralysis  is  usually  incomplete, 
variable  in  distribution,  and  tends  to  lessen.  A  very  superficial  lesion 
may  cause  no  hemiplegia,  but  partial  palsy  of  one  third  nerve,  from 
damage  to  the  root-fibres,  with  persistent  giddiness  supposed  to  be 
due  to  interference  with  fibres  from  the  cerebellum. 

Pons.— Unilateral  lesions  of  the  pons  often  cause  palsy  of  the 
limbs  on  one  side  and  of  the  fifth,  facial,  or  sixth  nerve  on  the  other, 
the  "  alternate  hemiplegia  "  described  at  p.  81.  But  a  lesion  may  be 
so  placed,  generally  in  the  upper  part  of  the  pons,  that  the  cranial 
nerves  and  nuclei  escape,  and  the  hemiplegia  is  then  indistinguishable 
from  that  which  results  from  disease  of  the  internal  capsule.  An 
important  unilateral  symptom  is  the  loss  of  the  conjugate  movement 
of  both  eyes  towards  the  side  of  the  lesion,  described  at  p.  186,  or 
corresponding  conjugate  spasm  (often  with  nystagmus)  when  the 
lesion  irritates  the  centres.  Bilateral  lesions  are  not  uncommon ;  the 
limbs  or  face  on  both  sides  may  then  be  involved.  Difficulty  in 
swallowing  and  in  articulation  is  common,  but  is  less  pronounced  and 
prolonged  than  in  lesions  of  the  medulla  oblongata.  The  fibres  for 
articulation  seem  to  run  in  the  medial-posterior  part  of  the  pyramidal 
tract  and  through  those  on  either  side  the  muscles  of  both  sides  can 
be  influenced.  Hence  a  unilateral  lesion  in  the  upper  part  of  the 
pons  does  not  affect  articulation,  but  a  bilateral  lesion  often  impairs 
it  extremely.  Occasionally  disease  of  the  pons  causes  a  defect 
curiously  like  that  of  some  cases  of  motor  aphasia,  unmeaning  syllables 
being  correctly  uttered,  as  "sej-je-pel"  instead  of  the  desired  word.* 
Convulsions  are  very  rare  in  chronic,  but  may  occur  at  the  onset  of 
acute  lesions  ;  they  have  often  a  peculiar  character,  both  arms  or  both 
legs  may  be  chiefly  involved,  or  there  may  be  semi-convulsive  parox- 
vsms  of  coughing.  Sometimes  there  is  general  rigidity  of  the  limbs, 
continuous  or  paroxysmal.  The  muscles  supplied  by  the  fifth  nerve 
mav  be  fixed  by  spasm  causing  trismus.  Choreoid  movements  have  been 
noted  in  rare  cases ;  in  one  instance  there  was  rhythmical  spasm  on 
voluntary  movement  (Bastian).  Loss  of  sensibility  in  the  limbs  and 
trunk  is  sometimes  associated  with  the  motor  palsy,  in  consequence  of 
the  implication  of  the  tegmental  region  of  the  pons,  and  loss  of 
muscular  sensibility  with  ataxy  in  the  arm,  has  followed  a  lesion 
1  etween  the  hypoglossal  roots  and  the  middle  line.f  The  region  of 
the  skin  &c,  supplied  by  the  fifth  nerve  usually  escapes  on  the  side  of 

*  It  may  be  tliat  the  rath  from  the  motor  speech-centre  is  distinct  from  that 
for  mere  articulation.  Several  similar  cases  are  on  record  in  which  there  was  no 
indication  of  any  disease  above  the  pons. 

+  Interrupting  fibres  supposed  to  ascend  to  the  quadrigeminal  fillet  (Goldscheidcr, 
'  Charite  Ann./  1891). 


LOCALISATION    OP    OEEEBEAL    DISEASE.  319 

the  hemiplegia,  but  is  anaesthetic,  and  is  sometimes  the  seat  of  pain  on 
the  side  of  a  lesion,  so  placed  as  to  involve  the  nucleus  or  root-fibres. 
The  motor  part  of  the  fifth  may  suffer  without  the  sensory  portion  ; 
loss  of  taste  may  accompany  the  palsy.  Ophthalmitis  is  also  met 
with,  but  much  less  frequently  than  when  the  disease  involves  the 
trunk  of  the  nerve.  Acute  irritating  disease,  especially  haemorrhage, 
may  cause  strong  contraction  of  the  pupils,  and  a  lesion  that  extends 
into  the  upper  part  of  the  pons,  beneath  the  corpora  quadiigemina, 
may  paralyse  the  external  ocular  muscles.  Auditory  symptoms  are 
rare,  but  deafness  has  existed  on  the  side  of  the  lesion,  or  a  subjec- 
tive sensation  of  sound  has  attended  the  onset  of  an  acute  process. 
Giddiness  occurs  chiefly  when  the  disease  is  in  the  neighbourhood  of 
the  middle  peduncle  of  the  pons;  it  may  be  most  intense  and 
even  amount  to  actual  movement.  It  is,  of  course,  attended  by 
vomiting,  which,  without  vertigo,  is  not  specially  frequent.  Disturb- 
ance of  respii-ation  and  of  the  action  of  the  heart  (even  to  108°), 
glycosuria,  and  albuminuria  are  sometimes  observed,  but  the  urine  is 
seldom  altered  in  cases  of  tumour.  Hyperpyrexia  is  not  uncommon 
immediately  after  the  onset  of  an  acute  lesion  of  the  pons,  especiallv 
bsemorrhage,  and  is  of  grave  significance. 

Medulla  Oblongata. — Severe  acute  lesions  of  the  medulla  are 
quickly  fatal  by  interference  with  the  respiratory  or  cardiac  centres, 
and,  on  account  of  the  small  size  of  the  medulla,,  and  the  close  proximity 
of  its  centres,  a  haemorrhage  usually  has  this  effect  even  when  of 
small  size.  The  chief  acute  lesion  that  may  give  rise  to  a  diagnostic 
problem,  is  softening  from,  vascular  obstruction.  Motor  symptoms  in 
the  limbs  are  often  bilateral,  and  sometimes  involve  especially  the 
upper  or  lower  limbs ;  if  one  sided,  the  tongue  may  be  paralysed  on 
the  side  opposite  to  the  lesion,  if  this  is  in  the  anterior  part  of  the 
medulla,  so  as  to  involve  the  pyramid  and  the  root-fibres  of  the 
hypoglossal  nerve.  The  face  (with  the  exception  of  the  lips)  always 
escapes.  The  most  characteristic  symptoms  are  those  that  are  due 
to  the  interference  with  the  bulbar  nerves,  the  hypoglossal,  glosso- 
pharyngeal, and  spinal  accessory.  Such  symptoms  are  seldom  uni- 
lateral, because  they  usually  depend  on  interference  with  the  nuclei, 
and  these  lie  for  the  most  part  near  the  middle  line,  and  suffer  on 
both  skies.  Hence  the  resulting  palsy  commonly  involves  the  orbicu- 
laris oris  (which  is  supplied  from  nerve- cells  near  the  hypoglossal 
nucleus),  the  tongue,  palate,  pharynx,  and  sometimes  the  larynx, 
with  impairment  of  articu'ation  and  of  deglutition.  The  paralysis 
often  amounts  to  almost  complete  loss  of  articulation,  but  loss  of 
power  in  the  pharynx  is  seldom  absolute,  perhaps  because  the  glosso- 
pharyngeal nucleas  is  farther  from  the  middle  line  than  are  those  of 
the  hypoglossal  and  spinal  accessory  nerves.  The  resulting  symptoms 
are  described  more  fully  in  a  separate  section  on  the  bulbar  paralysis 
that  resultsfrom  nuclear  degeneration,  andacute  lesions  of  the  medulla. 


320  LOCALISATION    OF    CEREBEAL    DISEASE. 

Bilateral  Lesions  in  the  motor  region  cause  paralysis  on  both 
sides,  and  if  the  disease  is  situated  in  the  centres  for  the.  muscles  of 
bilateral  use,  which  recover,  by  compensation,  when  one  hemisphere 
is  diseased,  the  paralysis  of  these  muscles  is  great  in  degree ;  in  com- 
pleteness it  resembles  that  caused  by  disease  lower  down  the  motor 
path  where  the  two  paths  are  near  togethei*.  Thus  disease  of  the 
highest  part  of  the  cential  regions,  which  sometimes  results  from 
meningeal  haemorrhage  during  birth,  causes  palsy  of  the  legs  closely 
resembling  that  due  to  disease  of  the  spinal  cord.  Disease  of  the 
lowest  part  of  each  ascending  frontal  convolution  causes  bilateral 
palsy  of  the  lips,  tongue,  and  throat,  closely  resembling  labio-glossal 
paralysis, — "  pseudo-bulbar  paralysis,"  it  is  termed.  Soo  too  in  the 
sensorv  regions  in  "which  compensation  occurs;  complete  deafness 
may  be  caused  by  disease  of  each  first  temporal  convolution.  In  the 
few  cases  on  record  in  which  the  symptoms,  commonly  due  to  disease 
of  both  hemispheres,  arc  produced  by  disease  on  one  side,  it  is  pro- 
bable that  there  is  a  congenital  or  old-standing  defect  on  the  other 
cide,  so  that  the  apparent  exceptions  do  not  really  contravene  the 
common  rule.  Bilateral  disease  of  the  occipital  lobes  may  cause 
absolute  blindness,  a  compound  of  double  hemianopia  ;  it  has  usually 
developed  in  two  separate  attacks,  but  need  not  necessarily  do  so. 
As  the  case  mentioned  on  p.  317  (foot-note)  shows,  it  is  often  needful, 
when  there  are  bilateral  symptoms,  to  wait  a  few  days  in  order  to 
exclude  inhibition  of  the  centres  on  the  second  side. 

Cerebellum. — Disease  of  the  middle  lobe  of  the  cerebellum  causes 
unsteadiness  of  movement,— a  reeling  gait  and  often  a  difficulty 
in  standing,  a  tendency  to-  sway  which  renders  difficult  the  main- 
tenance of  equilibrium.  Sometimes,  but  not  often,  there  is  a  tendency 
to  fall  backwards.  There  is  not  the  irregular  movement  of  the  legs 
that  characterises  locomotor  ataxy,  although  in  some  cases  of  tabes 
the  unsteadiness  closely  resembles  that  of  cerebellar  disease.  In 
walking,  the  tendency  to  oscillation  may  give  a  zigzag  direction  to  the 
walk,  and  the  resemblance  to  the  gait  of  a  drunken  person  is  often 
close.  The  arms  are  usually  steady  ;  rarely  they  present  some  jerky 
inco-ordination.  The  unsteadiness  is  due  to  damage  to  the  middle 
lube,  either  from  disease  in  it,  or  from  compressing  disease  in  one 
hemisphere.  If  a  lesion  in  one  hemisphere  does  not  compress  the 
middle  lobe,  this  symptom  is  absent,  and  such  a  lesion  seems  per  se 
to  cause  no  symptoms  by  which  it  can  be  recognised.  Other  sym- 
ptoms of  cerebellar  disease  occur  also  in  many  different  intracranial 
maladies,  but  are  more  frequent  in  disease  of  the  cerebellum  than  in 
disease  elsewhere,  so  that  they  have  a  slight  localising  value  ;  such 
are  giddiness  and  vomiting,  but  these  occur  only  in  active  diseases 
that  irritate  or  compress,  e.  g.  in  tumour  and  at  the  onset  of  acute 
vascular  lesiorvs.  The  unsteadiness  is  not  necessarily  rented  to 
vertigo  ;  the  two  are  sometimes  associated,  but  the  unsteadiness  may 


LOCALISATION    OP    CEREBRAL   DISEASE.  321 

be  extreme  when  there  is  no  subjective  sense  of  giddiness.  Nys- 
tagmus is  frequent  in  cases  of  tumour,  but  we  do  not  know  how  it  is 
caused.*  In  some  cases  of  tumour  of  the  middle  lobe  the  kuee:jerk 
cannot  be  obtained.  Its  loss  is  often  not  constant ;  a  slight  move- 
ment may  be  elicited  at  times,  and  at  other  times  none.  The  loss  has 
been  found  only  on  the  side  opposite  to  a  tumour  in  one  cerebellar 
hemisphere. f  There  is  no  evidence  regarding  the  mechanism  of  this 
curious  symptom,  but  we  may  note  the  contrast  it  presents  to  the  effect 
of  disease  of  the  motor  region  of  the  cerebral  cortex,  which  augments 
the  knee-jerk.  The  influence,  the  loss  of  which  leads  to  increase,  may, 
unrestrained,  have  the  opposite  effect,  and  cerebellar  disease  may 
involve  the  loss  of  such  a  controlling  and  guiding  upward  influence 
(see  p.  »59) .J  A  sudden  irritating  cortical  lesion  may  abolish  the 
knee-jerk  for  a  few  hours. 

Many  other  symptoms  are  produced  by  cerebellar  disease  that  exerts 
pressure.  The  pyramidal  tracts  often  suffer  thus,  and  hence  the 
limbs  are  weakened,  and  the  weakness  is  accompanied  by  the  usual 
inci'ease  of  myotatic  irritability.  Thus  in  one  case  of  cerebellar 
tumour  there  may  be  no  knee-jerk,  and  in  another  it  may  be  increased. 
The  cranial  nerves,  especially  the  sixth  nerves,  may  likewise  be 
affected  by  distant  pressure.  Occasionally  there  are  other  signs  of 
compression  of  the  medulla  oblongata,  such  as  difficulty  of  articula- 
tion, &c.  These  symptoms,  which  are  almost  confined  to  morbid 
growths,  are  described  more  fully  in  the  chapter  on  intra-cranial 
tumours. 

Convulsions  are  rare  in  disease  of  the  cerebellum,  but  have  occurred 
occasionally,  epileptiform  in  type,  and  probably  indirect  in  origin. 
Tetanoid  rigidity,  with  bending  back  of  the  head,  constant  or 
paroxysmal,  has  been  met  with,  and  has  been  ascribed  to  the  cere- 
bellar disease  (Hughliugs  Jackson).  But  it  occurs  only  in  tumour, 
and  is  met  with  also  in  cases  of  infiltrating  glioma  of  the  pons,  so 
that  it  may  be  pressure  effect.  Haemorrhage  into  the  cerebellum 
sometimes  extends  into  the  side  of  the  pons,  and  the  symptoms 
become  indistinguishable  from  those  of  an  acute  lesion  in  the  latter 
situation. 

Cerebellar  Peduncles. — The  superior  and  inferior  peduncles 
are  scarcely  ever  the  seat  of  isolated  disease.     The  middle  peduncle  is 

*  It  was  in  a  case  of  tumour  of  the  cerebellum  that  the  curious  rhythmical  spasm 
in  the  pharynx  mentioned  on  p.  20S  was  observed. 

f  Knapp,  '  Journ.  Nerv.  and  Ment.  Dis.,'  1S92. 

J  The  crossed  relation  of  the  symptom  to  its  cause,  just  mentioned,  is  a  difficulty, 
but  we  need  to  know  whether  it  is  constant,  and  also  more  $f  the  upward  connec- 
tion of  the  cerebellum.  If  the  above  hypothesis  is  correct,  the  fibres  through  which 
the  cerebellum  exerts  its  upward  influence  may  not  pass  directly  to  the  motor 
cortex,  and  a  tract  of  fibres  is  said  to  pass  by  the  superior  cerebellar  peduncle  to  the 
optic  thalamus  of  the  same  side  (Marchi).  The  knee-jerk  is  sometimes  lost  on  both 
sides  when  a  tumour  is  in  one  cerebellar  hemisphere. 

VOL.  II.  21 


322  LOCALISATION    OP    CEEEBRAL    DISEASE. 

sometimes  separately  damaged,  "but  the  lesion  often  involves  also 
either  the  side  of  the  pons  or  the  adjacent  cei*ebellar  hemisphere.  The 
chief  symptom  is  vertigo,  a  sensatiou  of  movement  and  actual  move- 
ment, but  this  is  present  only  in  irritating  lesions.  The  sensation  is 
often  most  intense  ;  the  movement  may  be  merely  an  involuntary 
motion  of  the  head  and  eyes,  or  there  may  be  a  strong  tendency  to  an 
actual  rotation  of  the  trunk  on  its  long  axis,  a  forced  movement, 
sometimes  present  whether  the  patient  is  lying  or  standing,  sometimes 
chiefly  marked  in  the  upright  posture,  when  it  may  cause  the  patient 
to  turn  round  and  round.  Occasionally  the  eyes  are  in  an  abnormal 
position,  one  being  on  a  different  level  from  the  other.  Hemiplegia 
on  the  same  side  is  said  to  occur  in  rare  cases.*  With  these  sym- 
ptoms there  is  often  evidence  of  damage  to  the  side  of  the  pons, 
such  as  symptoms  of  paralysis  of  the  fifth  nerve,  with  or  without 
hemiplegic  weakness.     A  stationary  lesion  may  cause  no  symptoms. 

Ventricles. — The  chief  disease  of  the  ventricles  that  gives  rise  to 
localising  symptoms  is  haemorrhage,  in  the  account  of  which  these 
symptoms  are  considered.  Of  the  diseases  that  affect  the  base,  the 
local  diagnosis  in  haemorrhage  and  inflammation  is  subordinate  to 
that  of  the  morbid  process,  and  the  indications  of  the  position  of 
morbid  growths  are  considered  in  the  chapter  on  intra-cranial  tumours. 
These  may  occupy  one  of  the  ventricles,  as  the  third  or  fourth,  but 
grow  into  it  from  a  neighbouring  part  of  the  brain  or  from  the  fornix. 
So  far  as  any  symptoms  can  be  referred  to  the  ventricular  growth,  those 
attending  a  tumour  in  the  third  ventricle  resemble  the  effects  of  a 
growth  in  the  corpus  callosum,  and  in  the  fourth  ventricle  a  tumour 
of  the  pons  or  medulla. 

*  Brown- Sequard,  Hughlinga  Jackson. 


DISEASES  OF   TEE  MEMBRANES   OF  THE 
BRAIN. 


CONGESTION. 


Active  congestion  of  the  membranes  of  the  brain  constitutes  the 
first  stage  of  inflammation,  and  has  been  supposed  to  exist  as  an 
independent  condition  in  some  cases,  chiefly  in  children,  in  which 
there  are  acute  cerebral  symptoms — headache,  delirium,  convulsions, 
coma — ending  sometimes  in  recovery,  sometimes  in  death.  In  the 
latter  cases  indications  of  meningeal  hyperemia  have  been  found.  It 
is  assumed  that  in  all  these  cases  the  condition  is  one  of  active  con- 
gestion of  the  membranes.  In  fatal  cases  the  symptoms  are  similar 
to  those  of  rapid  meningitis,  and  it  is  probable  that  the  condition  is 
of  this  nature.  In  other  cases  it  is  possible  that  the  congestion 
involves  the  whole  brain  or  part  of  the  brain.  The  treatment  of 
congestion  of  the  membranes,  if  it  can  be  recognised,  is  that  of 
meningitis. 


INFLAMMATION   (MENINGITIS). 

Of  the  three  membranes  that  enclose  the  brain,  only  two  are  patho- 
logically separable,  since  the  arachnoid  and  pia  mater  always  suffer 
together.  The  separate  inflammation  of  the  dura  mater  is  termed 
"pachymeningitis,"  and  is  much  less  common  than  the  affection  of  the 
pia  arachnoid,  which  is  commonly  meant  when  "  meningitis  "  is  spoken 
of.  The  affection  of  the  soft  membranes  has  been  of  late  termed 
"  leptomeningitis,"  in  more  precise  antithesis  to  pachymeningitis. 

INFLAMMATION  OF  TEF  DURA   MATFR   (PACEY3IFNINGITIS). 

In  the  dura  mater  there  are  two  layers ;  a  thin  inner  layer  with  a 
smooth  epitheliated  surface,  and  a  thicker,  looser,  outer  layer,  which 
serves  as  a  periosteum  for  the  bones.  Inflammation  may  affect  pri- 
marily either  of  these  layers,  and  thus  constitute  what  has  been 
termed  external  or  internal  pachymeningitis.  The  former  is  the  most 
common. 


324  OEEKBRAL    MEMBRANES. 

External  pachymeningitis  is  almost  always  secondary  to  injury 
or  to  adjacent  disease,  and.  is  very  rare  in  children.  The  injury  that 
causes  it  is  usually  a  blow  on  the  skull,  often  one  that  fractures  the 
bone,  and  causes  an  effusion  of  blood  between  the  bone  and  the  dura 
mater.  The  disease  is  usually  caries  or  necrosis  of  the  bone,  sometimes 
involving  only  the  outer  table;  in  caries  of  the  petrous  bone  there  is 
often  purulent  pachymeningitis  in  the  neighbourhood,  which  is 
believed  by  some  to  be  the  agency  by  which  the  pia  mater  becomes 
inflamed  in  these  cases.  The  disease  results,  in  rare  cases,  from 
mischief  outside  the  skull,  as  erysipelas,  probably  by  the  mechanism 
of  the  veins  of  the  diploe.  Yery  rarely  the  meningitis  occurs  without 
any  traceable  cause.  The  anatomical  changes  consist  at  first  in  red- 
ness and  cedematous  swelling  of  the  tissue,  which  soon  becomes  first- 
discoloured  and  then  infiltrated  with  pus,  which  may  accumulate  in 
considerable  quantity  between  the  dura  mater  and  the  bone.  Very 
rarely  pus  forms  between  the  two  layers  of  the  dura  mater.  The  in- 
flammation may  spread  to  the  inner  layer,  and  even  from  this  to  the 
pia  mater,  so  that  the  two  become  glued  together  by  lymph.  If  the 
inflammation  subsides  without  the  formation  of  pus,  there  remains  a 
thickening  of  the  outer  layer  of  the  dura  mater,  firmly  connecting  it 
with  the  skull,  and  into  this  tissue  osteophytic  growths  may  extend 
from  the  bone. 

The  symptoms  of  the  secondary  inflammation  are  usually  lost  in 
those  of  its  cause.  When  distinct  symptoms  exist  they  are  usually 
gradual  in  their  onset,  and  consist  in  headache,  delirium,  and  some- 
times convulsions.  When  there  is  a  collection  of  pus  compressing  the 
motor  region  of  the  cortex,  there  may  be  paralysis  of  the  opposite 
limbs.  There  may  be  fever,  but  often  there  is  no  elevation  of  tempe- 
rature that  can  be  referred  to  the  meningeal  inflammation.  The 
condition  is  serious,  but  not  quite  so  grave  as  most  other  forms  of 
meningitis.  The  treatment  is  first  and  chiefly  that  of  the  local  disease 
or  injury  exciting  the  intra-cranial  inflammation;  and  secondly,  the 
same  measures  as  are  suitable  for  other  forms  of  meningitis,  in  so  far 
as  they  are  compatible  with  the  treatment  of  the  cause  of  the  disease. 
If  there  is  reason  to  suspect  the  formation  of  pus  between  the  bone 
and  the  dura  mater,  this  may  be  let  out  by  trephining. 

Internal  pachymeningitis  is  met  with  in  two  forms,  purulent 
and  haemorrhagic,  the  latter  giving  rise  to  what  has  long  been  termed 
"hsematoina  of  the  dura  mater."  Both  are  uncommon;  the  former, 
indeed,  is  extremely  rare.  In  congenital  syphilis  the  whole  membrane 
may  be  much  thickened  by  fibroid  tissue. 

Purulent  internal  pachymeningitis  is  usually  associated  with  a 
similar  inflammation,  either  of  the  outer  layer  or  of  the  pia  mater.  In 
one  or  two  cases  it  has  been  met  with  as  an  apparently  primary 
condition.  The  symptoms  have  been  similar  to  those  of  purulent 
inflammation  of  the  pia  mater. 


PACHYMENINGITIS.  325 


■"  hemorrhagic  internal  pachymeningitis  ;"  hematoma  oe  the 
Dcra  Mater  ;  Meningeal  Blood-ttjmotjr. 

A  peculiar  formation  that  extends  over  the  brain,  commonly  over 
both  hemispheres,  and  consists  of  membranous  layers  with  the 
remains  of  blood  between  them,  has  long  been  known  by  this  name. 
The  malady  is  very  rare,  and  it  is,  indeed,  of  interest  chiefly  as  a 
pathological  curiosity  enigma,  for  it  has  not  been  often  suspected 
during  life,  and  we  do  not  know  whether  it  can  be  influenced  by  treat- 
ment. It  is  commonly  described  as  a  result  and  variety  of  inflamma- 
tion of  the  dura  mater,  because  Yirchow,  in  1854,  brought  forward 
•evidence  to  show  that  this  was  its  origin.  It  had  previously  been 
ascribed  to  primary  haemorrhage,*  and  this  view,  advocated  by 
Prescott  Hewett  in  1845. f  has  been  recently  revived  by  Huguenin 
and  strongly  supported  by  Wigglesworth  ;  the  question  is  still  un- 
decided. But  provisionally,  and  on  account  of  the  course  of  the  sym- 
ptoms, the  disease  may  be  considered  among  the  varieties  of  inflam- 
mation. It  is  so  uncommon^  that  a  brief  notice  of  it  may  suffice ; 
Hugueniu's  exhaustive  description  of  the  malady  in  Ziemssen's  *'  Hand- 
buch'§  and  "Wiggles worth's  account  of  it[|  are  accessible  to  all  readers 
likely  to  be  interested  in  the  subject. 

Causes. — The  condition  is  met  with  chiefly  in  males,  less  than  one 
fourth  of  the  cases  having  been  in  females.  It  is  least  rare  in  old  age  ; 
more  than  half  the  cases  occur  in  persons  above  fifty  years  of  age,  40 
per  cent,  are  over  sixty,  and  just  a  quarter  are  over  seventv.  Con- 
sidering the  comparatively  small  proportion  of  persons  who  reach  the 
age  of  seventy,  this  proportion  shows  that  the  tendency  to  the  disease 
is  enormously  increased  by  the  tissue  changes  incidental  to  age.  In 
early  life  it  is  relatively  as  well  as  absolutely  infrequent,  and  occurs 
chiefly  in  infancy,  as  frequently  in  the  first  year  of  life  as  between  one 
and  twenty  years  of  age.  The  affection  is  commonly  secondary  ;  some 
cases  have  followed  an  injury  to  the  head,  but  the  diseases  to  which 
it  is  most  frequently  consecutive  are  some  forms  of  chronic  insanitv 
(especially  general  paralysis  of  the  insane)  and  chronic  alcoholism.  In 
general  paralysis  it  occurs  at  any  age  over  thirty.  It  is  said  also  to 
have  followed  some  acute  and  chronic  blood  diseases,  especially  acute 
rheumatism  and  smallpox,  typhus  and  relapsing  fevers,  scurvy,  and 
profound  anaemia.  A  similar  condition  has  been  met  with  in  "scorbutic 
rickets,"  in  which  periosteal  haemorrhages  occur. 

*  By  Houssard,  Baillarger,  and  others.  t  'Med.-Chir.  Trans./  1845. 

J  Its  rarity,  at  any  rate  outside  asylums,  may  be  judged  from  the  fact  that 
during  the  first  forty  years  in  which  the  Pathological  Society  received  the  curiosities 
of  metropolitan  necroscopy,  not  a  single  specimen  was  brought  before  the  Society 
from  any  London  hospital. 

§  Bd.  xi,  p.  342  (1st  ed.);  vol.  xii  of  the  American  translation. 

II  '  Brain,'  1892.     See  also  Pitt,  '  Path.  Trans.,'  1892. 


326  CEREBRAL    MEMBRANES. 

Pathology. — The  condition  is  bilateral  in  about  half  the  cases. 
Within  the  dura  mater,  between  it  and  the  arachnoid,  and  commonly 
adherent  to  both,  are  layers  of  peculiar  membranous  tissue.     This 
extends  over  the  greater  part  of  one  or  of  both,  hemispheres.     The 
tissue  is  soft  and  red  at  first,  afterwards  paler  and  firmer.     There  may 
be  several  layers,  even  six  or  seven,  adherent  at  the  edges,  so  as  to 
form  a  series  of  sacs,  which  contain  blood,  liquid  or  coagulated,  or 
in  various  stages  of  degeneration  ;  and  ultimately  there  may  remain 
only  coloured  serosity,  in  which  crystals  of  cholesterine  are  sometimes 
found.     Occasionally  the  membranes  are  adherent  in  places,  so  as  to 
render  tbe  cavities  loculated.     The  red  tint  of  the  membranes  depends 
on  minute  vessels,  and  on  the  presence  of  degenerating  blood  ;  the  in- 
creased consistency  and  pallor  of  tbe  later  stage  is  due  to  the  develop- 
ment of  a  delicate  fibrous  tissue.     In  rare  cases,  suppuration  bas 
taken  place  so  as  to  convert  the  whole  mass  into  an  abscess,  in  which, 
however,  the  membranes  and  vessels  can  be  traced  to  the  dura  mater, 
so  as  to  demonstrate  the  nature  of  the  lesion.*     The  nature  of  the 
earliest  stage  of  haematoma  is  a  matter  on  which  some  doubt  exists ; 
as  already  indicated,  Yirchow  finds  in  it  a  process  of  inflammation,  and 
believes  tbat  a  delicate  vascular  membrane  is  formed  by  inflammation, 
and  that  into  this  haemorrhage  takes  place.     Huguenin  found  simple 
haemorrhage  as  tbe  initial  change  in  some  cases  of  general  paralysis, 
and  it  has  been  advocated  by  many  subsequent  investigators ;  the  facts 
ascertained  by  Wiggleswortb  are  of  especial  importance. f     Some  of  the 
veins  of  the  surface  of  the  brain  (arachnoid)  may  be  normally  attached, 
for  part  of  their  course,  to  the  dura  mater,  and  leave  it  to  open  into 
the  superior  longitudinal  sinus.     They  vary  in  number,  but  are  abun- 
dant in  tbe  foetus  and  newly  born  child.     In  some  cases  many  of 
them  persist,  and  their  walls  are  prone  to  degenerate,  especially  if, 
from  any  cause,  tbe  brain  undergoes  atrophy,  and  thus  their  external 
support  is  lessened,  while  their  walls  are  exposed  to  an  undue  amount 
of  strain,  before  whicb  their  nutrition  fails.     Such-  failure   is  also 
supposed  to  occur  in  the  acute  diseases  with  a  hemorrhagic  tendency 
in.  which  haematoma  is  met  with,   such  as  the  "  scorbutic   rickets " 
mentioned  above.     But  other  observed  facts  show  that  an  inflamma- 
tory membrane  may  be  formed,  and  thus  support  Virchow's  opinion. 
(See  "  Serous  Pachymeningitis,"  p.  328.) 

Symptoms. — In  some  cases  of  haematoma  in  general  paralysis,  no 
symptoms  have  been  present  other  than  those  that  are  common  in  this 
disease  when  no  unusual  condition  is  found  after  death.  In  other 
cases  there  have  been  apoplectiform  seizures,  recurring,  and  ascribed 
to  the  haemorrhages  that  occur  from  time  to  time  in  the  cavities  of  the 
haematoma,  and  there  have  been  more  persistent  symptoms  of  depressed 
cerebral  function — somnolence  or  coma,  with  contracted  pupils  and 

*  E.g.  Max  Klink,  Iuaug.  Diss.,  Greifswald,  1890. 
f  '  Journal  of  Mental  Science,'  1889. 


PACHYMENINGITIS.  327 

general  muscular  weakness.  Nystagmus  is  not  uncommon,  and  optic 
neuritis  sometimes  occurs  towards  the  close.  In  the  cases  that 
follow  injury,  mental  and  physical  weakness  develops,  and  the  pa- 
tient is  brought  almost  into  the  condition  of  the  iusane  subjects 
of  the  disease.  Headache  has  been  a  prominent  symptom  in  many 
cases,  and  has  been  sometimes  limited  to  the  vertex  or  to  the  tem- 
poral regions  in  the  early  stage.  Vomiting  is  occasionally  frequent 
throughout  the  course  of  the  disease.  Convulsions  are  not  common, 
but  have  occasionally  occurred,  generally  on  one  side.  In  many 
cases  there  is  hemiplegia,  seldom  complete,  with  or  without  early  con- 
tracture. The  unilateral  symptoms  occur  when  the  disease  is  confined 
to,  or  greater  on,  one  hemisphere  of  the  brain.  In  children  the  disease 
is  said  to  run  an  acute  course,  with  convulsions  and  sometimes  fever. 
It  is  doubtful  whether,  in  them,  the  malady  can  be  diagnosed,  unless 
chronic  cerebral  symptoms,  convulsions,  twitchings,  hemiplegic 
weakness,  &c,  occur  in  the  subject  of  hemorrhagic  rickets.  In  other 
cases,  symptoms  of  impairment  of  the  functions  of  the  brain  and 
headache,  following  or  coinciding  with  a  cause  of  hematoma,  may 
lead  to  a  suspicion  of  its  existence,  and  this  may  be  strengthened 
by  the  occurrence  of  apoplectic  seizures.  But  all  the  symptoms  of 
haernatoma  (at  any  rate,  when  it  is  unilateral),  including  the  apoplectic 
seizures,  may  be  caused  by  a  glioma  of  the  brain-substance.  The 
malady  has  caused  death  in  most  instances.  One  case  of  recovery  is 
on  record:  the  subject  was  a  drinker,  who  was  murdered  six  months 
after  the  cerebral  symptoms  had  passed  away,  and  in  whom  the  remains 
of  the  disease  were  found. 

Diagnosis. — The  symptoms  of  haernatoma  are  not  in  themselves 
decisive,  although  they  may  raise  a  suspicion  of  its  existence  from 
their  association  with  a  known  cause  of  the  condition,  especially 
general  paralysis  of  the  insane  and  chronic  alcoholism.  An  injury 
may  give  rise  to  other  lesions,  manifested  by  analogous  symptoms,  so 
that  it  is  of  comparatively  small  significance.  But  with  either  of  the 
first  two  conditions,  the  development  of  chronic  muscular  weakness, 
with  mental  failure  if  it  did  not  before  exist,  rigidity  of  the  limbs, 
paroxysms  of  tonic  spasm,  sometimes  with  unilateral  disturbance,  as 
hemiplegia  and  conjugate  deviation  of  the  eyes,  justifies  a  diagnosis. 
If  a  knowledge  of  the  symptoms  were  more  general,  it  is  probable 
that  the  malady  would  be  more  often  suspected  than  it  now  is,  outside 
the  walls  of  asylums  for  the  insane. 

Prognosis. — If  the  symptoms  are  so  pronounced  as  to  enable  a 
probable  diagnosis  to  be  made,  they  will  almost  certainly  increase 
and  have  a  fatal  result;  only  when  the  existence  of  the  malady  is 
suspected  at  an  early  stage,  and  in  an  alcoholic  patient,  is  there  any 
chance  of  its  arrest. 

Treatment. — The  part  which  extravasation  of  blood  manifestly 


328  CEliEBliAL    MEMBRANES. 

takes  in  tlie  production  of  the  morbid  state  suggests  treatment 
calculated  to  arrest  hemorrhage — rest,  elevation  of  the  head  and 
shoulders,  and  the  application  of  cold  to  the  head.  Moderate  pur- 
gation and  diuresis  may  also  be  employed.  The  removal  of  the  cause 
is  necessarily  essential.  The  possibility  that  inflammation  constitutes 
one  element  in  the  causation  of  hematoma  suggests  the  measures  suited 
to  chronic  meningitis;  but  treatment  is  generally  powerless  to  arrest 
the  course  of  the  disease,  and  it  is  doubtful  whether  depletion  does 
other  than  harm. 

Serous  Pachymeningitis  is  a  very  rare  condition,  met  with  in 
voung  children  and  occasionally  in  general  paralysis,  in  which  a 
membranous  layer  hues  the  dura  mater,  and  is  continuous  at  the 
base  with  a  thinner  layer  that  covers  the  arachnoid.  The  two  are 
separated  by  fluid,  which  has  led  such  cases  to  be  sometimes 
described  as  "  external  hydrocephalus."  The  microscope  may  reveal 
a  layer  of  extravasation  in  the  outer  membrane,  when  no  haemorrhage 
can  be  seen  with  the  unassisted  eye.  In  children,  enlargement  of 
the  spleen,  from  "  peri-spleuitis,"  has  been  found  associated.  En- 
largement of  the  head,  and  compression-atrophy  of  the  brain,  may  or 
may  not  be  present.  As  a  rule,  the  mind  is  not  affected,  and 
cerebral  symptoms  are  slight  (Henoch)  ;  but  if  the  brain  is  small  and 
indurated,  there  may  be  considerable  mental  deficiency.  Irregular 
periods  of  pyrexia  and  redness  of  the  scalp  may  be  present.* 

INFLAMMATION  OF   THE   FIA  MATER   (FIA  ARACHNOID); 
MEN  IN  GIT  IS,   LEPTOMENINGITIS. 

Meningitis  may  be  acute  or  chronic,  and  apart  from  this  funda- 
mental difference,  certain  varieties  are  commonly  distinguished,  ac- 
cording to  (1)  its  seat,  whether  this  is  at  the  convexity,  or  at  the  base, 
or  in  the  ventricles  ;  (2)  its  origin,  whether  primary  or  secondary  to  a 
local  cause  or  to  a  general  disease  ;  (3)  its  nature,  whether  simple,  puru- 
lent, tubercular,  or  syphilitic.  The  symptoms  of  these  forms  present 
certain  differences,  but  yet  have  much  in  common,  and  in  all  cases 
the  problem  in  diagnosis  is  first  to  ascertain  the  existence  and  seat  of 
meningitis,  and  then  to  distinguish  its  nature  and  origin.  Hence  it 
is  more  useful  to  consider  all  iorms  together,  noting,  as  we  go  on,  the 
differences  between  them,  than  to  give  a  separate  account  of  each 
variety.  Pour  filths  of  the  statements  that  must  be  made  about  each 
are  true  of  all.  Epidemic  cerebro-spinal  meningitis  is  separately 
described,  although  it  is  not  sharply  separated  from  the  simple  form. 

Causes. — Acute  meningitis  occurs  at  all  periods  of  life,  but  is  most 

common  in  children  under  ten.     Only  one  form  is  less  frequent  in 

children  than  in  adults  — meningitis  of  the  convexity  ;  and  this  is  due 

chiefly  to  its  common  traumatic  origin.     Taking  all  forms   together, 

*  Wliuaiuii   'Trans.  Path.  Soc.,r  1891. 


MENINGITIS.  329 

the  disease  is  more  frequent  in  males  than  in  females,  but  the  several 
varieties  exhibit  some  differences  in  this  respect.  Hereditary  tendency 
is  active  chiefly  in  causing  the  tubercular  form.  Station  in  life,  occu- 
pation, climate,  and  season  are  influential  only  to  a  small  extent  as 
determining  some  of  the  causes. 

Direct  Causes. —  (1)  Traumatic  influences  of  various  kinds,  acting 
■on  the  membranes  by  laceration,  hemorrhage,  or  concussion. 

(2)  Adjacent  disease,  especially  that  which  is  attended  with  suppu- 
ration, often  causes  purulent  meningitis  by  direct  extension  of  the 
pathogenic  virus.  The  adjacent  disease  may  be  (a)  outside  the  dura 
mater,  as  injury  and  disease  of  the  bone,  especially  caries  of  the 
petrous  bone  and  disease  of  the  ear  ;  or  it  may  be  outside  the  skull,  as 
erysipelas  and  other  suppurative  diseases  of  the  scalp.  In  several 
recorded  cases  inflammation  of  the  eye  has  set  up  a  fatal  meningitis, 
and  a  still  more  frequent  cause  is  inflammation  of  the  upper  part  of 
the  nasal  cavities.  Between  these  and  the  meninges  there  are  free 
communications,  which  are  described  in  the  chapter  on  "Abscess  of  the 
Brain."  Growths  in  the  bone  above  the  nose  have  been  found  to  afford 
&  ready  means  for  the  entrance  of  organisms.  (6)  The  adjacent 
disease  may  be  in  the  brain — a  tumour  or  an  abscess,  very  rarely 
hemorrhage  or  softening.  An  abscess  may  cause  meningitis  without 
rupture,  but  rupture  always  causes  intense  purulent  inflammation. 
A  superficial  growth  commonly  causes  some  meningitis,  of  which  the 
acute  symptoms  are  frequently  perplexing. 

(3)  Acute  disconnected  diseases  are  sometimes  attended  with  menin- 
gitis, (a)  Acute  specific  diseases :  measles,  scarlet  fever,  smallpox, 
typhoid  fever,  acute  rheumatism.  The  complication  is,  however,  rare 
in  any  of  them,  its  existence  being  often  erroneously  assumed  from 
mere  intensity  of  delirium.  It  is  least  rare  in  smallpox,  perhaps  on 
account  of  the  septicemic  influence  of  the  extensive  cutaneous  suppu- 
ration. It  is  rare  in  typhoid  fever,  according  to  pathological  evidence ; 
but  it  does  sometimes  occur  in  simple  form,  especially  over  the  con- 
vexity. I  have  also  known  tubercular  meningitis  to  develop  during  the 
fever,  (b)  Meningitis  has  a  special  relation  to  acute  pneumonia,  and 
is  probably  due  to  the  cause  of  the  inflammation  of  the  lung,  especially 
to  the  specific  "  cliplococcus  "  which  has  commonly  been  found  in  the 
inflamed  lung  since  Fraenkel  discovered  it.  The  same  organisms  are 
found  in  the  meningeal  exudation.  This  inflammation  is  usually  puru- 
lent, and  the  organisms  connect  it,  as  we  shall  see,  with  the  epidemic 
cerebro- spinal  form,  (c)  Septicemia  often  causes  meningitis,  what- 
ever be  the  source  of  the  blood-poisoning,  whether  external  injury, 
internal  abscess,  softening  of  caseated  glands,  septic  puerperal  pro- 
cesses, the  softening  of  clots,  or  ulcerative  endocarditis.  The  effect  is 
probably  produced  through  the  agency  of  an  organised  virus,  and  a 
minor  factor  in  the  process  may  be  the  microcOccal  embolism  of  minute 
vessels ;  it  is  not  uncommon  in  such  cases  to  see  minute  extravasations 
in  the  pia  mater,  with  pale  centres,  such  as  are  seen  in  the  retina  in 


330  CEREBRAL    MEMBRANES. 

similar  cases.  Sometimes  local  meningitis  exists  near  the  plug  in  a 
large  vessel,  when  the  source  of  the  plug  is  a  septic  form  of  endo- 
carditis. It  probably  follows  other  toxic  influences  received  from 
without.  Thus  I  have  known  fatal  meningitis  to  follow  exposure  to 
"bad  smells"  on  a  search  for  their  source.  From  all  these  septic 
causes  the  inflammation  is  usually  purulent. 

(4)  Insolation  is  an  occasional  cause,  and  influences  chiefly  the 
convexity.  The  meningitis  that  results  is  usually  simple,  and  not 
purulent.  In  cases  of  rapid  death,  only  indications  of  congestion 
may  be  discoverable. 

(5)  Excessive  mental  work  and  mental  excitement  are  usually 
regarded  as  occasional,  although  rare  causes.  A  predisposition  is 
probably  necessary  to  make  this  influence  operative,  and  the  effect 
of  mental  work  may  easily  be  over-estimated. 

(6)  Specific  Processes. — The  most  common  cause  of  acute  menin- 
gitis is  the  growth  of  tubercles  in  the  membranes,  which  is  usually 
attended  with  inflammation,  the  intensity  of  which  varies  much  in 
different  cases.  Syphilis  is  also  a  cause  of  meningitis  ;  although  the 
inflammation  is  usually  chronic,  a  very  acute  form,  yielding  to  treat- 
ment, is  occasionally  met  with. 

Lastly,  meningitis  may  occur,  either  at  the  convexity  or  the  base, 
for  which  no  cause  can  be  discovered  beyond  some  impairment  of  the 
general  health.  It  is  possible  that  ill-health  may  permit  organisms, 
which  would  otherwise  be  destroyed,  to  persist  and  assume  a  virulent 
development. 

Causation  in  Relation  to  Place. — Meningitis  limited  to  the  convexity 
may  result  from  local  adjacent  disease,  from  insolation,  or  from 
general  disease  (acute  specifics,  pneumonia,  and  septicaemia)  ;  but  in 
the  last  class  the  inflammation  is  often  general,  and  involves  the 
membranes  at  the  base  as  well  as  those  over  the  convexity  of  the  hemi- 
spheres, and  frequently  also  the  membranes  of  the  spinal  cord.  Menin- 
gitis limited  to  the  base  is  rare  except  in  association  with  tubercles, 
basal  growths,  disease  of  bone,  or  adjacent  disease,  but  occasionally 
results  from  syphilis.  Simple  basal  inflammation  may  be  precisely 
like  that  caused  by  tubercles.  Limited  ventricular  meningitis  is  met 
with  occasionally  in  young  children,  chiefly  during  or  after  acute 
diseases,  such  as  the  exanthemata ;  in  adults  it  is  extremely  rare. 

Causation  according  to  Nature. — Simple  meningitis  may  result  from 
any  of  these  causes,  except  perhaps  septicaemia  ;  the  etiological  facts 
just  stated  are  therefore,  in  general,  applicable  to  this  form. 

Purulent  meningitis,  in  which  pus  is  formed  from  the  first,  is 
usually  the  result  of  adjacent  suppuration  or  of  septicaemia.  The 
causes  of  the  former  have  been  already  enumerated  (see  also 
"Abscess").  A  septic  thrombus  in  a  vein  or  sinus  is  sometimes  the 
mechanism  by  which  such  meningitis  is  excited. 

Tubercular  meningitis  occurs  at  all  ages,  but  is  most  common  in 
children,   especially   between  the   ages  of  two  and  ten  years.      In 


MENINGITIS.  331 

infancy  it  is  not  common,  although  it  has  been  met  with  as  early  as 
six  weeks  after  birth.  It  is  not  rare  in  early  adult  life,  and  is 
occasionally  met  with  in  middle  life,  but  scarcely  ever  during  the 
later  period.  In  children,  general  tuberculosis  almost  always  exists, 
but  the  indications  of  this  may  be  slight,  and  the  meningeal  disease 
may  have  the  aspect  of  a  primary  affection.  In  adult  life,  distinct 
indications  of  phthisis  usually  precede  the  meningitis,  but  are 
sometimes  absent  in  youth,  in  whom,  however,  some  scrofulous  or 
caseating  process  commonly  exists,  and  is  a  focus  of  blood-infection. 
It  is  probable  that  there  is  little  difference  in  the  proclivity  of  the 
two  sexes,  at  any  rate  after  puberty.  It  is  generally  thought  that  in 
childhood  boys  suffer  rather  more  frequently  than  girls.*  Here- 
ditary tendency  is  of  unquestionable  importance.  Most  cases  occur 
in  families  in  which  there  is  a  clear  history  of  phthisis  or  of  infantile 
tuberculosis,  sometimes  evidenced  chiefly  by  the  early  death  of  many 
children.  The  disease  is  common  in  all  classes  of  society.  Imperfect 
nourishment  and  bad  air  no  doubt  aid  in  its  development,  but  the 
cases  are  very  numerous  in  which  no  accessory  cause  can  be  traced. 
A  distinct  excitant  is  also  rare,  although  a  blow  or  fall  on  the  head 
seems  distinctly  influential.  Brain-work  may  assist,  but  onlv  in  the 
subjects  of  the  general  disease.  Any  depressing  physical  influence, 
including  maladies  of  different  nature,  may  have  the  same  effect ;  thus 
it  occasionally  occurs  as  a  sequel  to  some  other  acute  disease,  espe- 
cially measles  (the  influence  of  which  in  exciting  tuberculosis  is  well 
known), whooping-cough,  broncho-pneumonia,  diarrhoea,  typhoid  fever, 
&c.  A  blow  or  fall  which  would  otherwise  cause  trifling  and  transient 
inflammation  may  excite  fatal  tubercular  meningitis  in  those  who 
have  even  caseous  deposits  in  some  locality.  Very  seldom  it  comes  on  in 
the  midst  of  apparent  health  ;  more  often  the  child  has  been  distinctly 
"  ailing  "  for  a  month  or  two  before  the  onset. 

Chronic  meningitis  may  be  the  sequel  of  an  acute  attack.  Apart  from 
this,  diffuse  chronic  meningitis  is  generally  the  result  of  alcoholism ; 
occasionally  it  is  due  to  injury.  Focal  chronic  meningitis,  when  not 
traumatic,  is  syphilitic  in  most  cases  ;  possibly,  in  later  life,  it  is 
sometimes  due  to  gout.  In  children,  chronic  basal  meningitis  is  not 
uncommon  in  the  posterior  fossa. 

Anatomical  Characters. — The  changes  may  be  found  in  all  parts 
of  the  membranes,  or  only  at  the  convexity  or  the  base.  When  the 
cause  is  adjacent  disease,  the  neighbouring  region  of  the  membranes 
may  alone  suffer.  Certain  changes  are  common  in  all  forms  of  menin- 
gitis. The  earliest  is  a  diffuse  reddening  of  the  pia  mater,  due  to  the 
injection  of  finer  vessels  than  are  distended  by  the  mechanical 
influence  of   the  mode  of  death.     Soon  there  occurs  opacity  of  the 

*  The  Registrar-General's  returns  for  the  twenty-five  years  ending  1872  give  the 
deaths  from  hydrocephalus  in  males  under  five  as  91,681,  and  females  G6,708. 
Probably  the  chief  cause  of  death  returned  as  "hydrocephalus"  at  this  age  was 
tubercular  meningitis. 


332  CEREBRAL    MEMBIiANES. 

-membranes,  recognisable  most  readily  in  the  arachnoid.  It  occurs 
also  along  the  vessels  of  both  arachnoid  and  pia  mater,  distinctly  in 
consequence  of  distension  of  their  lymphatic  sheaths.  It  is  well  seen 
over  the  sulci  of  the  convexity,  and  the  spaces  at  the  base  of  the  brain. 
Collections  of  yellowish-white  or  semi-purulent  lymph  form  at  these 
parts  and  around  the  nerve-trunks,  the  sheaths  of  which  may  be  dis- 
tinctlv  reddened.  In  the  early  stage  of  purulent  meningitis  these 
collections  may  be  punctiform,  and  may  resemble  very  closely  tuber- 
cular granulations  in  the  pia  mater ;  by  coalescence  they  constitute 
irregular  semi-purulent  areas.  In  cases  of  some  duration  the  puru- 
lent spots  may  have  undergone  caseation  or  induration,  the  latter 
•chiefly  in  simple  meningitis.  The  nerve- trunks  are  often  involved,  and 
under  the  microscope  the  inflammation  may  be  found  either  limited 
to  the  sheath  or  infiltrating  the  substance  of  a  nerve  that  has  been 
paralvsed.  Minute  haemorrhages  may  be  seen  in  the  nerve,  and  its 
fibres  may  be  in  various  stages  of  acute  degeneration.  Sometimes  no 
change  can  be  fownd.  The  inflammation  may  spread  on  the  one  hand 
•to  the  dura  mater,  and  on  the  other  to  the  substance  of  the  brain. 
The  inner  surface  of  the  dura  mater  may  be  reddened,  and  even  covered 
with  a  laver  of  lymph,  which  may  glue  it  to  the  pia  arachnoid.  Its 
outer  sm-face  is  often  the  seat  of  purulent  inflammation  in  cases  due 
to  adjacent  bone  disease.  The  superficial  layer  of  the  brain  is  often 
reddened,  and  even  spots  of  softening  may  be  seen  within  it.  Some- 
times it  contains  punctiform  hamiorrhages.  The  fluid  in  the  sub- 
arachnoid space  is  increased  in  quantity,  and  is  often  turbid.  Indica- 
tions of  inflammation  may  also  be  present  in  the  ventricles  ;  the 
lininp-  membrane  may  be  swollen  and  opaque,  sometimes  even  covered 
-with  a  layer  of  lymph  (ependymiiis) ;  the  subjacent  brain  tissue  may 
be  softened.  The  choroid  plexus  and  velum  interpositum  may  also 
present  signs  of  inflammation.  The  lateral  ventricles  often  contain  a 
great  excess  of  fluid,  which  may  be  turbid,  with  flocculi  of  lymph. 
It  mav  be  so  considerable  as  to  distend  the  ventricles  and  flatten  the 
convolutions,  a  circumstance  that  suggested  the  name  "  acute  hydro- 
cephalus "  formerlv  applied  to  all  these  cases.  The  ventricular  effusion 
seems  to  be  the  result,  in  some  cases,  solely  of  the  ventricular 
inflammation,  but  often  there  is  also  a  collection  of  lymph  about  the 
openings  by  which  the  fourth  ventricle  communicates  with  the  space 
around  the  brain,  and  the  obstruction  to  these  must  increase  or  cause 
the  ventricular  distension.  In  the  so-called  ventricular  meningitis, 
effusion  into  the  ventricles  and  slight  traces  of  inflammation  are  all 
that  is  found  ;  the  external  membranes  are  normal.  Although  the 
traces  of  inflammation  are  slight,  the  acute  and  febrile  course  of  the 
disease  is  consistent  only  with  its  inflammatory  nature.  In  all  forms, 
if  the  inflammation  of  the  ependyma  passes  away,  permanent  thick- 
ening of  the  lining  membrane  may  remain,  and  there  may  even  be 
adhesions  closing  the  cavity  of  the  posterior  cornu.  A  permanent 
excess  of  liquid  may  be  left  in  the  cavities. 


MENINGITIS.  333: 

In  purulent  meningitis  the  membranes  are  covered  with  a  layer  of 
greenish-yellow,  often  foetid  pus,  sometimes  at  the  convexity,  less 
commonly  at  the  base  only,  often  at  both.  The  purulent  inflamma- 
tion frequently  extends  down  the  membranes  of  the  spinal  cord,, 
sometimes  as  low  as  the  cauda  equina,  and  in  one  recorded  case 
suppurative  inflammation  in  the  orbit  was  secondary  to  that  within 
the  skull.*  The  surface  of  the  brain  is  often  softened,  and  small 
collections  of  pus  may  be  found  within  its  substance,  apparently 
secondary  to  the  meningeal  suppuration.  Very  rarely  primary 
purulent  inflammation  has  been  limited  to  the  ventricles. 

In  tubercular  meningitis  the  inflammation  is  never  actually  puru- 
lent.  The  appearances  are  usually  those  of  the  simple  inflammation 
already  described,  conjoined  with  the  characteristic  tubercles.  The 
amount  of  jelly-like  and  semi-opaque  lymph  is  often  considerable, 
but  it  is  found  chiefly  at  the  base,  and  is  generally  most  abundant 
about  the  optic  chiasma,  between  this  and  the  pons,  and  in  the 
commencement  of  the  fissures  of  Sylvius.  The  membrane  over  the 
convexity  has  a  dry  aspect,  but  to  the  finger  may  feel  somewhat 
sticky ;  and  if  a  scalpel  is  passed  over  the  surface,  it  removes  a  little 
pyo-lymph.  The  two  opposed  surfaces  of  the  hemisphere,  in  the 
longitudinal  fissure,  may  be  slightly  adherent  where  in  contact. 
There  is  often  an  excess  of  arachnoid  fluid  at  the  base  of  the  brain,, 
and  then  the  sheaths  of  the  optic  nerves  are  usually  distended,  so  as 
to  form  a  pyriforni  swelling  behiud  each  eye.  Ventricular  effusion 
is  present  in  the  majority  of  cases  (about  four  out  of  five)  ;  generally 
the  quantity  does  not  exceed  a  few  ounces,  but  it  may  be  so  large  as 
to  compress  the  cortex,  and  to  distend  all  the  ventricles.  The  indica- 
tions of  closure  of  the  communication  between  the  fourth  ventricle- 
and  the  surface,  already  mentioned,  are  more  frequent  in  tubercular 
than  in  simple  meningitis.  The  lining  membraue  of  the  ventricles 
and  the  choroid  plexuses  may  be  distinctly  inflamed.  In  addition  to 
the  signs  of  inflammation  in  the  membranes,  these  present  the 
distinctive  characteristic  of  this  variety,  miliary  tubercle.  The 
granulations  are  most  easily  seen  where  the  inflammation  is  slight 
or  absent,  especially  on  the  under  surface  of  the  temporal  lobe. 
They  are  at  first  very  minute,  and  so  transparent  that  they  can 
often  be  detected  only  when  their  prominence  is  recognised  by 
looking  obliquely  at  the  surface.  Although  seated  in  the  pia  mater, 
they  cause  a  prominence  of  the  arachnoid  where  this  covers  the 
pia  mater  closely,  resembling  the  minute  air-bubbles  beneath  the 
arachnoid  that  are  often  produced  during  the  process  of  removing  the- 
brain ;  these  disappear  if  the  finger  is  passed  over  the  surface,  while 
the  tubercles  remain  unchanged.  In  other  places  they  are  of  larger 
size  and  semi -opaque,  and  in  some  places  several  are  aggregated 
together.  Where  the  lymph  is  abundant,  only  the  larger  and  older 
tubercles  can  be  recognised.  The  microscope  shows  the  granulations- 
*  Eross.  '  Cent.  f.  Nerv.,'  18S3,  221. 


334  CEREBRAL    MEMBRANES. 

to  consist  of  lymphoid  cells,  situated  usually  around  a  vessel,  within 
its  perivascular  sheath.  It  is  important  to  remember  that  meningeal 
tubercle  and  tubercular  meningitis  are  not  quite  identical.  Tubercles 
may  be  found  in  the  membranes  when  there  is  no  sign  of  inflamma- 
tion, in  cases  of  general  tuberculosis,  and  they  may  be  accompanied 
by  symptoms  of  cerebral  disturbance  resembling  those  caused  by 
inflammation.  When  inflammation  accompanies  them,  its  extent  and 
degree  vary.  It  is  usually  considerable  only  at  the  base,  and  is 
scarcely  ever  seen  at  the  convexity  and  not  at  the  base  ;  not  rarely  it 
is  general.  Sometimes  the  inflammation  is  confined  to  one  small  area, 
as,  for  instance,  to  the  neighbourhood  of  the  central  convolutions  on 
one  side  ;  such  local  meningitis  is  usually  associated  with  tubercles  of 
some  size :  very  rarely  inflammation  and  tubercles  of  the  ordinary 
character  are  confined  to  the  convexity  of  one  hemisphere.*  Even 
when  the  inflammation  is  apparently  confined  to  the  base,  tubercles 
can  usually  be  detected,  often  in  abundance,  over  the  convexity,  but 
they  are  still  more  numerous,  larger,  older,  and  more  opaque  at 
the  base,  especially  about  the  commencement  of  the  Sylvian  fis- 
sure. 

The  characteristic  bacilli  of  tubercle  have  been  found  in  the  pia 
mater  in  these  cases  (Cornil  and  others).  Moreover  the  organisms 
have  been  found  when  no  tubercles  could  be  seen  with  the  naked  eye, 
although  commencing  granulations  were  discovered  by  the  micro- 
scope^ and  even  in  the  grey  substance  of  the  cortex  beneath  a  focus 
of  limited  inflammation.  J  Tubercles  may  sometimes  be  recognised 
in  the  lining  membrane  of  the  lateral  ventricles,  and  in  the  choroid 
plexuses.  A  careful  examination  of  the  inner  surface  of  the  dura 
mater  often  shows  minute  tubercles  scattered  over  it.  They  are 
frequently  met  with  in  the  spinal  membranes,  dura  mater,  and  pia 
mater,  sometimes  one,  sometimes  both,  and  occasionally  in  great 
abundance,  especially  over  the  cauda  equina,  where  the  membrane 
may  look  as  if  it  had  been  exposed  to  a  shower  of  fine  sand.§  Signs 
of  inflammation  are  always  slighter  in  the  spinal  than  in  the  cerebral 
membranes,  and  are  often  absent,  especially  when  the  granulations 
are  upon  the  dura  mater  only.  The  cortex  of  the  brain  may  be 
injected  and  softened  at  the  surface,  but  if  there  is  much  effusion  in 
the  ventricles  the  amount  of  blood  in  the  vessels  of  the  cerebral 
substance  may  be  less  than  normal.  Under  the  microscope  the  walls 
of  the  cortical  vessels  are  often  found  to  be  crowded  with  leucocytes, 
and  sometimes  minute  aggregations  of  tubercles  may  be  detected 
within  the  cortical  tissue.  Small  extravasations  are  common,  in 
adults,  in  the  membranes  or  in  various  parts  of  the  brain-substance, 

■  *  Huguenin,  Hilton  Fagge. 
f  Dawson  and  Hebb,  '  Lancet,'  1884,  Ap.  12,  p.  660. 
J  Dejerine,  '  Revue  de  Med.,'  March,  1885,  p.  174. 

§  Wortmann  found  no  tubercles  in  tbe  spinal  membranes  only  in  four  of  twenty- 
seven  cases  examined  ('  Jahrb.  f.  Kinderheilk./  Bd.  xx,  1883,  p.  300). 


MENING1TJS.  335 

and  are  probably  due  to  changes  in  the  walls  of  the  vessels  and 
thrombosis  within  them. 

In  these  cases  a  tubercular  tumour  is  occasionally  found  in  the 
brain,  sometimes  more  than  one.  I  have  seen  a  mass  of  tubercle  the 
size  of  a  filbert  growing  from  the  under  surface  of  the  dura  mater. 
Extensive  miliary  tuberculosis  of  the  small  vessels  and  the  substance 
of  the  brain,  causing  almost  universal  softening,  has  once  been 
observed.* 

In  young  children  tubercles  are  almost  invariably  found  widely 
scattered  through  the  other  organs  of  the  body.  They  are  most 
constant  in  the  spleen, — very  frequent,  also,  in  the  enlarged  mesen- 
teric glands.  Exceptions  to  the  general  character  of  the  affection 
are  rare,  but  Gee  mentions  a  case  in  a  girl,  aged  four,  in  whom  a 
cheesy  mass  in  each  lung  was  the  only  indication  of  tubercle  outside 
the  membranes,  and  similar  cases  have  been  recorded  by  others.  The 
caseating  scrofulous  material,  in  such  cases,  was  probably  the  source 
of  the  blood-infection,  and  thus  the  cause  of  the  meningitis.  Tubercles 
are  often  to  be  seen  in  the  choroid  in  tubercular  meningitis,  although 
generally  only  late  in  the  course,  and  after  its  nature  has  become 
clear. 

Thrombosis  in  a  vein  of  the  convexity  is  occasionally  found  in 
tubercular  meningitis,  sometimes  with  the  intense  secondary  con- 
gestion of  the  corresponding  region  of  the  brain.  It  occasionally 
precedes  the  formation  of  visible  tubercle.  Very  rarely  a  clot  extends 
to  a  sinus,  but  the  special  symptoms  of  this  are  usually  lost  in  those 
of  the  meningitis. 

Chronic  Meningitis. — The  diffuse,  chronic  meningitis  of  alcoholism 
affects  chiefly  the  convexity,  and  is  always  slight  in  degree.  The  pia 
arachnoid  is  somewhat  opaque,  especially  over  the  sulci,  and  there 
may  be  lines  of  opaque  lymph  along  the  sides  of  the  vessels.  The 
focal  chronic  meningitis  of  syphilis  is  often  associated  with  a  syphilitic 
growth,  or  with  disease  of  the  walls  of  the  arteries.  There  is  much 
thickening  of  the  pia  arachnoid,  with  the  peculiar  exudation — at  first 
"  gummy  "  in  aspect,  while,  later,  caseous  foci  are  scattered  through 
it — which  glues  all  adjacent  structures  together,  and  often  unites  the 
pia  mater  to  the  dura  mater.  It  may  be  so  abundant  at  a  certain 
spot  as  to  occasion  doubt  whether  it  should  not  be  regarded  as  a 
"gumma,"  with  secondary  inflammation.  Ultimately,  if  caseation  is 
prevented  by  treatment,  fibroid  transformation  may  occur,  and  a 
thick  layer  of  tissue,  tendinous  or  cartilaginous  in  aspect,  extends 
over  a  certain  region,  more  often  at  the  base  than  at  the  convexity, 
surrounding  and  compressing  the  nerves,  and  uniting  the  various 
membranes.  The  thickness  of  the  layer  may  be  as  much  as  a  third 
of  an  inch  ;  the  dura  mater  is  often  also  thickened. 

In  children,  chronic  inflammation  occui-s  chiefly  in  the  posterior 
fossa,   about   the   pons,   medulla,  and  cerebellum,  which  are  often 
*  Gee,  *  Reynolds'  System  of  Medicine,'  vol.  ii,  2nd  ed.,  p.  408. 


33(3  CEBEBRAL    MEMBRANES. 

firmly  adher*ent.  In  another  chronic  form,  which  is  perhaps  only  a 
later  stage  of  the  syphilitic  inflammation,  the  inflammatory  tissue 
has  undergone  fibrous  transformation.  When  chronic  inflamma- 
tion involves  the  membranes  about  the  medulla  oblongata,  it  gener- 
ally closes  the  openings  of  the  fourth  ventricle,  and  internal  hydro- 
cephalus results. 

Symptoms. — Certain  symptoms  occur  in  meningitis  irrespective  of 
its  seat  or  form,  while  others  depend  on  its  situation,  whether  at  the 
base  or  over  the  convexity  of  the  brain  ;  the  special  pathological 
forms  differ  in  their  course,  and  in  the  relative  prominence  of  various 
symptoms.  In  every  form  and  position,  the  manifestations  of  the 
disease  present  wide  diversity  in  different  cases  ;  yet,  as  a  rule,  certain 
symptoms  are  present,  and  develop  in  such  a  manner  as  to  be 
fairly  characteristic. 

The  symptoms  consist  partly  in  general  disturbance,  such  as  attends 
any  local  inflammation,  partly  in  cerebral  symptoms,  some  general  and 
others  local.  In  many  cases  there  are  also  associated  symptoms  due 
to  the  pathological  process  to  which  the  meningitis  is  secondary.  The 
chief  symptoms  common  to  all  forms  will  be  first  described. 

Premonitory  symptoms  are  often  present,  although  never  distinctive 
in  character.  There  may  be  such  general  indisposition  as  may  precede 
any  malady,  languor  and  malaise,  to  which  is  sometimes  added  mental 
irritability.  In  children,  vomiting  without  cause,  or  on  some  slight 
indiscretion  in  diet,  often  precedes  other  symptoms  for  some  days. 
Occasionally  prodromata  are  absent,  and  the  pronounced  symptoms  of 
the  disease  set  in  suddenly. 

The  most  important  of  these  are  headache,  delirium,  vomiting,  con- 
vulsions, rigidity  and  weakness  of  the  limbs,  and  paralysis  of  cranial 
nerves,  strabismus  and  inequality  of  the  pupils,  coming  on  acutely 
or  subacutely,  but  not  suddenly.  They  are  usually  accompanied  by 
elevation  of  temperature,  and  followed  in  a  few  or  many  days  by 
somnolence  and  coma. 

Headache  is,  of  all  symptoms,  the  most  common,  and  is  usually  one 
of  the  earliest ;  it  is  prominent  throughout,  until  the  patient  becomes 
unconscious.  It  is  most  frequently  frontal,  but  sometimes  general. 
Continuous  in  some  degree,  severe  exacerbations  occur,  in  which  the 
pain  is  very  intense,  and  may  cause  shrieks  of  suffering,  which  have 
received  the  name  of  the  "  hydrocephalic  cry  ;"  and  these  may  continue 
even  when  the  patient  is  almost  unconscious.  In  rare  cases,  meningitis 
runs  its  course  with  little  or  no  pain,  especially  the  secondary  purulent 
meningitis  of  septicemia  and  in  the  simple  meningitis  of  some  other 
blood-states.  Vertigo  is  occasionally  complained  of,  especially  at  the 
onset,  but  on  the  whole  is  not  frequent. 

Delirium  is  another  important  symptom.  It  may  be  either  slight  and 
quiet,  or  active  and  violent.  It  is  often  an  early  symptom,  although 
it  chiefly  occurs  at  the  onset  of  the  disease,  and  only  in  those  who- 


MENIKG1TIS.  837^ 

iire  specially  predisposed,  and  then  may  have  its  character  modifier!  by 
the  predisposition,  such  as  alcoholism  or  hysteria.  Diagnostic  errors 
are  then  easy.  The  delirium,  as  a  rule,  derives  its  significance  from 
its  association  with  headache.  At  first  there  is  mei'ely  wandering 
during  sleep,  and,  as  the  mental  disturbance  increases,  periods  of 
perfect  or  imperfect  consciousness  alternate  with  periods  of  delirium, 
when  the  cries  of  pain  are  often  frequent  and  severe.  When  it  has  set 
in,  it  usually  persists,  sometimes  with  intermissions,  until  the  coma 
comes  on. 

Vomiting  consists  in  the  rejection  of  the  contents  of  the  stomach, 
often  without  nausea;  there  is  not  usually  retching  when  the  stomach 
is  empty.  It  is  a  frequent,  and  often  a  very  early  symptom,  whatever 
be  the  seat  of  the  inflammation.  The  tongue  is  at  first  clean,  but  it 
may  afterwards  become  thickly  furred  and  the  breath  very  offensive. 
The  bowels  are  confined,  often  obstinately,  and  the  abdomen  is  retracted. 

General  convulsions  occur,  irrespective  of  the  seat  of  the  inflamma- 
tion, but  are  rather  more  frequent  in  children  than  in  adults.  They 
may  occur  at  any  time  during  the  course  of  the  disease,  from  the  onset 
to  the  end.  They  are  occasionally  almost  the  only  symptom  of  the 
meningitis  that  is  produced  by  septic  processes.  Rigidity  of  the 
muscles  of  the  neck,  with  retraction  of  the  head,  is  common  in  menin- 
gitis about  the  posterior  part  of  the  base,  and  may  extend  to  the 
muscles  of  the  back  if  the  inflammation  passes  clown  the  spinal  canal. 
It  is  a  symptom  of  very  great  importance,  being  frequently  the  first 
unequivocal  indication  of  the  malady. 

Optic  neuritis  is  a  common  symptom  of  meningitis  of  the  base,  but 
is  rare  when  the  inflammation  is  confined  to  the  convexity.  It  is  not 
an  early  symptom,  being  seldom  met  with  until  the  end  of  the  first 
week.  I  have  once  seen  it  (unilateral)  as  early  as  the  fifth  day  after 
the  onset  of  the  symptoms  of  tubercular  meningitis.  It  is  clue  to  the 
extension  of  inflammation  from  the  membranes  to  the  sheath  and 
substance  of  the  optic  nerve  within  the  skull,  and  the  descent  of  this 
inflammation  to  the  eye,  probably  aided  by  the  passage  of  material 
down  the  sheath  of  the  nerve  to  the  neighbourhood  of  the  globe.  The 
intra-ocular  changes  are  seldom  intense.  There  is  swelling  of  the 
papilla,  blurring  the  edges  of  the  disc,  and  often  (especially  in  tuber- 
cular meningitis)  the  swelling  is  paler  than  in  commencing  inflam- 
mation from  other  causes.  The  veins  are  full,  but  haemorrhages  are 
rare,  and  the  neuritis  is  never  so  intense  as  in  cases  of  tumour. 
Choroidal  tubercles  are  sometimes  seen  in  the  tubercular  variety. 

Hypersesthesia  of  the  skin  is  occasionally  met  with,  and  that  of  the 
special  senses  is  very  common,  so  that  light  and  noise  distress  the 
patient  and  increase  his  suffering.  Both  are  apparently  due  to  the 
general  excitability  of  the  brain.  Retention  of  urine  is  common  in 
the  later  stage,  when  consciousness  is  obscured.  Occasionally  there 
is  incontinence  of  urine  and  faeces. 

Local  symptoms  occur  in  the  cranial  nerves  and  limbs.  In  the 
vol.  n.  22 


338  CEREBRAL    MEMBRANES. 

former  they  depend  chiefly  on  the  affection  of  the  base,  in  the  latter  on 
that  of  the  convexity.  These  symptoms  are  partly  those  of  irritation, 
partly  those  of  paralysis.  The  most  common  symptoms  are  in  the 
ocular  nerves,  causing  alteration  in  the  position  or  movement  of  the 
eyeballs  or  in  the  size  of  the  pupils.  Strabismus  is  a  very  important 
symptom  ;  it  is  often  at  first  transient,  or  present  only  on  movement, 
and  even  then  inconstant,  depending  apparently  on  varying  over- 
action  of  a  muscle.  In  other  cases  there  is  persistent  and  evidently 
paralytic  weakness  of  certain  muscles.  Slight  ptosis  may  occur,  but 
complete  paralysis  of  the  third  nerve  is  not  common.  Indeed,  the 
whole  of  any  nerve  is  scarcely  ever  paralysed  unless  other  nerves 
suffer  in  some  degree — a  point  of  some  importance.  The  pupils  are 
usually  contracted  in  the  early  stage,  especially  when  there  is 
intolerance  of  light ;  subsequently  they  are  often  dilated.  Inequality 
is  a  very  common  and  most  important  symptom;  it  occurs  in 
inflammation  of  the  convexity  as  well  as  of  the  base.  It  is  often 
transient  and  variable,  present  at  one  time  and  absent  a  few  hours 
later ;  now  one  pupil,  now  the  other,  may  be  the  larger.  An  undue 
sensitiveness  of  the  dilator  fibres  to  cutaneous  stimulation  has  been 
noted  by  Parrot. 

Next  in  frequency  is  an  affection  of  the  facial  nerve,  weakness  of 
which  is  indicated  by  inequality  of  the  mouth,  or  distinct  defect  of 
movement.  When  the  disease  is  at  the  base,  all  parts  of  the  facial 
nerve  may  be  affected;  when  it  is  over  the  convexity,  the  lower  part 
suffers  alone  inmost  cases  ;  perhaps  there  is  occasionally  brief  weaken- 
ing of  the  upper  part.  The  muscles  of  mastication  may  be  rigid,  but 
this  is  not  frequent,  and  their  paralysis  is  still  more  rare.  The  hypo- 
glossal nerve  sometimes  suffers,  and  deviation  of  the  tongue  results. 

The  bypersesthesia  of  the  special  senses  has  been  already  mentioned. 
An  affection  of  the  olfactory  nerve  is  very  rare.  So  also  is  consider- 
able impairment  of  sight,  which  scarcely  ever  occurs  except  in  cases 
in  which  the  inflammation  passes  into  a  chronic  stage,  and  damages 
the  optic  nerve  considerably,  partly  directly,  and  partly  by  the  con- 
traction of  lymph  that  forms  around  it.  The  auditory  nerve  suffers 
more  frequently,  usually  in  association  with  the  facial  (which  lies 
beside  it  at  the  base  of  the  brain),  but  in  greater  degree.  Both 
auditory  nerves  are  sometimes  supposed  to  be  damaged  alone  in 
meningitis  associated  with  bilateral  otitis  interna,  but  it  is  certain 
that  in  these  cases  the  deafness  is  due  to  the  labyrinthine  inflamma- 
tion, and  not  to  the  meningitis. 

One-sided  symptoms  are  not  uncommon — muscular  rigidity,  uni- 
lateral convulsion,  or  hemiplegia.  Complete  hemiplegia  is  rare,  and 
occurs  only  when  the  membranes  about  the  central  convolutions  are 
involved.  Sometimes  no  difference  can  be  seen  in  the  state  of  the 
membranes  over  the  two  hemispheres  to  account  for  the  difference  in 
the  limbs ;  the  paralysis  is  apparently  due  to  arrest  of  function  by  the 
irritation.     In  rare  cases  the  hemiplegia  is  due  to  the  occurrence  of 


MENINGITIS.  339 

thrombosis  in  a  surface  vein.  Rigidity  of  tbe  limbs  of  one  side  or  of 
both  is  very  frequent.  It  may  be  slight  or  considerable,  and  often 
varies  from  time  to  time  ;  passive  movements  then  cause  pain,  and  the 
pain  produced  is  often  greater  than  the  amount  of  rigidity  would 
suggest.  Convulsions,  beginning  locally,  or  pai'tial  in  extent,  are  also 
,  common  in  meningitis  of  the  convexity.  Unilateral  hyperesthesia 
may  also  occur,  and  tbei'e  may  be  areas  of  anesthesia,  but  complete 
hemianesthesia  is  very  rare.  Aphasia  occurs  chiefly  in  the  tubercular 
variety,  perhaps  because  such  inflammation  is  apt  to  extend  along  the 
fissure  of  Sylvius.     It  is  occasionally  an  early  symptom. 

The  pyrexia  of  meningitis  varies  much  in  different  cases.  Often 
there  is  from  the  first  a  considerable  elevation  of  temperature,  101° — 
103°,  and  it  remains  high,  with  irregular  variation,  throughout  the 
disease.  In  the  most  acute  purulent  form  the  temperature  may  rise 
quickly  to  104°  or  105°,  and  remain  high  till  death.  In  other  cases 
the  temperature  is  at  first  raised  and  towards  the  end  falls  below  the 
normal,  and  a  rectal  temperature  of  96°  or  97°  has  been  observed. 
On  the  other  hand,  towards  the  end  the  temperature  may  be  very 
high,  106°  or  108°.  It  is  said  that,  in  very  rare  cases,  the  disease  runs 
its  course  without  fever,  and  it  is  certain  that  for  some  days  the 
temperature  may  not  be  above  the  normal;  apparently  this  is  the 
result  of  an  influence  exerted  by  the  nervous  system  which  neutralises 
the  tendency  of  the  inflammatory  process. 

The  pulse  presents  as  wide  variations  as  the  temperature,  but  there 
may  be  no  correspondence  between  the  variations  in  the  two  symptoms. 
In  some  cases  it  is  frequent  throughout ;  more  often  it  is  slow,  68,  50, 
or  even  40,  and  it  is  often  not  only  slow  but  irregular  in  rhythm.  The 
pre-mortem  rise  in  temperature  is  usually  attended  by  extreme  fre- 
quency of  pulse,  160,  180,  and  sometimes  uncountable  rapidity. 

The  vaso-motor  system  is  often  disturbed.  The  well-known  tache 
cerebrate,  in  which  cutaneous  irritation  is  followed  by  unusually  vivid 
and  enduring  congestion  of  the  skin,  has  tTeen  erroneously  supposed 
to  be  of  special  diagnostic  significance,  but  it  is  met  with  in  many 
other  affections.  There  is  often  a  strong  tendency  to  the  formation  of 
sloughs  and  bedsores,  and  the^e  vesications  are  frequently  produced 
by  the  application  to  the  skin  of  hot  bottles,  the  heat  of  which  is 
insufficient  to  cause  the  effect  in  a  healthy  person  ;  uncovered  metallic 
bottles  are  especially  dangerous.  These  trophic  changes  are  more 
frequent  in  subacute  than  in  acute  meningitis. 

Respiration  is  sometimes  slightly  quickened,  but  it  is  rarely  much 
disturbed  until  the  final  period,  when  in  tubercular  meningitis  the 
Cheyne-Stokes  rhythm  is  often  observed,  and,  in  this  disease,  is  always 
of  fatal  significance.  More  frequent  are  irregular  pauses,  in  which 
the  child  ceases  to  breathe  for  several  seconds.  In  meningitis  of  the 
posterior  fossa  there  is  sometimes  almost  sudden  failure  of  breathing, 
irregular  feeble  respiration,  with  rapid  cyanosis,  quickly  followed  by 
death. 


310  CEREBRAL    MIUIBRANES. 

The  urine  is  scanty  and  febrile  in  character.  Albumen  or  a  trace 
of  sugar  sometimes  appears. 

Course. — The  onset  is  sometimes  rapid  and  violent,  marked  by  sud- 
den and  high  pyrexia,  by  rigors,  and  by  special  symptoms  of  intense 
degree.  In  such  cases  the  inflammation  is  usually  purulent ;  the 
spinal  membranes  are  commonly  involved,  and  tbe  eases  resemble  the 
epidemic  form.  The  course  of  these  cases  is  sometimes  so  rapid  as  to 
resemble  that  of  the  slower  forms  of  cerebral  haemorrhage.  Death 
may  occur  within  forty-eight  hours  after  the  onset  of  the  symptoms. 
In  other  cases  the  onset  is  gradual  and  insidious,  and  this  is  especially 
frequent  in  tubercular  meningitis.  During  the  early  period,  symptoms 
of  excitement  of  function  predominate;  delirium  accompanies  the 
headache,  there  are  convulsions  and  muscular  contractures.  At  a 
later  period  there  is  depression  of  function,  somnolence  deepens  to 
coma,  and  various  paralyses  occur.  These  are  often  distinguished  as 
first  and  second  stages  of  the  disease,  and  the  deep  coma  that  precedes 
death  is  regarded  as  a  third  stage.  These  stages  are  not  always  dis- 
tinctly recognisable.  Coma  sometimes  develops  almost  at  the  outset, 
and  palsy  of  limb  or  face  may  be  the  earliest  symptom.  Often  the 
local  symptoms  are  trifling,  and  only  the  general  cerebral  symptoms 
ai*e  marked. 

The  duration  of  meningitis  varies  from  two  or  three  days  to  as  many 
weeks.  The  most  rapid  cases  are  those  due  to  septic  processes,  and 
cases  of  the  primary  purulent  inflammation  already  mentioned.  But 
the  maximum  duration  mentioned  above  is  occasionally  exceeded,  and 
cases  are  met  with  that  must  be  regarded  as  subacute.  They  are 
generally  examples  of  simple  inflammation,  and  occur  chiefly  in 
children  ;  they  constitute  a  transition  to  the  form  of  chronic  infantile 
meningitis  mentioned  on  p.  346. 

Symptoms  in  Relation  to  Locality. — In  meningitis  of  the  convexity 
delirium  is  more  pronounced,  local  convulsions  and  hemiplegic  weak- 
ness are  more  common,  vomiting  is  less  frequent,  palsies  of  the  cranial 
nerves  are  for  the  most  part  absent,  and  optic  neuritis  is  rare.  In 
meningitis  of  the  base  the  cranial  nerves  suffer  early,  delirium  occurs 
later,  vomiting  is  frequent,  and  optic  neuritis  usually  develops  before 
the  symptoms  have  reached  a  high  degree  of  intensity.  When  delirium 
is  the  chief  symptom,  the  aspect  of  the  case  may  closely  resemble 
delirium  tremens.  When  meningitis  is  limited  to  one  part  of  the 
base,  the  cranial  nerves  suffer,  that  have  their  course  in  that  part. 
There  is  usually  retraction  of  the  head  when  the  inflammation  affects 
the  membranes  about  the  pons  and  medulla — a  symptom  of  very  great 
diagnostic  importance.  Hemiplegia  and  convulsions  may  occur  during 
its  course,  from  the  secondary  thrombosis  already  mentioned.  Uni- 
lateral convulsion,  beginning  locally,  may  succeed  recovery. 

In  ventricular  meningitis,  in  which  abundant  effusion  and  traces  of 
inflammation  in  the  choroid  plexus  and  ependyma  are  the  only  morbid 


MENINGITIS.  341 

changes,  the  general  symptoms  are,  strange  to  say,  the  same  as  in 
other  forms, — headache,  vomiting,  fever,  convulsions,  rigidity, delirium, 
irregularity  of  pulse  and.  breathing,  and  final  coma,  but  the  functions 
of  the  cranial  nerves  are  seldom  interfered  with.  The  fontanelle,  if 
open,  is  distended  and  pulsates.  Death  may  occur  in  a  few  days,  or 
at  the  end  of  ten  days  or  a  fortnight.  Occasionally,  after  an  acute 
onset,  the  symptoms  lessen,  but  the  remission  is  followed  by  their 
renewal  in  fatal  intensity.  It  is  said  that  incomplete  recovery  may 
occur,  with  enduring  defect  in  mind  or  muscular  power,  contractures, 
oscillating  gait  or  convulsions.  Enlargement  of  the  head  may  develop, 
and  the  case  practically  becomes  one  of  chronic  hydrocephalus.  There 
is  nothing  in  these  symptoms  that  is  distinctive.  All  are  common  to 
meningitis  that  is  external  as  well  as  internal,  and  there  is  considerable 
room  for  doubt  as  to  the  accuracy  of  the  diagnosis  of  cases  that  are 
not  fatal. 

Symptoms  in  Relation  to  Form. — In  simple  meningitis  the  symptoms 
are  those  above  described,  and  their  precise  character  depends  on  the 
scat  of  the  inflammation.  The  course  of  the  disease  is  olten  lono-er 
than  in  the  other  forms — three,  four,  or  six  weeks ;  and  the  symptoms 
present  greater  variations  in  degree  and  in  character.  The  rise  of 
temperature  is  often  at  first  great,  but  it  may  subside  as  the  disease 
passes  into  a  subacute  stage.  Probably  in  consequence  of  the  longer 
course,  optic  neuritis  is  frequent  and  considerable  in  degree,  especial! v 
if  the  base  is  involved.  In  meningitis  secondary  to  local  disease  the 
seat  of  the  inflammation,  and  therefore  the  attendant  symptoms,  differ 
according  to  the  position  of  the  disease  that  excites  it.  Moreover,  the 
symptoms  of  the  primary  malady  often  mask  those  of  the  meningitis 
which  it  excites. 

Ttibercular  Meningitis.—  The  symptoms  differ  to  some  extent  in 
children  and  in  adults. 

In  the  child  prodromata  are  frequent.  Loss  of  flesh  and  indica- 
tions of  general  failure  of  strength  are  the  most  common.  Thev  are 
usually  due  to  the  pi-ocess  of  tuberculosis,  of  which  the  menino-itis 
is  one  result.  Slight  evening  pyrexia  often  accompanies  these 
symptoms.  Other  premonitory  symptoms  are  met  with  in  the 
nervous  system, — mental  irritability,  restlessness  at  night,  and  a 
tendency  to  frontal  headache,  the  pain  being  excited  by  mental  work 
and  fatigue. 

These  symptoms  may  exist  for  a  few  weeks,  sometimes  for  a  month 
or  two  before  the  actual  onset.  When  the  meningitis  is  secondary  to 
considerable  tubercular  mischief  elsewhere,  as  in  the  lungs,  the  sym- 
ptoms of  this  usually  obscure  any  premonitory  symptoms  of  the 
meningitis.  Occasionally,  as  the  cerebral  inflammation  develops,  the 
symptoms  of  the  luug  affeclion  lessen  in  a  remarkable  degree.  The 
headache,  which  may  exist  for  two  or  three  weeks  before  the  onset  of 


342  OEEKBRAL    MEMBUANES. 

the  acute  symptoms,  is  perhaps  due  to  the  formation  of  tubercle  in  the 
membranes,  if,  as  is  generally  believed,  this  precedes  the  inflammation. 
Another  antecedent  symptom  is  the  vomiting,  which  may  be  appa- 
rently causeless,  or  may  follow  an  inadequate  cause,  i.  e.  it  occurs  after 
food  that  is  not  quite  judicious,  although  not  so  indigestible  as  to  be 
alone  a  sufficient  cause  of  its  rejection.  This  symptom  should  always 
excite  suspicion  if  it  occurs  without  other  indications  of  gastric  dis- 
turbance, and  especially  if  it  is  repeated  and  is  associated  with  other 
premonitory  symptoms. 

Such  vomiting,  more  severe  in  degree,  is  a  common  symptom  of  the 
onset,  which  is  usually  attended  by  a  great  increase  in  the  headache, 
or  by  the  development  of  headache  if  this  was  absent  before,  some- 
times by  drowsiness,  and  often  by  attacks  of  general  convulsion.  In 
the  early  stage  of  the  disease  the  prominent  symptoms  are  usually 
those  of  general  cerebral  disturbance,  headache,  somnolence,  wander- 
ing at  night,  sometimes  vertigo,  vomiting,  constipation,  and  the  condi- 
tions of  pulse  and  temperature  already  described.  The  rigidity  of 
the  neck  and  retraction  of  the  head  are  frequent.  Aphasia  is  some- 
times an  early  symptom.  At  the  end  of  the  first  week,  sometimes 
earlier,  sometimes  later,  the  symptoms  in  the  cranial  nerves,  already 
mentioned,  come  on.  About  this  time  also  changes  in  the  optic 
disc  are  often  recognisable.  In  the  course  of  the  second  week  the 
somnolence  deepens  to  coma,  but  in  older  children  this  may  be  pre- 
ceded by  definite  delirium,  occasionally  violent.  The  other  symptoms 
become  more  conspicuous  or  develop.  Rigidity  of  the  limbs,  local 
convulsion,  or  hemiplegia  may  be  added.  Defect  of  sensation  is 
sometimes  associated  with  the  palsy,  and  may  be  more  extensive;  it 
may  be  preceded  by  hyperaesthesia.  The  paralysis  may  be  transient 
or  permanent.  The  pulse  often  becomes  frequent,  140 — 180,  sometimes 
suddenly,  sometimes  gradually.  Respiration  is  often  sighing  or  irre- 
gular. Towards  the  end  of  this,  or  in  the  beginning  of  the  third  week, 
the  child  lies  unconscious  and  motionless,  often  with  rigidity  or 
flaccidity  of  the  muscles  of  one  side ;  muco-pus  accumulates  on  the 
cornea;  convulsions  are  more  frequent ;  the  respiration  is  more 
irregular,  and  may  present  an  occasional  pause  or  a  distinct  Cheyne- 
Stokes  rhythm.  The  patient  may  die  during  the  coma  with  accumula- 
tion of  mucus  in  the  chest;  bedsores  may  form,  and  hasten  the  fatal 
issue;  or  death  may  immediately  succeed  an. attack  of  convulsions. 
Sometimes  there  is  an  apparent  improvement  shortly  before  death, 
but,  as  Oxley*  has  pointed  out,  the  pulse  seldom  shares  in  this. 
The  temperature  towards  the  end  may  sometimes  remain  at  about  the 
same  degree  of  moderate  elevation,  sometimes  it  becomes  very  high, 
sometimes  falls  below  the  normal,  and  is  sometimes  very  low.  Thus 
in  one  recorded  case  on  the  seventeenth  day  of  the  disease,  the  day 
before  death,  the  temperature  was  only  93°  (Bokai). 

In   the    cases   in   which    tubercular    meningitis    affects    only   the 
*  '  Liverpool  Med.-Chir.  Journal/  July,  1885. 


MENINGITIS.  343 

convexity  (which  are  less  rare  than  is  commonly  supposed)  the 
symptoms  in  the  cranial  nerves  are  absent,  vomiting  is  less  obtrusive, 
and  headache  and  delirium,  with  convulsions  and  rigidity  of  limb, 
constitute  the  chief  symptoms.  Inequality  of  pupil  is  often  present 
when  other  ocular  symptoms  (including  neuritis)  are  absent,  Lut 
slight  strabismus  or  diplopia  will  often  be  discovered  by  a  careful 
search,  which  should  "include  the  upward  movement.  Partial  tuber- 
cular meningitis,  affecting  only  a  small  part  of  the  convexity,  causes 
local  symptoms  resembling  those  of  a  tubercular  growth,  with  which, 
indeed,  it  is  commonly  associated. 

The  duration  from  the  onset  varies  from  one  to  three  weeks.  It  is 
rarely  less  than  a  week,  and  occasionally  as  much  as  four  weeks.  The 
average  is  two  weeks.  In  cases  that  begin  insidiously  the  duration  is 
determined  with  difficulty,  and  if  the  premonitory  period  is  included 
the  average  is  more  than  two  weeks.  The  average  duration  of  tuber- 
cular meningitis  limited  to  the  convexity  is  said  to  be  less  than  when 
the  base  is  affected.  The  usual  termination  is  death,  but  it  is  not  open 
to  Cjuestion  that  cases  do  sometimes  recover.  Unquestionably  cases 
recover  in  which  the  existence  of  meningitis  admits  of  no  doubt,  and 
in  which  there  is  a  strong  presumption  that  the  inflammation  is 
tubercular,  although  the  recovery  removes  the  possibility  of  rigid 
proof.  In  most  cases  of  children  who  recover  from  an  illness  resem- 
bling tubercular  meningitis,  the  cerebral  symptoms  were  general 
pain,  delirium,  and  convulsions ;  as  a  rule  there  have  not  been 
symptoms  in  the  cranial  nerves  beyond  inequality  of  pupil  and  slight 
optic  neuritis. 

In  ihe  adult  the  symptoms  of  tubercular  meningitis  are  essentiallv 
the  same  as  in  the  child,  but,  if  possible,  even  more  varied  in  their 
character  and  combination.  Headache,  vomiting,  and  cranial  nerve 
symptoms  are  the  same.  Palsy  of  ocular  nerves  is  common,  but 
seldom  involves  the  whole  of  one  third  nerve  (one  case  in  twenty — 
Seitz) ;  ptosis  is  more  frequent  (one  in  seven).  General  convulsions 
are  not  common,  delirium  usually  occurs  earlier,  and  its  association 
with  persistent  headache  is  very  conspicuous.  The  insidious  cha- 
racter of  the  onset  is  as  common  as  in  childhood,  in  spite  of  the 
ability  of  the  sufferer  to  describe  his  symptoms.  In  young  women 
the  early  stage  of  the  disease  is  sometimes  attended  by  symptoms  of 
hysteroid  character ;  the  morbid  functional  tendency  incidental  to 
the  age  aud  sex  determines  the  form  of  the  general  functional  dis- 
turbance that  is  at  first  produced  by  the  disease  of  the  membranes. 

The  disease  commonly  comes  on  in  the  course  of  phthisis,  but  the 
indications  of  lung  disease  may  be  so  slight  as  to  escape  notice,  and 
sometimes  the  malady  has  the  aspect  of  a  primary  affection,  although 
tubercles  are  found  elsewhere  after  death.  Besides  the  symptoms 
already  described,  it  should  be  noted  that  hemiplegia,  coming  on  in 
the  course,  of  a  few  days  or  a  week,  and  often  attended  by  convul- 
sions, may  be  the  chief  symptom  when  the  inflammation  involves  the 


344  OEEEliBAL    MEMBHANES. 

convexity  of  one  hemisphere.  The  duration  of  the  disease  in  the 
adult  is  sometimes  the  same  as  in  the  child,  but  often  it  is  apparently 
shorter,  perhaps  because  the  early  symptoms  are  overlooked  in  the 
presence  of  the  more  obtrusive  pulmonary  disease.  Occasionally,  on 
the  other  hand,  it  is  much  longer.  Headache  generally  precedes 
other  symptoms,  and  the  sufferers  have  often  been  liable  to  headache, 
and  increasingly  so  during  the  ill-health  that  preceded  the  meningitis 
in  most  cases.  The  habitual  headache  passes  into  that  of  the  intra- 
cranial disease,  and  increases  the  difficulty  of  fixing  the  commence- 
ment of  the  latter.  The  fatality  of  the  disease  is  great,  but  cases  of 
recovery  from  what  is  apparently  tubercular  meningitis  are  observed 
in  young  adults  more  frequently  than  in  children.  Doubt  always 
hangs  over  the  exact  nature  of  cases  that  recover,  but  the  evidence 
of  the  probable  tubercular  character  of  some  of  these  cases  is  very 
strong  * 

Partial  tubercular  meningitis  is  rare.  The  development  of  tubercle 
in  the  meninges  may  be  local,  affecting  one  part  of  the  pia  mater 
only,  and  giving  rise  only  to  symptoms  of  irritation  of  the  underlying- 
cortex.  "When  the  disease  is  over  or  near  the  motor  region  of  the 
cortex  it  may  cause  convulsion  of  local  commencement  or  range,  and 
the  svmptdms  are  distinguishable  from  those  of  a  tumour  only  by 
their  course. 

Purulent  Meningitis. — The  symptoms  depend  upon  its  locality. 
The  course  is  usually  very  acute,  and  the  pyrexia  considerable  and 
constant,  often  with  an  evening  rise ;  the  temperature  is  far  more 
regular  in  its  variations  than  in  tubercular  meningitis.  The  general 
description   given  of   the  symptoms   of   meningitis  is  in  the   main 

*  As  an  instance  of  this  class  may  be  mentioned  the  case  of  a  girl  aged  nineteen, 
who  had  lost  a  brother  from  caries  of  the  spine,  and  a  cousin  from  phthisis.  For 
some  months  she  had  been  growing  anaemic  and  languid,  especially  after  the  death 
of  a  sister  two  months  previously.  Three  weeks  before  I  saw  her,  having  previously 
complained  for  a  week  or  two  of  slight  headache,  this  suddenly  became  intense, 
chiefly  on  the  left  side  of  the  head,  keeping  her  awake  at  night,  making  her  scream 
with  the  pain  ;  it  was  accompanied  by  frequent  vomiting.  After  a  few  days  these 
symptoms  lessened,  but  recurred  from  time  to  time,  and  with  especial  severity  two 
weeks  after  the  onset,  a  day  or  two  before  I  saw  her.  After  this  attack  she  was 
somnolent,  did  not  speak,  and  the  urine  was  passed  into  the  bed.  The  temperature, 
at  first  normal,  rose  to  100°.  She  moved  the  right  arm  less  than  the  left,  and  had 
several  convulsions  with  tonic  spasm,  flexion  of  the  arms,  and  deviation  of  the  head 
to  the  right.  When  seen,  she  could  be  roused  to  take  notice,,  but  not  to  speak- 
There  was  slight  rigidity  of  the  limbs,  greater  on  the  right  side.  The  legs  and 
upper  aims  were  moved,  but  not  the  hands.  The  pulse  was  88  and  irregular. 
There  was  slight  but  distinct  optic  neuritis,  in  aspect  exactly  that  seen  in  tubercular 
meningitis.  .  Her  head  was  shaved,  ice  applied  to  it,  and  a  blister  to  the  back  of  the 
neck,  and  phosphate  of  iron,  iodide  of  potassium,  and  nitric  ether  given  internally. 
That  evening  she  had  four  more  convulsions,  commencing  in  the  right  leg.  The 
day  after  that  on  which  the  blister  rose  she  spoke,  and  afterwards  slowly  improved ; 
for  several  days  more,  however,  urine  was  passed  into  the  bed,  and  the  right  arm  was 
dist  nctly  weaker  than  the  left.     She  ultimately  recovered  perfectly. 


MENINGITIS.  845 

applicable  to  the  purulent  form.  But  no  form  of  inflammation,  not 
oven  the  tubercular,  presents  greater  variations  in  symptoms  and 
course  in  proportion  to  the  intensity  of  the  process.  Some  cases, 
secondary  to  suppuration  elsewhere,  present  extraordinary  latency. 
I  have  known,  for  instance,  slight  occasional  strabismus,  slight 
retraction  of  the  bead,  moderate  headache,  irregular  fever,  and  optic 
neuritis  to  be  the  only  symptoms',  although  after  death  both  cerebral 
and  spinal  membranes  were  bathed  in  pus,  and  the  meningitis 
certainly  commenced  a  fortnight  before  death.  On  the  other  hand, 
the  meningitis  that  follows  rupture  of  a  cerebral  abscess  causes 
symptoms  of  extreme  intensity  aud  has  a  rapid  course. 

Focal  meningitis,  involving  only  a  small  area  of  the  membranes  on 
one  side  of  either  the  base  or  the  convexity,  is  generally  chronic — 
traumatic  cases  of  course  excluded.  The  condition  is  therefore 
described  in  the  next  section.  In  the  very  rare  cases  in  which  focal 
meningitis  is  acute,  the  symptoms  are,  for  the  most  part,  similar  to 
those  of  the  chronic  form,  the  chief  difference  being  in  their  course. 

Chronic  Meningitis. — The  symptoms  of  chronic  meningitis  consist 
chiefly  in  local  disturbance  of  f  uncupn ;  the  symptoms  outside  the 
nervous  system,  so  conspicuous  in  most  cases  of  acute  meningitis, 
are,  as  a  rule,  absent  in  the  chronic  form.  In  the  adult  the  sym- 
ptoms vary  much  according  to  the  cause  and  nature  of  the  inflamma- 
tion. In  the  chronic  alcoholic  meningitis,  which  affects  chiefly  the 
convexity  over  both  hemispheres,  the  chief  symptoms  are  headache, 
moderate  in  degree  and  sometimes  absent,  slight  delirium,  mental 
failure,  and  sliyht  optic  neuritis.  The  malady  always  runs  a  very 
chronic  course,  and  its  symptoms  are  often  overshadowed  by  those  of 
some  other  of  the  effects  of  alcoholism,  such  as  liver  disease  or 
multiple  neuritis.  The  symptoms  may  subside  if  the  cause  of  the 
morbid  state  can  be  arrested.  It  is  probable  that  they  are  iu  part 
due  to  the  action  of  the  alcohol  on  the  brain  substance. 

Chronic  syphilitic  meningitis  in  the  adult  is  generally  local.  It 
usually  occurs  chiefly  in  the  vicinity  of  a  syphilitic  growth,  and  its 
chief  effect  is  to  extend  the  symptoms  of  tie  latter  over  a  wider  area 
than  corresponds  to  the  actual  tumour.  Thus  in  the  case  of  a  syphi- 
loma growing  into  the  hemisphere  from  the  outer  side  of  the  crus,  the 
effects  of  this  were  accompanied  by  palsy  of  the  fifth  nerve  on  the 
same  side  in  consequence  of  syphilitic  meningitis  extending  from  the 
tumour.  Sometimes  such  meningitis  exists  apart  from  any  distinct 
growth,  and  may  then  extend  widely,  even  sheathing  the  whole  base 
with  its  products.  There  is  always  a  considerable  formation  of  tissue 
thickening  the  pia-arachnoid,  sometimes  to  such  an  extent  as  to 
suggest  a  diffuse  growth.  The  seat  of  the  disease  may  be  at  the  base 
or  the  convexity  ;  in  either  situation  focal  symptoms  are  produced, 
s-carcely  distinguishable  in  the  more  chronic  cases  from  those  of  a 
syphilitic   growth  except   by  the    slighter  degree    of    optic  neuritis, 


346  0EJ4EBBAL   MEMBKANES. 

llie  slighter  indications  of  compression  of  the  parts  affected,  and  the 
less  gradual  onset.  The  side  of  the  medulla  is  an  occasional  seat  of  this 
inflammation,  which  is  one  of  the  most  common  causes  of  the  con- 
joint palsy  of  one  half  of  the  tongue,  side  of  the  palate,  and  vocal  cord 
(seep.  307).  Another  occasional  seat  is  the  neighbourhood  of  the 
motor  convolutions  producing  unilateral  fits,  and  local  pain  and 
tenderness.  It  is  probable  that  focal  inflammation  in  adults  is 
generally  syphilitic  in  nature,  the  traumatic  form  of  course  excepted.* 

In  such  cases  it  is  often  useless  and  even  cruel  to  suggest  the 
probable  cause  of  the  malady.  It  is  unlikely  that  by  such  questions 
syphilis  can  be  absolutely  excluded,  and  unless  it  can  be  excluded  the 
employment  of  antisyphilitic  treatment  in  such  a  case  is  the  first  duty 
of  the  practitioner.  Moreover,  if  syphilis  can  be  excluded,  the  treat- 
ment suitable  for  syphilis  (mercury)  remains  the  most  promising  for 
a  simple  inflammation. 

Chronic  infantile  meningitis,  which  is  also  in  some  cases  associated 
with  syphilis,  causes  symptoms  that  depend  on  the  special  proclivity 
of  the  inflammation  to  affect  the  posterior  fossa  of  the  base.  The 
most  important  and  characteristic  symptom  is  retraction  of  the  head. 
In  a  valuable  paper  on  these  casesf  Drs.  Gree  and  Barlow  point  out 
that  the  onset  of  this  symptom  is  sometimes  sudden,  sometimes 
gradual;  when  sudden  it  is  occasionally  attended  by  other  symptoms, 
— fever,  vomiting,  rigidity  of  the  limbs,  convulsions.  I  have  known 
general  convulsions  to  precede  for  a  week  the  onset  of  the  retraction. 
The  holding  back  of  the  head  is  due  to  a  tonic  contraction  in  the 
muscles,  and  becomes  greater  when  the  child  is  made  to  sit  up.  It 
varies  in  degree  at  different  times,  and  is  occasionally  intermittent. 
When  the  condition  has  become  established,  it  is  often  attended  by 
rigidity  of  the  limbs,  sometimes  by  epileptiform  convulsions.  Palsy 
is  rare,  but  strabismus  aud  nystagmus  are  sometimes  observed.^ 
Occasionally  hydrocephalic  enlargement  of  the  head  follows  after  a 
time.  The  symptoms  continue  for  a  period  that  varies  from  a  month 
to  a  year  and  a  half,  and  may  end  in  recovery  or  death.     After  death 

*  The  following  case  is  probably  an  instance  of  it.  A  married  lady,  a  month  after 
her  confinement,  suffered  for  a  week  or  two  from  neuralgic  pain  about  the  right 
temple  and  eye,  and  then  became  feverish  ;  one  or  two  convulsions  occurred  of  uncer- 
tain character,  and  left  hemiplegia  developed  rapidly,  the  paralysis  of  arm  aud  leg 
becoming  almost  complete  in  the  course  of  a  few  days.  There  was  no  optic  neuritis. 
Iodide  of  potassium  was  given  and  mercury  rubbed  in,  &c. ;  as  soon  as  the  influence 
of  the  drugs  became  established  the  symptoms  began  to  lessen,  and  they  passed  away 
entirely  in  the  course  ot  a  lew  weeks.  In  this  case  the  evidence  of  local  meningitis 
afforded  by  the  symptoms  and  their  mode  of  onset  was  conclusive ;  and  although  the 
effect  of  the  drugs  employed  is  not  certain  evidence  of  the  nature  of  the  lesion,  it 
gave  some  support  to  the  opinion,  based  on  the  limited  extent  of  the  disease,  that  it 
was  of  syphilitic  origin. 

t  "On  the  Cervical  Opisthotonos  of  Infants,"  'St.  Bartholomew's  Hospital 
Reports,'  vol.  xiv,  1878,  p.  22.  The  occasional  relation  to  syphilis,  noted  by  them,  is 
confirmed  by  Money,  '  Treatment  of  Disease  in  Children,'  1887,  p.  456. 

J  Money  (loc.  cit.),  who  found  also  persistent  slight  pyrexia  in  one  case. 


MENINGITIS.  347 

the  signs  of  chronic  meningitis  are  always  found,  chiefly  in  the 
posterior  fossa  of  the  base;  generally  lymph  glues  together  the 
medulla  and  cerebellum,  the  openings  from  the  fourth  ventricle  are 
closed  by  the  lymph,  and  the  ventricles  are  distended.  There  may 
also  be  slight  inflammation  in  the  membranes  of  the  spinal  cord,  and 
this,  as  I  have  seen,  without  special  symptoms  of  spinal  meningitis. 
In  some  cases  such  retraction  of  the  head  dates  from  the  time  of 
birth,  and  it  is  highly  probable  that  in  these  cases. there  is  haemor- 
rhage into  the  membranes  abont  the  medulla,  a  proved  lesion  depend- 
ing generally  on  laceration  of  the  cerebellum  (see  "Meningeal 
Ha^morrlage  ").  The  retraction  of  the  head  must  be  distinguished 
from  mere  inability  to  support  the  head  due  to  weakness  of  the 
muscles.  I  have,  however,  known  such  inability  to  follow  the  retrac- 
tion in  cases  in  which  the  symptom  dated  from  birth. 

Pathology. — The  pia- arachnoid  differs  from  most  other  membranes 
that  enclose  viscera,  in  its  separation  into  two  layers.  Nevertheless 
it  is  commonly  regarded  as  a  serous  membrane,  and  it  presents  some 
analogies  to  other  serous  membranes  in  its  pathological  liability,  but 
also  wide  differences  from  them.  Like  the  pleura,  it  is  prone  to  spon- 
taneous inflammation ;  but  the  most  common  cause  of  primary  pleurisy, 
exposure  to  cold,  seems  to  have  little  influence  in  exciting  meningitis. 
It  is  the  seat  of  specific  processes  more  frequently  than  any  other 
serous  membrane,  and  this,  together  with  its  liability  to  suffer  in 
states  of  blood-poisoning,  must  be  regarded  as  its  chief  pathological 
characteristic.  The  process  of  inflammation  also  presents  some  pecu- 
liarities in  the  cerebral  membrane.  The  tendency  to  the  formation  of 
lymph  is  smaller,  and  of  pus  is  greater,  than  in  the  case  of  the  pleura 
or  the  pericardium.  Embolic  processes  may  play  a  part  in  the  gene- 
ration of  some  forms  of  septicemic  inflammation,  but  it  is  probable 
that  the  circulation  of  septic  matter  in  the  blood,  not  necessarily  organ- 
isms, suffices  to  excite  in  the  membranes  the  inflammation  to  which 
they  are  prone. 

The  acute  simple  or  purulent  meningitis  that  occurs  in  children 
and  adults,  as  an  apparently  primary  affection,  seems  to  be  insepai-- 
able  from  the  sporadic  form  of  cerebro- spinal  meningitis.  Although 
spinal  symptoms,  beyond  some  retraction  of  the  head,  may  be  absent, 
purulent  inflammation  extends,  in  most  oases,  down  the  membranes 
of  the  cord.  The  probable  pathology  of  these  cases  is  considered 
in  the  section  on  the  epidemic  form. 

The  relation  between  the  morbid  process  and  the  symptoms  that 
reveal  its  presence  is  still,  in  part,  obscure.  The  affection  of  the 
cranial  nerves  is  usually  due  to  their  actual  inflammation,  indications 
of  which  may  be  found  in  the  changes  of  interstitial  tissue,  and  in  the 
degeneration  of  the  nerve-fibres.  With  regard  to  the  character  of  the 
symptoms,  we  are  doubtless  safe  in  recognising,  with  the  older  writers, 
the  early  stage  of  over-action  as  the  result  of  irritation  of  the  nerve- 


313  CEREBRAL    MEMBKANES. 

elements  "by  the  inflammation  of  the  enclosing  membranes.  In  some 
cases  the  excitement  of  function,  geueral  so  far  as  the  raenin^itic 
influence  is  concerned,  seems  to  he  determined  in  its  special  form  by 
predisposition,  or  by  coincident  influences.  Hence  it  is  that  in  spe- 
cially disposed  subjects  the  early  symptoms  may  present  characters 
definitely  hysterical  in  their  character.  But  the  process  of  irritation 
may  at  first  arrest  fuuetion  instead  of  exciting  its  activity.  In  the 
early  stage  of  meningitis  there  is  sometimes  complete  hemiplegia,  and 
I  have  even  known  the  inflammation  to  be  apparently  slighter  over 
the  hemisphere  the  function  of  which  was  thus  arrested,  than  over 
the  other.  We  can  only  explain  such  an  arrest  of  function  as  the 
result  of  irritative  inhibition,  and  must  remember  that  pus  may  be 
abundant  in  the  pia  mater  and  jet  not  penetrate  the  centre.  (See 
"  Spinal  Cord,"  in  vol.  i,  p.  272.)  Hence  the  frequent  disproportion 
between  the  amount  of  inflammation  and  the  strange  fact  that  exten- 
sive purulent  meningitis  may  run  a  latent  course.  For  the  depression 
of  function  in  the  later  stage  there  are  two  possible  mechanisms : 
first,  the  ventricular  effusion  and  compression  of  the  brain  ;  and 
second,  the  greater  damage  of  nerve-elements  that  have  been  pre- 
viously excited*  Whether  the  tubercles  precede  inflammation  or 
excite  any  .symptoms  by  their  presence  is  as  yet  an  undecided 
problem. 

Considei-ahle  paralysis  of  the  cranial  nerves  is  no  doubt  always  due 
to  the  affection  of  these  nerves  at  the  base  of  the  brain,  with  the  ex- 
ception of  palsy  of  the  face  and  tongue,  which  may  be  considerable 
in  decree  when  of  cortical  origin.  Thus  I  have  seen  paralysis  of  all 
parts  of  the  face  associated  with  paralysis  of  the  limbs  on  the  same 
side,  but  the  palsy  of  the  face  involved  voluntary  and  not  emotional 
movements — conclusive  evidence  that  it  was  not  due  to  an  affection  of 
the  nerve,  and  it  soou  becomes  confined  to  the  lower  part.  Spas- 
modic strabismus  and  inequality  of  pupil  may  also  probably  be  due 
to  the  affectiou  of  the  cortex,  as  well  as  to  that  of  the  nerve-trunks. 
E,io-iditv  of  muscles  is  a  result  of  irritation,  either  of  the  cortex,  crus, 
or  pons;  the  retraction  of  the  head  is  due  to  inflammation  about  the 
pous  and  medulla, — not,  as  is  often  said,  to  the  ventricular  effusion. 
Whether  anv  symptoms,  in  the  occular  muscles  or  elsewhere,  are  due 
to  inflammatory  irritation  of  the  corpora  quadrigemina,  or  of  the 
o-iw  matter  lining  the  third  ventricle,  is  uncertain.  The  nerve  nuclei 
are  sometimes  damaged  by  haemorrhage,  &c,  from  interference  with 
those  arteries  that  pass  through  the  posterior  perforated  spr3t. 

Diagnosis. — The  diagnosis  of  meningitis  rests  on  the  presence  of 
such  svmptoms  as  indicate  organic  disease  at  the  surface  of  the  brain, 
on  the  development  of  these  in  au  acute  or  subacute,  but  not  sudden 
manner,  and  on  the  presence  of  the  general  symptoms  of  inflammation, 

*  Rilliet  and  Bartlicz,  Hnguenin,  &c. ;  sils  >  Wilks  and  Moxon, '  P.ith.  Anal./ 
2nd  ed.,  p.  210;  Hilton  Fagge,  '  Priuc.  aud  Pract.  of  Med.,'  ed.  by  Pye-Smitli. 


MENINGITIS.  349 

and  of  a  probable  cause.  Of  the  cerebral  symptoms,  those  of  local 
character  are  the  most  conclusive,  bnt  often  of  least  actual  diagnostic 
importance,  since  they  occur  com  paiutively  late  in  the  course  of  the 
affection  ;  and  although  it  is  now  and  then  impossible  to  recognise  the 
disease  until  they  appear,  they  more  often  serve  to  confirm  than  to  esta- 
blish the  diagnosis.  These  general  cerebral  symptoms  are  significant 
by  their  degree  and  combination,  since  most  of  them  maybe  produced 
by  processes  commencing  outside  the  nervous  system.  The  signifi- 
cance of  the  headache  depends  on  its  persistent  intensity ;  of  the 
delirium,  on  its  co-existence  with  headache ;  of  vomiting,  on  its 
causeless  recurring  character  ;  of  general  convulsions,  on  their  associa- 
tion with  the  other  symptoms  ;  of  frequency  of  pulse,  on  its  combina- 
tion with  the  pyrexia  that  usually  accelerates  the  action  of  the  heart. 
It  is  in  the  early  stige,  when  these  general  symptoms  alone  exist,  that 
the  chief  diagnostic  errors  occur  ;  but  when  the  inflammation  is  at  the 
convexity,  this  difficulty  may  persist  until  late  in  the  disease.  A 
child  of  five  had  headache,  vomiting,  and  drowsiness  for  a  fortnight, 
then  became  comatose,  and  died  in  a  few  hours,  even  the  optic  discs 
being  normal.  Among  important  local  symptoms  are  the  inequality 
of  pupil;  strabismus,  even  if  transient;  nystagmus;  retraction  of  the 
head,  anl  weakness  in  the  face.  The  ophthalmoscopic  changes  may 
also  decide  the  diagnosis,  chiefly  in  cases  in  which  they  occur  early,  or 
local  symptoms  develop  late.  In  some  obscure  cases  the  occurrence  of 
retention  or  incontinence  of  urine,  or  the  readiness  with  which  the 
skin  blisters,  gives  sufficient  weight  to  other  symptoms  to  determine 
the  diagnosis.  In  all  cases  the  Protean  character  of  the  disease  should 
be  remembered,  and  above  all  the  fact  that  there  is  no  symptom  of 
meningitis  that  is  not  sometimes  absent.  Headache  is  the  most 
constant,  rarely  wanting,  but  cases  have  been  known  to  run  their 
course  without  any  obtrusive  pain  ;  its  absence,  therefore,  does  not 
destroy  the  value  of  other  symptoms  that  are  of  significance,  and 
there  is  no  other  symptom  (not  excepting  pyrexia)  the  absence  of 
which  is  of  much  negative  value.  The  presence  or  history  of  a  possible 
cause  of  meningitis  often  assists  the  diagnosis  by  directing  attention 
to  symptoms  that  might  otherwise  be  unnoticed.  This  is  especially 
the  case  with  injuries,  ear  disease,  pyaemia,  and  phthisis.  Any  brain 
symptoms  in  the  subjects  of  tubercular  or  scrofulous  disease,  even 
at  a  distance,  should  excite  concern.  Occasionally  disease  near  the 
brain  may  render  the  diagnosis  more  difficult  by  obscuring,  with  its 
own  obtrusive  symptoms,  those  of  its  effect. 

The  existence  of  meningitis  being  recognised,  the  diagnosis  of  its 
seat  depends  chiefly  on  the  character  of  the  symptoms  — whether  they 
are  such  as  to  indicate  disturbance  of  the  convexity  or  of  the  base. 
The  differences  that  depend  upon  locality  have  been  already  described. 
Sometimes  the  cause  of  the  meningitis  also  helps  the  diagnosis  of 
locality,  since  adjacent  disease  excites  inflammation  first  in  its  own 
neighbourhood. 


350  CEREBRAL    MEMBRANES. 

In  determining  the  nature  of  the  inflammation  we  are  guided  by  its 
cause,  its  associations,  its  seat,  the  age  of  the  patient,  and  the  relative 
frequency  of  the  several  forms.  Each  of  these  points  must  be  con- 
sidered, not  only  in  itself,  but  in  relation  to  tbe  others.  The  apparent 
cause  often  decides  the  question  :  from  adjacent  caries  and  in  pysemia 
the  inflammation  is  almost  cer-tainly  purulent  ;  but  if  there  is  distant 
suppuration  of  scrofulous  origin  the  inflammation  may  be  either 
tubercular  or  purulent,  and  the  former  is  more  probable  unless 
there  are  other  signs  of  septicaemia.  In  pneumonia  or  acute  specific 
diseases  the  inflammation  may  be  either  simple  or  purulent.  If  there 
are  signs  of  phthisis  or  a  tubercular  family  history,  and  no  other 
cause  can  be  detected,  the  meningitis  is  almost  certainly  tubercular. 
The  discovery  of  tubercles  of  the  choroid  renders  the  nature  of  the 
inflammation  certain.  A  boy,  aged  five,  was  seized  with  acute 
pain  in  the  head  on  the  twentieth  day  of  typhoid  fever  (with 
characteristic  eruption)  ;  this  was  followed  by  coma,  inequality  of 
pupil,  deviation  of  head  and  eyes  to  the  left,  rigidity  of  the  left  limbs, 
and  half -purposive  movements  of  the  right.  I  saw  him  on  tbe 
fifth  day  after  the  onset  of  these  symptoms,  and  found  optic  neuritis 
in  the  right, eye  only,  with  tubercles  in  each  choroid, — a  proof  that  the 
inflammation  was  tubercular,  complicating  the  fever  and  not  due  to  it. 
If  the  inflammation  is  at  the  base  of  the  brain,  and  no  cause  is  dis- 
coverable, the  probability  that  it  is  tubercular  is  very  great.  If  the 
inflammation  is  at  the  convexity  tbe  probability  of  its  tubercular 
nature  is  considerable  in  childhood  and  youth,  but  in  adult  life  such 
inflammation  is  probably  not  tubercular.  Under  twenty  years  of  age 
there  is  a  presumption,  in  the  absence  of  other  causal  indications, 
that  any  meningitis  is  of  tubercular  origin  ;  but  over  forty  there  is  a 
presumption  against  this,  which  becomes  greater  as  life  advances,  and 
is  increased  by  a  history  of  alcoholism  or  of  syphilis.  The  special 
diagnosis  of  ventricular  meningitis  is  practically  impossible  during 
life." 

Differential  Diagnosis.- — Meningitis  may  be  confounded  with 
general  diseases,  and  with  other  diseases  of  the  nervous  system 
These  errors  occur  chiefly  with  tubercular  meningitis,  because  most 
other  forms  have  an  association  with  some  cause  which  prevents  a 
mistake,  or  else  produce  symptoms  so  acute  and  characteristic  that 
there  is  neither  time  nor  room  for  error.  The  following  remarks  on 
the  differential  diagnosis  apply,  however,  also  to  the  rare  simple 
basal  meningitis  which,  during  life,  cannot  be  distinguished  with 
certainty  from  the  tubercular  form. 

The  error  of  mistaking  an  acute  general  disease  for  meningitis  is 
more  common  than  the  opposite  error.  Typhoid  fever  and  catarrhal 
febiicula  are  the  diseases  with  regard  to  which  a  mistake  is  most 
common  ;  the  former  in  older  children  and  adults,  the  latter  in  young 
children.  The  error  always  arises  from  ascribing  initial  headache  and 
subsequent  delirium  to  cerebral  disease  in  the  presence  of  sufficient 


MENINGITIS.  35 1 

pyi'exia  to  account  for  the  symptoms,  and  from  disregarding  the 
relation,  "between  the  two.  When  they  are  the  result  of  a  general 
disease,  as  Sir  William  Jenner  long  ago  pointed  out,  the  headache 
ceases  when  the  delirium  begins.  In  meningitis  the  headache  con- 
tinues, and  co-exists  with  the  delirium.  In  children,  convulsions 
may  occur  at  the  onset  of  the  general  disease.  In  all  cases,  there- 
fore, in  which  there  is  first  headache  and  then  delirium,  and  in 
which  there  is  pyrexia  sufficient  to  account  for  both,  the  presumption 
is  strongly  against  meningitis ;  this  should  only  be  suspected  when 
local  cerebral  symptoms  appear,  or  if  there  be  general  cerebral 
symptoms  such  as  optic  neuritis,  that  do  not  occur  during  general 
diseases.  The  difficulty  of  the  diagnosis  between  typhoid  fever  and 
tubercular  meningitis  is  increased  by  the  fact  that  the  former  is 
sometimes  attended  by  constipation,  and  the  latter  by  diarrhoea  due 
to  tubercular  ulceration  of  the  bowels,  or  by  general  abdominal 
tenderness  from  the  formation  of  tubercles  in  the  peritoneum.  It  is 
sometimes  necessary  to  wait  and  watch  the  course  of  the  symptoms 
before  a  confident  opinion  can  be  formed.  As  a  rule,  the  pyrexia 
runs  a  more  regular  course  in  typhoid,  and  the  pulse  is  more  frequent 
and  is  seldom  irregular.  The  optic  neuritis  that  is  occasionally 
associated  with  acute  specific  diseases  does  not  accompany,  but 
succeeds  them.  It  should  be  remembered  that  convulsions  which 
are  partial,  and  begin  locally,  are  local  and  not  general  cerebral 
symptoms.  Avoidable  error  arises  in  most  cases  from  the  judgment 
being  warped  by  the  initial  headache,  and  the  practitioner  omits  to 
keep  a  look-out  for  other  symptoms  outside  the  nervous  system.  In 
coiisequence  of  this,  gross  mistakes  are  sometimes  made. 

Retraction  of  the  head,  resembling  that  which  occurs  in  meningitis, 
is  sometimes  the  result  of  rheumatism  of  the  muscles  at  the  back  of 
the  neck.  Legroux  asserts  that  in  such  cases  there  may  be  consider- 
able fever,*  but  distinct  cerebral  symptoms  are  of  course  absent,  and 
the  muscles  are  more  painful  than  in  meningitis.  Such  muscular 
rigidity  is  said  to  be  also  produced,  in  some  cases,  by  peripheral  irri- 
tation, tender  cervical  glands,  and  abdominal  disturbance. f 

Among  diseases  of  the  nervous  system,  one  that  sometimes  gives 
rise  to  considerable  difficulty  in  diagnosis  is  intra-cranial  tumour.  A 
rapidly  growing  tumour,  especially  one  that  at  first  interferes  little 
with  function,  may  cause  symptoms  which  develop  so  rapidly  as  to  be 
easily  mistaken  for  those  of  meningitis.  This  is  the  case  sometimes 
with  tubercular  tumours,  and  with  glioma  of  the  pons,  which  may  run 
an  almost  latent  course  until  they  have  reached  a  considerable  degree 
of  intensity.  The  symptoms  in  the  limbs  often  assist  the  diagnosis, 
since  the  loss  of  power  is  more  often  an  early  symptom  in  tumour 
than  in  meningitis,  and  it  comes  on  gradually  in  the  former,  whereas 
early  paralysis  of  the  limbs  in  meningitis  usually  comes  on  suddenly 

*  Legroux,  'L'Encephale,'  1885,  No.  1. 

t  Money, (  Treatment  of  Disease  in  Children,'  1887,  p.  457, 


352  CEREBRAL    MEMBRANES. 

from  irritative  inhibition.  The  ophthalmoscopic  appearances  are  of 
great  importance.  A  slight  degree  of  neuritis  may  be  clue  to  either 
tumour  or  meningitis,  but  an  intense  neuritis,  with  considerable  swell- 
ing and  haemorrhages,  is  practically  conclusive  of  tumour.  The 
neuritis  of  a  rapidly  growing  tumour  is  usually  intense,  and  when  the 
apparances  are  slight  at  first,  if  the  disc  be  watched  for  a  few  days, 
the  course  of  the  neuritis  often  decides  the  diagnosis.  It  must  be 
remembered  that  from  the  absence  of  neuritis  no  conclusion  can  be 
drawn.  In  many  cases,  however,  the  question  can  be  only  decided 
from  the  course  of  the  disease.  If,  after  the  first  two  weeks  from  the 
commencement,  the  symptoms  continue,  slowly  increasing,  and  the 
patient  does  not  become  comatose,  the  diagnosis  of  tumour  is  almost 
certain.  It  must  not  be  forgotten  that  meningitis  often  co-exists  with 
tumour,  by  which  it  is  excited,  but  the  symptoms  of  tumour  in  these 
cases  have  usually  preceded  those  of  meningitis,  and  continue  un- 
changed when  the  latter  have  passed  away  or  lessened.  When  such 
meningitis  is  excited  by  some  adequate  exciting  cause,  as  a  fall, 
the  fact  that  there  is  more  than  inflammation  may  only  be  shown  by 
the  persistence  of  some  significant  symptom  after  the  meningitic  dis- 
turbance has  passed  away.*  A  difficulty  is  met  when  tubercular 
tumours  co-exist  with  tubercular  meningitis,  but  the  difficulty  in 
all  these  cases  is  rather  in  the  recognition  of  the  tumour  than  in  that 
of  the  meningitis. 

In  some  cases  of  meningeal  haemorrhage  the  symptoms  have  an 
acute,  not  sudden  onset,  and  may  closely  resemble  those  of  inflamma- 
tion over  the  convexity  ;  headache  and  delirium  are  conspicuous  ;  and 
both  diseases  inay  follow  an  injury.  This  form  of  meningeal  haemor- 
rhage is,  however,  very  rare.  The  most  important  criterion  is  the 
absence  of  fever  and  the  rapidity  of  course.  Sudden  symptoms  in  the 
course  of  meningitis  do  not  lessen  the  probability  of  the  diagnosis, 
because  they  may  le  due  to  a  secondary  vascular  lesion. 

A  considerable  difficulty  in  diagnosis  is  presented  by  some  cases 
of  disease  of  the  ear,  in  which  symptoms  resembling  meningitis  occur 
and  may  prove  fatal,  although  after  death  only  thrombosis  in  a  sinus 
can  be  discovered,  and  sometimes  even  that  is  absent.  The  central 
symptoms  are  for  the  most  part  general,  and  may  be  in  part  due  to 
pyaemia;  but  strabismus  has  been  observed,  and  the  difficulty  in 
diagnosis  is  increased  by  the  fact  that  optic  neuritis  may  occur  and 
may  even  reach  a  considerable  degree.  It  is  doubtful  whether  in  these 
cases  a  positive  diagnosis  is  always  possible. 

The  same  difficulty  presents  itself  in  another  formjn  cases  of  acute 
double  otitis  in  children,  which  may  be  attended  with  intense  pain  in  the 
head,  vomiting,  fever,  delirium,  giddiness,  convulsions,  and  bilateral 

*  Thus  characteristic  and  severe  meningitis  of  the  convexity,  bilateral,  followed  a 
fall  on  an  ice-covered  hill-side.  The  patient  recovered  save  for  optic  neuritis,  which 
per.-isted  without  diminution,  and  there  followed  hemiplegia,  evidence  of  a  tumour 
of  the  right  hemisphere,  and  death. 


MENINGITIS.  353 

deafness.  In  most  instances  the  labyrinth  is  chiefly  affected,  and  a 
post-mortem  examination  at  a  later  period  has  shown  only  symmetrical 
changes,  sometimes  limited  to  the  cochlea  and  semicircular  canals. 
with  atrophy  of  the  auditory  nerve.*  Such  cases  are  constantly 
thought  to  be  meningitis  ;f  but  it  is  probable  that  inflammation  of 
the  membranes  never  damages  gravely  the  auditory  nerves  without 
the  adjacent  facial  nerves  J  The  general  cerebral  symptoms  alone 
scarcely  warrant  the  diagnosis  of  secondary  meningitis  excited  by  the 
inflammation  of  the  ears.  It  is  probable,  moreover,  that  in  some  of 
these  cases  there  is  optic  neuritis,  although  there  is  no  meningitis. 
Most  practitioners  have  met  with  cases  in  which  complete  deafness  and 
blindness  came  on  in  childhood  with  such  acute  cerebral  symptoms, 
and  in  whom  the  ophthalmoscope  reveals  the  form  of  optic  nerve 
atrophy  that  succeeds  inflammation. §  It  is  probable,  on  account  of- 
the  age  of  the  sufferers  and  the  symmetry  of  the  disease,  that  the 
affection  is  due  to  a  blood-state,  sometimes  induced  by  cold,  and  it 
has  been  conjectured  that  this  state  is  analogous  to  that  which  causes 
polio-myelitis.  The  cases  present  a  very  difficult  diagnostic  problem, 
and  the  difficulty  is  increased  by  the  fact  that  the  internal  ear  may 
be  in  flamed  secondarily  to  meningitis.  Such  secondary  otitis  has  been 
observed  in  cerebro- spinal  meningitis,  but  it  is  very  rare.  || 

The  condition  of  depressed  cerebral  function  that  was  termed  by 
Marshall  Hall  hydrocephaloid,  and  is  apparently  due  to  anaemia  of 
the  brain,  may  be  confounded  with  tubercular  meningitis.  In  this 
condition,  which  is  almost  confined  to  young  children,  there  is  somno- 
lence and  coma,  with  depressed  fontanelle,  and  local  symptoms  are 
absent.  It  is  said,  indeed,  that  rigidity  of  the  neck  and  strabismus 
have  been  observed,  but  there  is  some  doubt  as  to  the  real  nature  of 
cases  that  present  such  symptoms.  The  cases  are  distinguished  from 
meningitis  by  the  depression  of  the  fontanelle,  and  especially  by  the 
occurrence  of  the  symptoms  in  the  profound  exhaustion  that  results 
from  diarrhoea  or  loss  of  blood. 

Of  the  general  diseases  of  the  nervous  system  there  is  only  one  that 
is  liable  to  be  confounded  with  meningitis,  and  especially  with  tuber- 

*  Pulitzer,  •  Diseases,  of  the  Ear,'  Caswell's  translation,  1883,  p.  714. 

f  The  facility  with  which  this  mistake  may  be  made  was  pointed  out  hy 
Votolini  ('  Monatschr.  f.  01i«mheilk.,'  1870,  Nos.  7  and  8)  and  Reichel  ('  Berl.  kl. 
Wochenschr.,'  1S70,  Nos.  24  and  25). 

J  It  has  been  assumed  that  the  auditory  nerves  may  be  so  damaged  at  the  base  as 
to  cause  complete  deafness  without  any  paralysis  of  the  facial.  This  assumption 
rests  on  no  evidence,  and  is  most  improbable,  although  no  doubt,  as  already  stated, 
the  auditory  nerves  may  suffer  somewhat  more  readily  than  the  facial  in  slight 
inflammation  of  the  membranes. 

§  A  series  of  such  cases  has  been  recorded  by  Mr.  Hutchinson,  '  Ophth.  Hosp. 
Rep.,'  1866. 

||  Lucae,  'Arch.  f.  Ohrenheilk.,'  Bd.  v,  1870,  p.  188.  The  otitis  is  so  rave,  and 
so  remarkable  in  its  bilateral  character,  that  it  may  possibly  be  a  coincident  efftct 
of  the  blood-state. 

vol.  ii.  23 


354  CEEEBEAL    MEMBRANES. 

cular  meningitis, — hysteria.  This  error  is  by  no  means  rare,  "but 
occurs  only  in  the  cases  in  later  childhood  and  youth,  and  especially 
in  the  female  sex.  Meningitis,  especially  tubercular,  is  far  more  fre- 
quently mistaken  for  hysteria  than  hysteria  for  meningitis.  The 
former  error  is  very  common;  it  is  usually  due  to  the  fact  than  when 
there  exists  the  state  of  nervous  system  that  underlies  hysteria, 
pronounced  hysterical  symptoms  are  often  developed  during  the  early 
stage  of  tubercular  meningitis.  The  case  is  diagnosed  as  one  of 
hysteria,  and  -when  other  symptoms  develop,  they  are  disregarded 
under  the  influence  of  the  preconceived  idea.  Even  when  no  hys- 
terical symptoms  attend  the  attack,  if  such  have  occurred  in  the 
previous  history  of  the  individual  (as  is  often  the  case  in  tubercular 
girls),  the  assumption  that  the  cerebral  symptoms  are  due  to  hysteria 
•is  often  made  when  there  is  not  the  slightest  justification  for  it. 
Indeed,  in  not  a  few  instances  the  fact  that  a  girl  is  the  subject  of 
vague  general  cerebral  symptoms  is  allowed  to  determine  the  dia- 
gnosis. The  only  way  in  which  error  can  be  avoided  is  to  search  and 
watch  for  symptoms  of  organic  origin,  and  allow  these  the  same  weight 
as  in  a  case  in  which  there  are  no  hysterical  symptoms,  or  as  in  a 
patient  in  whom  hysteria  would  not  be  expected.  Pyrexia  is  of 
especial  diagnostic  value  in  these  cases,  and  so  also  are  convulsions 
beginning  locally,  and  the  ophthalmic  symptoms.  Strabismus  in 
hysteria  is  always  convergent  and  attended  by  spasmodic  contraction 
of  the  pupils.  Divergent  strabismus,  or  inequality  of  pupil,  or  nys- 
tagmus, is  certain  evidence  of  organic  disease,  and  as  much  so  if  it  is 
transitnt  as  if  it  is  permanent.  Retention  of  urine  may  be  due  to 
hysteria,  but  incontinence  never  is.  The  significance  of  a  tendency 
for  the  skin  to  blister  has  been  mentioned  ;  signs  of  trophic  lesions  of 
the  skin  should  be  carefully  looked  for  in  every  doubtful  case.* 

An  illustration  of  the  difficulty  that  sometimes  attends  the  dia- 
gnosis, and  of  the  significance  of  pyrexia,  was  afforded  by  the  case  of  a 
servant,  aged  twenty-two,  who  had  had  a  child  three  years  previously, 
and  had  suffered  from  some  headache  for  six  weeks.  On  account  of 
slight  indisposition,  her  mistress  suspected  another  pregnancy,  and, 
without  telling  the  girl,  sent  for  a  medical  man  to  see  her.  The  girl 
was  intensely  annoyed,  and  refused  to  answer  any  questions.  She 
went  up  to  her  room  and  fell,  bruising  her  face.  All  the  rest  of  the 
day  she  was  dull  and  lethargic,  occasionally,  however,  throwing  her 
arms  about,  screaming,  and  complaining  of  pain  in  her  head.  The 
symptoms  were  ascribed  to  hysteria,  but  as  she  was  no  better  next 
day  she  was  brought  to  University  College  Hospital,  and  admitted. 
Her  temperature  was  found  to  be  101°,  and  the  bladder  full,  so  that 
the  catheter  was  used.  For  some  days  she  continued  dull  in  aspect 
and  manner,  sometimes  answering  when  spoken  to,  sometimes  not 

*  It  should  b<>  remembered  that  these  trophic  disturbances  are  often  not  men- 
tioned, or  are  even  denied,  by  nurses,  who  fear  that  the  sores  may  be  ascribed  to 
carelessness. 


MENINGITIS.  355 

She  complained  of  pain  in  the  head  and  abdomen.  One  day  she  was 
childish,  playing  with  a  doll.  The  temperature,  however,  continued 
raised,  varying  from  102°  to  99°.  On  the  seventh  day  she  became 
semi-comatose,  and  passed  urine  into  the  bed.  On  the  ninth  day  she 
rather  suddenly  became  dusky,  with  irregular  breathing,  and  mucus 
in  the  chest.  Death  from  respiratory  failure  being  manifestly  immi- 
nent, artificial  respiration  was  employed,  and  by  this,  faradism  to  the 
chest  wall  from  time  to  time,  and  food  through  a  long  catheter,  she 
was  kept  alive  for  twenty-four  hours,  and  died  on  the  eighth  day 
from  the  onset.  Throughout  there  had  been  no  symptoms  in  the 
limbs  or  cranial  nerves.  The  post-mortem  examination  revealed 
general  tuberculosis  of  lungs,  peritoneum,  and  intestine,  some  small 
masses  of  yellow  tubercle  in  the  cerebral  hemispheres,  and  menin- 
gitis of  the  base,  the  lymph  being  especially  abundant  about  the 
pons  and  medulla,  with  opaque  tubercular  granulations. 

The  converse  error,  in  which  hysterical  symptoms  are  regarded  as 
meningitis,  is  far  less  common.  The  mistake  is  sometimes  made  in 
cases  of  hysterical  sopor  with  the  strong  convergent  strabismus,  but 
the  distinct  spasmodic  character  of  the  latter  is  usually  distinctive, 
and  there  is,  as  a  rule,  no  alteration  of  temperature.  The  last  point 
is  also  of  diagnostic  importance  in  the  curious  state  of  trance-like 
sleep  that  sometimes  comes  on  in  states  of  brain-exhaustion,  usually 
in  hysterical  subjects,  but  in  lads  as  well  as  girls.  When  this 
succeeds  severe  headache,  as  it  often  does,  the  difficulty  of  diagnosis 
may  be  great.  But  it  should  be  remembered  that  it  is  rare  for  coma 
to  come  on  early  in  the  course  of  meningitis.  Tetanus  may  be 
thought  to  exist  in  the  cases  of  meningitis  in  which  contracture 
involves  the  muscles  of  mastication,  but  the  symptom  soon  passes 
off. 

Prognosis. — In  every  form  of  meningitis  the  prognosis  is  grave ; 
it  is  least  serious  in  the  traumatic  form,  and  in  simple  meningitis 
from  adjacent  disease  it  is  most  grave  in  the  purulent  form,  recovery 
from  which  is  practically  unknown.  Nevertheless  I  have  twice 
known  recovery  from  distinct  symptoms  of  meningitis  in  post-puer- 
peral septicaemia.  In  any  form,  if  the  stage  of  coma  has  been 
reached,  death  is  all  but  certain.*  But  the  patient  has  some  small 
chance  of  recovery  in  simple  meningitis,  and  perhaps  (although  still 
slighter)  in  tubercular  meningitis  ;  and,  moreover,  the  very  important 
fact  must  be  borne  in  mind  that  the  diagnosis  between  the  two,  and 
between  these  and  meningitis  secondary  to  obscure  adjacent  disease, 
is  a  matter  of  probability  only,  however  high  the  probability  may  be. 

*  A  case  of  recovery  from  an  illness  resembling  tubercular  meningitis,  in  which 
the  stage  of  coma  was  reached,  and  the  child  seemed  for  days  to  be  on  the  point  of 
death,  is  recorded  by  West  (c  Diseases  of  Infancy  and  Childhood,'  7th  ed.,  p.  96). 
It  is  said,  however,  that  the  child  became  blind  and  afterwards  recovered  her  sight, 
a  feature  which  does  not  suggest  tubercular  meningitis. 


353  CEREBRAL    MEMBRANES.  , 

Hence  it  is  not  right,  in  any  case,  to  assert  the  certainty  of  a  fatal 
issue  * 

In  all  cases  the  most  material  prognostic  indication  is  afforded  by 
the  course  of  the  disease.  The  less  acute  the  attack,  the  more  chance 
of  recovery  the  patient  has.  If,  at  the  end  of  the  third  week  from  the 
onset,  the  patient  has  not  passed  into  a  state  of  coma,  there  is  an 
appreciable  diminution  in  the  probability  of  death.  The  chance  that 
death  may  be  escaped  is  least  of  all  when  the  coma  comes  on  before 
the  first  week  is  over. 

Treatment. — If  the  meningitis  is  due  to  adjacent  disease,  the  treat- 
ment of  this  is  of  the  first  importance.  If  none  is  obtrusive,  the  ears 
should  be  carefully  examined,  since,  as  the  case  just  mentioned  shows, 
suppuration  in  the  middle  ear  may  excite  meningitis  even  though  no 
discharge  has  previously  been  noticed.  A  free  exit  should  always  be 
made  for  any  collection  of  pus  in  the  neighbourhood  of  the  skull,  and 
if  there  are  any  indications  of  the  presence  of  pus  in  the  tympanic 
cavity,  the  membrane  should  be  incised.  If  no  such  cause  can  be 
discovered,  the  treatment  must  be  directed  to  the  diminution  of  the 
local  inflammation  and  the  counteraction  of  the  general  state  on 
which  it  depends.  Neither  the  seat  nor  the  form  of  inflammation  has 
much  influence  on  the  treatment.  This  has  to  be  conducted  in  each 
case  on  the  same  general  principles,  variations  being  determined  by 
individual  differences  much  more  than  by  pathological  nature. 

In  no  disease  is  perfect  tranquillity  of  greater  importance.  The 
patient  should  be  disturbed  as  little  as  possible,  kept  free  from  all 
excitement  and  all  mental  exertion  ;  the  room  should  be  darkened  if 
there  be  any  intolerance  of  light,  and  in  all  cases  it  should  be  kept  as 
quiet  as  possible.  But  mental  depression  should  be  avoided  only 
less  carefully  than  mental  excitement.  Sleep  should  be  encouraged, 
and  the  patient  roused  only  for  the  purpose  of  feeding.  Light  nutri- 
tious food  should  be  given  every  three  or  four  hours,  and  if  the 
patient  cannot  be  made  to  swallow,  nutrient  enemata  should  be 
administered.  Stimulants  are  best  withheld  unless  the  state  of  the 
pulse  urgently  calls  for  them.  The  head  should  be  high,  but  the 
shoulders  also  raised  to  avoid  flexion  of  the  neck  and  mechanical 
hindrance  to  the  return  of  blood  from  the  head. 

*  As  an  illustration  of  this  I  may  mention  tLe  case  of  a  boy,  five  and  a  half  years 
old,  with,  tubercular  family  histi  ry,  who,  after  five  days  of  vague  general  indisposi- 
tion, became  feverish,  with  severe  headache  and  double  vision.  He  soon  became  so 
weak  as  to  be  unable  to  walk.  I  saw  him  after  the  cerebral  symptoms  had  lasted 
fur  five  clays.  The  child  appeared  very  ill ;  the  temperature  was  101°;  the  tongue 
was  covered  with  a  thick  white  fur,  both  sixth  nerves  were  paralysed,  and  there  was 
weakness  of  the  left  side  of  the  face.  There  was  no  histoi'y  of  injury  or  discharge 
from  the  ear.  The  case  was  certainly  one  of  meningitis,  and  it  seemed  highly 
probable  that  it  was  tubercular.  Two  da\s  later,  however,  there  was  a  sudden  and 
copious  discharge  of  pus  from  one  car,  the  cerebral  symptoms  rapidly  disappeared, 
aud  the  boy  recovered  perfectly. 


MENINGITIS.  357 

Abstraction  of  blood,  while  undoubtedly  in  many  cases  a  powerful 
agent  in  lessening  local  inflammation,  is  rarely  desii'able  in  meningitis. 
Exceptions  to  this  rule  are  acute  forms  following  injury,  exposure 
to  the  sun,  or  excessive  mental  excitement,  and  inflimmation  for  which 
no  probable  cause  can  be  traced.  In  these,  if  the  patient  be  strong  and 
full-blooded,  leeches  may  be  applied  bebind  the  ears  or  to  the  temples 
in  the  early  stage  of  the  disease.  During  the  late  period  abstraction 
of  blood  can  do  only  harm.  In  strong  children  leeching  has  also 
been  recommended,  but  the  cases  are  few  in  which  this  is  desirable. 
Most  cases  occur  in  weakly  anaemic  individuals  in  whom  loss  of  blood 
reduces  the  strength  of  the  inflammation  less  than  it  does  the  strength 
of  the  patient.  Attempts  may  be  made  to  keep  the  blood-awav  from 
the  head  by  warmth  and  mustard  to  the  extremities,  and  by  cold  to 
the  head.  The  hair  should  be  cut  short,  or  the  head  shaved.  The 
application  of  cold  should  be  continuous,  either  by  an  ice-bag  (half 
filled,  and  containing  no  air,  so  that  it  may  adjust  itself  to  the 
head),  or  by  a  cap  made  of  metal  tubing,  wound  in  a  spiral,  through 
which  water  may  flow  from  a  vessel  above  the  level  of  the  head  to  one 
on  the  floor.*  This  is  a  very  convenient  mode  of  applying  cold,  as 
effective  as  ice,  and  available  when  ice  cannot  be  obtained. 

Counter-irritation  to  the  occiput  is  also  sometimes  distinctly  useful. 
Mustai-d  may  be  employed,  but  a  blister  is  more  effective.  There  is  a 
natural  reluctance  to  add  the  pain  of  a  blister  to  the  sufferings  of  the 
patient,  but  a  blister  certainly  often  lessens  the  intensity  of  the 
symptoms,  and  it  is  probable  that  the  total  amount  of  pain  endured 
is  at  least  not  increased  thereby.  Counter-irritation  over  the  whole 
scalp,  by  blister  or  irritating  ointment,  has  sometimes  been  recom- 
mended, but  it  interferes  with  the  application  of  cold,  and  it  is 
doubtful  whether  its  influence  counterbalances  this  disadvantage. 

Vomiting  is  best  allayed  by  ice  to  the  head  and  given  by  the  mouth  ; 
and  by  two  mustard  plasters  applied,  one  to  the  back  of  the  neck,  and 
the  other  to  the  epigastrium,  or  by  the  administration  of  cocaine  to 
lessen  the  peripheral  impulses  from  the  mucous  membrane,  which  act 
on  the  centre.  The  bowels  should  be  opened  with  a  freedom  which 
must  depend  on  the  strength  of  the  patieut.  Constipation  is  often 
difficulty  to  overcome,  but  is  injurious,  while  purgation  is  one  of  the 
most  effective  derivatives.  Headache  is  often  lessened  by  ice,  and 
sometimes  by  antipyrin ;  opium  should  be  avoided. 

Internal  remedies  must  vary  with  the  state  of  the  patient.  In  all 
cases  with  elevation  of  temperature  a  diuretic  is  safe  and  often  useful. 
Digitalis  in  small  doses  may  be  given  if  the  pulse  is  irregular  or  unduly 
frequent  in  the  early  stage.  When  the  patient  was  previously  anaemic 
and  the  temperature  is  not  very  high,  iron  may  be  given  in  some  non- 
irritating  form,  such  as  dialysed  iron,  or  the  citrate  of  iron  aud 
quinine,  but  the  bowels  must  be  carefully  kept  open. 

Yarious  drugs  have  been  given  with  a  view  of  influencing  directly 
*  Such  caps  can  be  obtained  from  Krohnc  and  Seseinann. 


358  UEREBEAL    MEMBKANES. 

tlie  process  of  inflammation,  and  each  has  been  in  turn  extolled,  but 
tbe  only  one  wbich  lias  obtained  wide  recognition  as  distinctly  useful 
is  mercury.  With  this  opinion,  my  own  experience  fully  agrees.  It 
is  naturally  more  often  effective  in  simple  than  in  tubercular  inflam- 
mation, but  it  was  used  in  each  of  the  cases  apparently  of  the  latter 
form  in  which  I  have  seen  recovery  take  place.  The  patient  should 
be  brought  slightly  but  distinctly  under  its  influence,  so  as  just  to 
"  touch  the  gums,"  as  the  phrase  is,  as  quickly  as  may  be,  because 
only  thus  have  we  evidence  that  it  is  not  excreted  as  fast  as  it  enters 
the  blood,  and  that  it  actually  acts  upon  the  tissues.  Inunction  is  by 
far  the  best  method  of  effecting  this.  A  little  mercurial  ointment 
or  oleate  of  mercury  should  be  rubbed  into  the  armpits  and  groins 
every  four  hours,  or  on  the  back  of  the  neck  or  the  scalp,  until 
the  effect  is  produced.  Iodide  of  potassium  is  another  remedy  that 
has  been  much  used,  but  the  evidence  of  its  value  is  slighter  than  is 
that  of  mercury.  It  may  be  given,  however,  combined  with  a  tonic, 
after  mercury  has  been  discontinued. 

When  the  temperature  is  very  high,  cold  baths  have  been  employed 
with  some  apparent  temporary  advantage,  but  the  almost  invariably 
fatal  issue  has  not  been  retarded  by  the  reduction  of  temperature. 
The  same  may  be  said  of  saliciu,  quinine,  and  antipyrin  given  for  the 
s:ime  purpose. 

In  cases  of  septicaemia  meningitis,  what  slender  chance  of  benefit 
there  may  be  is  most  likely  to  be  obtained  by  the  free  administration 
of  perchloride  of  iron,  a  drug  which,  more  than  any  other,  has  seemed 
to  me  to  have  the  power  of  saving  life  in  septicaemia.  This  treat- 
ment was  adopted  in  each  of  the  cases  of  apparently  septicsemic 
meningitis  which  recovered.  In  one  such  case  there  was  severe 
headache  and  delirium,  rigidity  of  the  limbs  on  one  side,  and  a  tempe- 
rature of  105"o°. 

The  treatment  of  acute  ventricular  meningitis  does  not  differ  from 
that  of  estra- cerebral  meningitis— a  fortunate  circumstance,  since  the 
recognition  of  its  situation  is  scarcely  practicable  during  life. 


EPIDEMIC    CEREBRO-SPINAL   MENINGITIS. 

(CEREBRO- SPINAL   FEVER.) 

Acute  meningitis  sometimes  occurs  in  epidemic  form,  many  patients 
being  attacked  in  a  certain  district  in  the  course  of  a  few  months. 
The  spinal  membranes  are  affected  as  well  as  those  within  the  skull, 
and  hence  the  name  by  which  the  disease  is  known  ;  but,  as  we  have 
seen,  other  forms  of  inflammation  may  not  be  limited  to  the  cerebral 


EPIDEMIC    MENINGITIS.  359 

membranes.  There  is  usually  considerable  fever,  and  often  an  erup- 
tion appears  on  the  skin.  Sporadic  cases  occur,  closely  resembling 
those  of  the  epidemic  form,  and  probably  identical  iu  nature. 

The  disease  has  been  met  with  during  the  present  century  in  various 
parts  of  Europe  and  in  the  United  States.  In  certain  countries,  as 
Sweden  and  Germany,*  it  has  been  especially  prevalent.  In  Sweden 
alone  4000  persons  are  said  to  have  died  from  the  disease  between 
1854  and  1860.  A  very  severe  epidemic  occurred  in  France  in  1837. 
In  Great  Britain  the  chief  epidemics  have  occurred  in  Ireland, 
especially  in  1846  and  1868 ;  in  -England  only  slight  outbreaks  have 
been  recorded,  while  in  Scotland  one  small  group  of  cases  has  been 
met  with.f  It  has  been  doubted  whether  the  isolated  cases  of  acute 
severe  and  primary  meningitis  ought  to  be  classed  with  the  epidemic 
form,  but  they  are  not  separable  by  any  clinical  or  pathological 
features,  and  they  have  a  distinct  tendency  to  be  multiple,  which  seems 
to  associate  them  clearly  with  the  epidemic  form.  Thus  in  the  spring 
of  1887  four  cases  were  admitted  to  University  College  Hospital,  and 
two  others  came  under  my  notice  in  other  parts  of  London.  Three  of 
the  cases  occurred  in  the  same  street ;  and  two  others,  though  quite 
separate,  developed  within  a  quarter  of  a  mile  of  each  other.  In 
Hamburg,  where  the  disease  has  prevailed  for  ten  years,  most  of  the 
cases  came  from  a  few  streets ;  and  in  an  epidemic  in  Copenhagen 
most  of  the  cases  (185  in  number)  came  from  two  centres,  distant 
and  unconnected.  But  cases  that  are  quite  solitary,  although  typical, 
are  not  rave. 

Causes. — No  age  is  exempt,  but  young  persons  under  twenty  suffer 
much  more  frequently  than  others,  and  in  some  epidemics  children 
have  been  almost  exclusively  affected.  Males  are  said  to  be  attacked 
more  frequently  than  females.  J  As  it  is  a  disease  chiefly  of  temperate 
and  cold  countries,  so  it  has  prevailed  chiefly  in  winter  and  spring, 
ceasing  about  July  until  the  winter.  No  relation  has  been  traced,  as 
a  rule,  to  local  endemic  influences,  although  some  observers  who  have 
watched  epidemics  have  thought  that  the  incidence  of  the  disease 
suggested  some  malarial  or  miasmatic  influence,  or  that  a  relation  could 
be  traced  to  the  amount  of  watery  vapour  in  the  air.  But  it  has 
broken  out  simultaneously  in  places  far  apart,  and  has  even  been 
prevalent  at  the  same  time  in  Europe  and  America.  It  has  occasion- 
ally preceded  measles,  subsiding  temporarily,  or  continuing  during 
the  exanthem.  Personal  ill-health  seems  to  have  but  little  pre- 
disposing   influence,   but   insanitary   conditions     and    overcrowding 

*  It  is  curious  that  in  1862  Hirsch  wrote,  "As  far  as  I  know,  Germany  has  been 
entirely  spared,  with  one  small  exception  ;"  and  that,  according  to  Ziemsseu,  since 
the  first  distinct  outbreak  in  18G3  hardly  six  months  have  passed  without  an  epidemic 
iu  some  part  of  Germany. 

t  Frew,  '  Glasgow  Med.  Journal,'  1S84. 

X  Of  255  fatal  cases  iu  Stockholm,  149  were  boys,  106  girls. 


b'60  UEllliBBAL    MEMBRANES. 

apparently  favour  its  occurrence,  although  it  often  occurs  -when  there 
is  no  suspicion  of  this,  aud  even  in  an  epidemic  the  malady  may  not  be 
worst  where  sanitation  is  worst.  The  relation  to  season  has  been 
explained  by  the  overci-owdiug  in  the  houses  of  the  poor  during  cold 
weather.*  In  one  epidemic  in  France  the  only  persons  attached  were 
soldiers  crowded  together  in  barracks ;  another  in  Ireland  fell 
exclusively  on  the  inmates  of  workhouses.  Nevertheless,  contagion 
seems  to  play  a  very  small  part  in  the  production  of  the  malady. f 
The  attendants  on  the  sick  scarcely  ever  suffer.  In  an  epidemic  of 
ihirty  cases  recently  in  Cologne  no  two  cases  came  from  the  same 
house. X  Nevertheless,  instances  have  been  observed  in  which  an 
influence  exciting  the  disease  seemed  to  be  conveyed  by  a  third  person. 
A  series  of  such  facts  has  been  collected  by  Hirsch,  and  Frew  believed 
that  he  traced  such  a  connection  between  the  cases  in  the  small  Scotch 
outbreak.  Although  even  very  young  children  are  prone  to  suffer,  a 
woman  who  had  a  mild  attack,  in  the  course  of  an  epidemic,  suckled 
her  child  throughout  her  three  weeks'  illness,  and  the  child  remained 
perfectly  well.§  It  is  said  that,  in  Ireland,  each  epidemic  coincided 
with  an  outbreak  of  a  similar  malady  in  pigs  and  dogs.||  One  attack 
does  not  seem  to  confer  immunity.  A  woman  died  from  the  disease 
during  one  epidemic  who  had  passed  through  a  similar  attack  five 
-vears  before.^"  The  period  of  incubation  (when  conditions  for  exact 
observation  have  been  secured)  has  not  exceeded  five  days. 

Symptoms.— The  manifestations  of  the  disease  are  in  part  those  of 
the  local  inflammation  from  which  it  takes  its  name,  in  part  they  are 
those  of  a  blood  disease.  In  cases  of  moderate  severity,  malaise  and 
discomfort  in  the  head  may  precede  the  onset  for  a  few  hours  or  for  two 
or  three  days,  seldom  for  a  longer  time — one  or  two  weeks.**  Some- 
times there  is  vomiting,  or  slight  stiffness  at  the  back  of  the  neck,  for 
a  dav  or  two  before  the  acute  symptoms  come  on.  In  other  cases  the 
ouset  is  almost  sudden.  Vomiting  and  headache  are  usually  the  first 
pronounced  symptoms ;  their  commencement  may  be  attended  by  a 
rigor  :  sometimes  there  is  also  pain  iu  the  back.  The  headache  varies 
in  its  initial  seat,  but  it  often  soon  becomes  general,  and  is  always 

*  Medin,  cNord.  Med.  Ark.,'  1880,  and  'Deut.  med.  Wochenschr.,'  1881,  Nos. 
41,  42. 

f  Common  exposure  to  causal  influence  may  readily  be  mistaken  for  contagion, 
and  many  alleged  instances  are  not  free  from  this  source  of  fallacy.  Cf.  Oebeke, 
«  Berlin  kl.  Wocb.enscb.rift/  1891. 

J  Leiclitenstern,  '  Deut.  med.  Woclienschr.,'  1885,  No.  31. 

§   Rzadowski,  '  Virchow's  Jahresb./  1879,  ii,  5. 

||  Fagge,  '  Principles  and  1'ract.  of  Med.,'  on  the  authority  of  Ferguson,  Vet. 
Off.  to  the  Privy  Council  of  Ireland.  Epidemic  cerebro-spinal  meningitis  has 
also  occurred  in  horses;  an  outbreak  of  37  .cases  was  observed  by  Ackermann 
('  Virchow's  Jahresb./  1880,  i,  701). 

%  '  Virchow's  Jahresb.,"  1879,  ii,  5. 

**  Sabarth,  'Breslnuer  Ar/.t.  Zeitsch.,'  1879,  No.  18. 


EPIDEMIC    MENINGITIS.  361  ■ 

severe ;  it  is  constant,  but  tlieve  are  from  time  to  time  intense  exacer- 
bations. Often  the  headache  is  accompanied  by  giddiness,  and,  as  in 
other  forms  of  meningitis,  by  intolerance  of  light  and  sound.  Deli- 
rium in  many  cases  is  quickly  added  to  the  headache ;  it  may  be  quiet 
or  violent,  but  it  soon  gives  place  to  somnolence  and.  stupor,  from 
which  the  paroxysms  of  violent  pain  may  at  times  rouse  the  patient. 
Severe  pain  in  the  back  is  generally  soon  added  to  the  pain  in  the 
head ;  it  is  felt  chiefly  in  the  neck  and  loins,  and  often  referred  to  the 
neighbourhood  of  the  spine  rather  than  to  the  vertebral  column  itself. 
Sometimes  it  is  severe  in  the  sacrum.  It  is  increased  by  movement, 
and  may  radiate  around  the  trunk  or  into  the  limbs  ;  it  is  sometimes 
severe  in  the  knee-joints.  Whether  there  is  pain  in  the  back  or  not, 
rigidity  in  the  muscles  of  the  neck  is  almost  invariable,  and  in  those 
of  the  back  is  frequent.  This  gives  rise  to  the  characteristic  retrac- 
tion of  the  head,  usually  moderate  in  degree,  sometimes  so  great  as  to 
cause  the  neck  to  be  at  right  angles  to  the  rest  of  the  spinal  column. 
Often  the  contraction  seems  to  be  chiefly  in  the  deeper  muscles. 
Any  attempt  to  flex  the  neck  gives  rise  to  pain.  The  retraction 
of  the  head  is  usually  an  early  symptom,  although  it  is  not  often 
present  at  the  actual  onset :  sometimes  it  is  delayed  until  the  later 
stage  of  the  disease.  The  rigidity  of  the  rest  of  the  spinal  muscles  is 
generally  merely  enough  to  prevent  bending  of  the  trunk,  but  it  is 
occasionally  so  great  cs  to  cause  opisthotonos.  The  limbs  also  are 
sometimes  rigid  ;  the  legs  are  often  drawn  up,  and  the  abdomen  is 
retracted.  .Barely  there  has  been  slight  trismus.  General  hyper- 
esthesia of  the  skin  is  a  frequent  symptom  and  of  some  diagnostic 
importance.  Convulsions  occasionally  occur  at  the  onset  of  the 
malady  or  during  its  course ;  they  are  usually  general,  sometimes  uni- 
lateral or  local. 

The  face  is  often  pale,  and  has  a  shrunken  aspect.  The  pulse 
varies  much  in  frequency ;  in  some  cases  it  is  not  much  above  the 
normal,  while  in  others  it  rises  to  120,  140,  or  more.  It  is  not  often 
infrequent.  The  temperature  is  almost  always  raised,  and  it  is  gene- 
rally considerably  raised,  often  reaching  104°,  105°,  or  106°,  the 
greatest  amount  of  pyrexia  being  noted  towards  the  termination  of 
the  disease.  Both  the  temperature  and  pulse-frequeucy  present  irre- 
gular variations,  sometimes  together,  more  often  without  any  corre- 
spondence. The  bowels  are  generally  confined ;  the  spleen  is  rarely 
enlarged.  The  amount  of  urine  has  been  sometimes  increased,  and 
albumen  is  occasionally  present ;  su^ar  rarely. 

Eruptions  on  the  skin  are  an  important  feature  of  the  disease;  they 
occur  both  in  epidemics  and  in  sporadic  cases,  but  are  more  fre- 
quent in  the  former,  although  they  vary  much  in  different  outbreaks. 
Various  forms  have  been  met  with — erythema,  herpes,  urticaria, 
purpura ;  but  the  most  significant  are  herpes  and  the  purpuric  spots. 
The  latter  are  met  with  in  a  large  proportion  of  the  more  severe 
cases,  and  are  occasionally  present  in  attacks  of  moderate  severity. 


362  CEREBRAL    MEMBRANES. 

They  vary  in  seat,  and  are  sometimes  chiefly  on  the  lower  legs  or 
forearms  ;  in  the  most  intense  cases  they  may  coalesce  so  as  to  give 
rise  to  dark  diffuse  extravasation  into  the  skin  over  a  considerable 
area.  Herpes  is  very  variable,  but  is  common  in  some  epidemics  ;  in 
one  outbreak  of  29  cases  herpes  was  present  in  26  (Leichtenstern). 
In  another,  of  32  cases,  only  6  developed  herpes  (v.  Sydow).  It 
usually  begins  on  the  lips,  and  may  spread  to  other  parts  of  the  face, 
but  has  been  seen  on  the  ears  and  sometimes  on  the  limbs.  These 
eruptions  frequently  present  bilateral  symmetry,  and  the  several  forms 
are  sometimes  conjoined.  They  usually  appear  after  the  disease  has 
lasted  three  or  four  days.  Occasionally  there  is  intense  conjunctivitis, 
and  even  ulceration  of  the  cornea. 

Paralysis  of  cranial  nerves,  strabismus,  inequality  of  pupil,  &c, 
may  be  met  with  in  this  as  in  other  forms  of  meningitis.  The  pupils 
are  dilated,  sometimes  after  initial  contraction,  and  may  be  unequal. 
Deviation  of  the  eyes  to  one  side  has  been  occasionally  observed. 
Optic  neuritis  is  common  in  cases  that  last  for  more  than  four  or  five 
days,  and  may  cause  permanent  loss  of  sight  if  the  patient  recovers. 
In  the  Copenhagen  outbreak  it  was  found  in  one  quarter  of  the  cases. 
Palsy  of  the  limbs  is  not  common ;  when  complete  hemiplegia  occurs 
early  it  is  often  due  to  irritative  inhibition,  but  sometimes  at  a  later 
period  it  is  due  to  a  focus  of  more  intense  inflammation  over  the 
motor  region.*  Occasionally  there  is  paralysis  of  part  of  one  side 
from  this  cause.  In  rare  instances  the  symptoms  of  the  spinal 
meningitis  predominate  over  those  of  the  intra-cranial  inflammation, 
and  complete  paraplegia  may  result.f  Myotatic  irritability  is  usually 
lost  in  the  legs  in  such  cases,  and  sometimes  towards  the  close  in 
others,  in  which  spinal  symptoms  are  not  specially  marked. J 

Among  the  occasional  effects  of  the  disease,  deafness  is  of  especial 
importance.  It  seems  commonly  to  depend,  not  on  damage  to  the 
auditory  nerve  at  the  base  of  the  brain§  or  to  the  medulla,  but  either 
on  extension  of  inflammation  from  the  membranes  to  the  labyrinth 
and  middle  ear,  or  on  a  simultaneous  inflammation  of  the  iuternal 
ear.  The  inflammation  of  the  middle  ear  is  shown,  not  only  by  the 
interference  with  conduction,  but  also  by  injection  of  the  membrana 
tympani,  and  sometimes  by  the  discharge  of  pus  through  it ;  it  may 
succeed  that  of  the  labyrinth,  or  may  be  simultaneous  and  apparently 
due  to  the  same  cause., 

The  delirium  that  attends  the  early  stage  of  the  disease  soon  gives 
place  to  a  condition  of  stupor,  deepening  to  coma.  The  period  at 
which  this  comes  on  varies  according  to  the  severity  of  the  case  ;  the 
delirium  may  last  a  few  hours  only,  and  the  patient  may  become 

*  An  instance  is  recorded  by  Charlcwood  Turner,  '  Path.  Trans.,'  1884. 

f  Sti-uiupcll,  '  Deut.  Arch.  f.  Id.  Med.,'  Bd.  xxx. 

+  CarrinKon, '  Path.  Trans.,'  1884,  xxxv,  pp.  54,  55;  Leichtenstern,  loc.  cit. 

S  See  note  on  p.  353.  Infiltration  of  the  sheath  of  the  auditory  nerve  with  pus 
has  been  found  when  no  deafness  was  noted,  and  there  has  generally  been  evidence 
of  suppuration  in  the  labyrinth  when  there  has  been  absolute  deafness. 


EPIDEMIC    MENINGITIS.  o63 

comatose  before  the  end  of  the  first  day,  or  the  coma  may  only  come 
on  at  the  end  of  a  week.  In  cases  that  terminate  fatally  the  coma  is 
attended  by  signs  of  failure  of  the  heart,  and  by  sighing  or  irregular 
breathing,  and  the  temperature  may  fall,  or  may  rise  to  an  extreme 
degree. 

The  severity  of  the  spinal  symptoms,  sometimes  great,  is  more  often 
moderate,  and  even  transient  or  recurrent.  Barely  the  inflammation 
becomes  severe  at  one  spot,  as  in  a  case  in  which  rigidity  became 
extreme  in  the  muscles  of  one  shoulder,  which  afterwards  wasted 
(Broadbent).  Occasionally,  in  subacute  cases,  the  spinal  and  cerebral 
symptoms  seem  to  alternate. 

The  variations  in  the  severity  of  the  disease  are  accompanied  by 
corresponding  variations  in  duration.  In  the  most  acute  cases  the 
patient  quickly  becomes  comatose,  and  dies  at  the  end  of  one  or  two 
days,  sometimes  even  in  five  or  six  hours  from  the  onset.  Tbe  acute 
form  has  been  termed  "fulminant."  On  the  other  hand,  slight  cases 
sometimes  occur,  in  which  the  illness  is  trifling,  and  the  symptoms 
consist  in  headache,  pain  in  the  back,  and  slight  rigidity  of  the  neck 
muscles — a  form  that  has  been  termed,  somewhat  inaptly,  "  abortive." 
A  remarkable  epidemic  occurred  at  a  village  in  Lincolnshire  a  few 
years  ago,  in  which  all  the  cases  were  of  this  form.  As  in  the  case  of 
other  epidemic  diseases,  the  severe  cases  are  most  frequent  at  the 
commencement,  and  the  slight  cases  during  the  decline  of  the 
epidemic.  The  most  acute  cases  are  often  attended  by  extensive 
cutaneous  extravasation,  and  death  seems  to  be  due  rather  to  the 
blood-change  than  to  the  meningeal  inflammation.  In  the  less  severe 
form  death  generally  results  from  asthenia,  increased  often  by  bed- 
sores. In  cases  that  recover,  the  patient  begins  to  mend  some  time 
during  the  second  week.  The  mortality  has  varied,  in  different  epi- 
demics, from  20  to  80  per  cent.  Of  185  cases  in  an  outbreak  in 
Copenhagen  about  one  half  (49  per  cent.)  died.  In  sporadic  cases  it 
is  also  very  high. 

Besides  the  varieties  that  depend  on  severity,  other  forms  have 
been  occasionally,  met  with.  The  fever  has  been  observed  to  dis- 
tinctly intermit,  somewhat  after  tbe  type  of  a  quotidian  or  tertian 
ague,  but  with  much  less  regular  variations  in  the  temperature  than 
are  presented  by  true  intermittent  fever.  Other  cases,  in  which  the 
fever  and  a  low  asthenic  state  continue  for  a  considerable  time,  have 
been  described  as  a  "  typhoid  "  form. 

Among  other  rare  complications  may  be  mentioned  tonsillitis, 
multiple  arthritis  (sometimes  suppurative),*  endocarditis,  and  peri- 
carditis. Abundant  albuminuria  has  been  associated  with  collections 
of  the  specific  organisms  in  the  glomeruli  of  the  kidney.  Combina- 
tions of  cerebro- spinal  meningitis  with  other  maladies,  such  as  scarlet 
fever,  have  also  been  described ;  it  is  doubtful  whether  the  combina- 
tion has  been  more  than  a  coincidence. 

*  Meuiii,  loc.  cit. 


364  CEREBRAL    MEMBKANES. 

Tlie  process  of  recovery  is  generally  very  slow,  and  is  occasionally 
interrupted  by  a  distinct  relapse.  In  one  case  of  moderate  severity, 
deatb,  at  the  end  of  three  montbs,  seemed  due  to  a  secondary  cerebral 
abscess.  Headache  persists  for  a  long  time,  and  a  lasting  liability 
to  headache  may  succeed  the  disease.  Of  the  sequelae  of  the  disease, 
the  most  important  is  the  deafness  from  inflammation  of  the  ear.  It 
may  be  complete,  and,  occurring  as  it,  often  does  in  young  children, 
it  may  cause  a  loss  of  any  power  of  speech  that  has  been  acquired, 
and  permanent  deaf-muteness.  In  some  countries  an  epidemic  of 
this  disease  has  added  enormously  to  the  proportion  of  the  popula- 
tion who  were  deaf  and  dumb.  With  the  deafness  there  is  often,  for 
a  time,  a  difficulty  in  maintaining  equilibrium,  due,  no  doubt,  to  the 
damage  to  the  semicircular  canals.  It  gradually  passes  away  as 
compensation  for  the  loss  becomes  established.*  Noises  in  the  ears 
may  also  persist  for  a  long  time.  Another  consequence  occasionally 
observed  is  elrronic  internal  hydrocephalus,  which  may  cause  its 
characteristic  symptoms  some  weeks  or  mouths  after  the  primary 
disease.  It  probably  depends,  in  some  cases  at  least,  on  its  common 
cause,  closure  of  the  openings  of  the  fourth  ventricle,  but  it  may 
sometimes  be  due  to  inflammation  of  the  lining  membrane  of  the 
ventricles  (Merkel).  An  excess  of  fluid  is  sometimes  found  outside 
the  cord.  Mental  change  may  persist  for  a  time,  but  gradually 
passes  away. 

Pathological  Anatomy. — In  the  most  acute  "  fulminant "  cases 
there  may  be  only  that  transudation  of  haamatin  into  the  fluids  of  the 
body  and  the  rapid  decomposition  which  attend  all  intense  toxemic 
states,  together  with  congestion  of  the  membranes  ;  in  these  the 
microscope  may  show  collections  of  lymphoid  cells  along  the  vessels, 
or  red  corpuscles  infiltrating  the  tissue.  In  cases  of  less  rapid  course 
there  is  intense  hyperasmia  of  the  pia  mater  of  the  brain  and  cord, 
with  opacity  and  exudation  of  lymph,  and  in  most  cases  that  have 
lasted  more  than  three  or  four  days  there  is  distinct  formation  of 
pus,  which  may  accumulate  in  the  subarachnoid  space.  It  is  more 
abundant  over  the  posterior  than  over  the  anterior  surface  of  the 
cord.  The  dura  mater  of  the  brain  is  little  affected,  but  there  are 
commonly  some  signs  of  inflammation  on  that  of  the  cord.  The 
■ventricles  of  the  brain  may  contain  turbid  fluid,  sometimes  pus,  and 
their  lining  membrane  may  present  signs  of  inflammation.  Throm- 
bosis in  sinuses  is  rare.  The  substance  of  the  brain  may  be  pale,  or 
may  contain  small  haemorrhages  or  points  of  softening,  or  small 
collections  of  pus.  The  spinal  cord  may  also  be  inflamed  and  soft- 
ened in  places.  The  lesions  in  other  organs  of  the  body  are  such  as 
result  from  other  acute  febrile  blood  diseases.  The  spleen  and  folli- 
cular glands  of  the  intestinal  canal  may  be  found  enlarged,  but  the 
enlargement  of  the  spleen  is  slight  and  has  seldom  been  detected 
*  Moos,  'Meningitis  cerebro-spinalis  epidemiea,  &c.,'  Heiddberg-,  1881. 


EPIDEMIC    MENINGITIS.  365 

during  life.  The  kidneys  are  sometimes  in  a  state  of  acute  parenchy- 
matous inflammation,  as  in  other  acute  general  diseases.  The  lungs 
often  present  signs  of  congestion,  and  endocarditis  has  been  met  with. 

Pathology. — All  the  facts  of  the  disease  point  to  the  existence  of 
a  specific  poison  acting  on  the  blood,  and  through  the  blood  exciting 
the  local  inflammation.  It  is,  however,  to  the  latter  l  hat  the  symptoms 
are  chiefly  due  in  all  save  the  most  intense  cuses.  But  of  the  nature 
of  the  influence  which  causes  the  disease,  and  the  way  it  spreads, 
little  is  known.  It  is  clear  that  children  possess  a  special  liability, 
which  cannot  be  explained,  as  in  so  many  specific  diseases,  by  the 
mere  absence  of  the  protection  afforded  by  a  previous  attack.  The 
very  slight  part  played  by  personal  intercourse  in  the  transmission  of 
the  disease  has  been  already  mentioned.  The  manner  in  which 
disconnected  cases  appear  about  the  same  time  has  suggested  an 
analogy  to  influenza,  but  a  still  closer  analogy  exists  between  this 
disease  and  some  forms  of  pneumonia,  with  which  it  is  not  unfre- 
quently  associated.  The  occurrence  of  herpes  of  the  lips  in  each 
disease  is  a  small  but  noteworthy  point  of  resemblance.  Pneumonia 
has  been  observed  to  be  especially  frequent  at  the  time  of  epidemics 
of  meningitis,  and  often  co-exists  with  this  disease.  In  such  cases, 
either  the  specific  organism  associated  with  pneumonia  (discovered  by 
Fraenkel)  is  always  to  be  found  in  both  the  lungs  and  the  meningeal 
exudation,  or  else  an  organism  of  closely  allied  form,  which  is  also 
present  when  there  is  no  pneumonia.  It  usually  presents  the  aspect, 
fhvt  noted  by  Leyden,  of  a  diplococcus  of  oval  or  lanceolate  outline.* 
It  has  been  cultivated,  but  only  above  86°  P.,  and  best  between  95° 
and  99°.  Inoculated,  they  bill  quickly  by  blood-infection.  These 
organisms  are  met  with  alike  in  the  epidemic  and  the  sporadic  cases, 
but  their  source  is  quite  obscure.  Even  iu  cases  of  very  acute  course 
and  purulent  character,  with  abundant  diplococci,  there  may  be  no 
discoverable  source  of  infection. 

The  organisms  have  been  found  chiefly  in  the  lymph-spaces  of  the 
pia-arachnoid,  penetrating  the  substance  of  the  nerve-centres  only  in 
connection  with  aggregations  on  the  surface.f 

Diagnosis. — The  symptoms  of  meningitis,  the  severe  headache  and 
coincident  delirium,  the  retraction  of  the  head,  the  cutaneous  hyperes- 
thesia, &c,  are  generally  sufficiently  distinct  to  prevent  any  confu- 
sion of  the  disease  with  other  febrile  maladies.  The  pain  in  the  back 
vomiting,  and  headache  may  suggest  smallpox,  but  in  cases  in  which 
the  pain  in  the  back  is   severe,  the  muscular  rigidity  usually  soon 

*  Leyden,  'Cent.  f.  Id.  Med./  1883;  Eberth,  '  Deut.  Arch.  f.  kl.  Med./  xiii,  p.  1 ; 
Nauwerck,  '  Deut.  Arch.  f.  kl.  Med./  xxix,  p.  1;  Senger,  'Arch.  f.  exp.  Path./  xx, 
389;  Cornil  et  Babes,  '  Les  Bacteries/  Paris,  1886,  p.  446.  See  also  Ziemssen, 
'  Hundbuch  der  spec.  Path./  &c./  ii,  Th.  2,  and  Leichtenstcrn,  loc.  cit. 

f  Hoche,  '  Psych.  Vcrcins/  Karlsruhe,  Nov.,  1892. 


366  CEREBHAL    MEMBRANES. 

manifests  itself.  It  is  said  that  in  some  cases  of  typhoid  fever  there 
is  hypersesthesia  of  the  skin  and  some  tenderness  of  the  muscles  of  the 
neck  (Leyden),  but  these  symptoms  quickly  lessen,  whereas  in  menin- 
gitis tbey  increase.  The  herpes  of  the  face  may  help  to  distinguish 
the  disease  from  the  continued  fevers.  In  tetanus  the  opisthotonic 
spasm  is  generally  secondary  to  trismus,  which  is  scarcely  ever  an 
early  symptom  in  meningitis. 

Uraemia  may  cause  muscular  rigidity,  convulsions,  and  coma,  thus 
occasionally  giving  rise  to  symptoms  somewhat  like  those  of  cerebro- 
spinal meningitis  (Murchison),  hut  the  temperature  is  normal,  and 
other  symptoms  of  each  malady  are  usually  recognisable.  It  must 
be  remembered  that  in  children  retraction  of  the  head  may  occur 
from  rheumatic  affectiou  of  the  muscles  and  other  causes.  It  may 
also  be  produced  by  various  morbid  processes  in  the  neighbourhood 
of  the  medulla;  thus  an  aneurism  on  each  vertebral  artery  (due  to 
incomplete  closure  by  embolism),  and  accompanied  by  optic  neuritis, 
has  been  mistaken  for  this  disease. 

The  greatest  difficulty  is  the  distinction  of  this  from  other  forms 
of  meningitis,  and  the  question  whether  sporadic  cases  are  to  be 
regarded  as  examples  of  the  disease.  Iu  other  forms  of  cerebral 
meningitis  spinal  symptoms  are  seldom  conspicuous,  but  it  must  be 
remembered  that,  in  the  epidemic  form,  there  may  not  be  more  than 
retraction  of  the  head.  In  tubercular  meningitis  the  onset  is  more 
insidious,  and  coma  is  a  rather  late  symptom,  while  a  predisposition 
can  usually  be  traced.  The  occurrence  of  the  skin  eruptions,  the 
prevalence  of  the  disease  in  an  epidemic  form,  or  associated  with 
pneumouia,  give  material  help  to  the  diagnosis.  The  identification  of 
isolated  cases  is  a  subject  ou  which  opinions  differ,  but  it  will  probably 
be  settled  by  the  microscope.  My  own  belief  is  that  cases  of  acute 
severe  rapidly  fatal  inflammation  of  the  cerebral  and  spinal  membranes 
are  not  separable  from  the  epidemic  disease,  and  the  opiniou  is  sup- 
ported by  the  frequency  with  which  pneumonia  co-exists.  The  group 
of  cases  referred  to  on  p.  359,  of  which  three  came  from  one  street 
withiu  a  few  weeks,  must  be  regarded  as  belonging  to  the  epidemic 
form,  but  these,  and  the  other  cases  that  occurred  at  the  same  time 
elsewhere  in  Loudon,  differed  in  no  respect  from  the  isolated  cases 
that  are  met  with  every  year.  In  at  least  one  case  of  this  group 
there  was  pneumonia. 

Lastly,  when  the  disease  has  been  epidemic,  some  of  its  symptoms 
have  been  produced  by  the  influence  of  fear,  in  what  has  been  termed 
"  meningitophobia,"  and  the  distinction  of  this  from  the  "abortive 
form"  has  sometimes  been  difficult.  The  absence  of  fever  and  of 
definite  objective  symptoms  usually  suffices. 

Prognosis. — The  disease  is  most  serious,  except  in  the  slightest 
form,  but  even  in  this  a  benign  course  cannot  be  counted  on  with  cer- 
tainty.    Recovery  can  scarcely  be  looked  for  if  coma  comes  on  before 


EPIDEMIC    MENINGITIS.  367 

the  fifth  day.  The  prognosis  in  different  epidemics  must  be  influenced 
by  the  prevailing  character  of  the  disease;  it  is,  as  a  rule,  decidedly 
worse  in  the  isolated  cases  than  it  is  in  epidemics.  It  is  said  to  be 
least  grave  between  ten  and  fifteen  years.  If  there  is  inflammation 
of  the  labyrinth,  some  degree  of  permanent  deafness  is  probable.  In 
cases  in  which  hearing  is  lost,  any  return  of  the  perception  of  sounds 
conducted  through  the  bone  is  of  favorable  significance. 

Treatment. — No  agent  has  been  proved  to  exert  a  specific  influence 
on  the  disease.  The  treatment  does  not  differ  from  that  suitable  to 
other  forms  of  meningitis,  but  there  is  perhaps  less  to  be  hoped  for 
from  mercury.  Among  the  other  drugs  that  have  been  used,  for  the 
most  part  without  distinct  result,  may  be  mentioned  iodide  of  potas- 
sium, salicylate  and  benzoate  of  soda,  quinine,  digitalis,  and  chloral. 
Iodide  of  potassium,  salicylate  of  soda,  and  antipyrin  have,  it  is  true, 
been  credited  with  a  beneficial  influence  in  some  cases.  In  cases  that 
are  not  rapidly  fatal,  great  care  is  needed  to  secure  cleanliness  and  to 
avert  bedsores.  The  patient  should,  if  possible,  lie  on  the  side,  or  at 
least  not  on  the  back,  being  supported  by  a  plank  protected  by 
padding  or  pillows,  so  that  the  spinal  column  is  not  the  lowest  part 
towards  which  blood  gi-avitates.  Although  we  are  still  without  the 
means  of  counteracting  directly  the  active  element  in  the  disease,  we 
may  reasonably  hope  that  the  exact  knowledge  of  its  nature  which  we 
now  possess  may  bring  such  means,  before  long,  within  our  reach. 
For  the  prevention  of  the  disease,  fresh  air  and  the  avoidance  of  over- 
crowding are  the  most  important  measures. 


368 


ORGANIC   DISEASES   OF   THE   BRAIN. 


AKEMIA  OP  THE  BEAIN. 


The  blood  within  the  brain  is  contained  in  arteries,  capillaries,  and 
veins.  The  functional  condition  of  the  brain  depends  on  the  quantity 
and  quality  of  the  blood  circulating  in  its  capillaries,  and  it  is  to  this 
that  the  special  symptoms  are  related,  and  the  effects  thus  produced 
are  for  the  most  part  the  same.  Deficiency  in  the  quality  of  the 
blood  supplied  to  the  brain  is  always  of  gradual  occurrence,  and 
affects  the  whole  brain ;  deficiency  in  quantity  of  the  circulating  blood 
may  affect  the  whole  brain  or  part  only,  and  it  may  be  sudden  or 
gradual  in  its  production. 

Causes.  —  General  cerebral  anxmia  may  be  due  to  the  following 
causes : — (1)  It  may  be  a  part  of  systemic  anaemia — defect  in  quantity 
or  quality  of  the  whole  blood,  due  to  various  causes,  as  haemorrhage, 
exhausting  discharges,  or  defective  blood-nutrition.  (2)  The  supply 
of  blood  to  the  brain  may  be  deficient,  the  quantity  of  blood  in  the 
body  being  normal.  This  may  be  due  to  cardiac  weakness,  or  to 
causes  acting  through  the  nervous  system  on  the  heart,  as  in  swooning. 
In  systemic  anaemia  the  lessened  cardiac  power  increases  the  cerebral 
deficiency.  Whatever  lessens  the  amount  of  blood  discharged  from 
the  heart,  such  as  aortic  obstruction  or  mitral  disease,  may  be  a  cause 
of  cerebral  anaemia.  Pressure  on  the  vessels  conveying  the  blood  to 
the  head,  as  by  an  aortic  aneurism,  has  a  similar  effect.  Unequal 
distribution  of  the  systemic  blood  is  another  cause.  The  intestinal 
vessels,  if  dilated,  are  capable  of  containing  a  large  part  of  the  blood 
of  the  body,  and  the  effect  of  their  engorgement  is  often  seen  after 
paracentesis  abdominis,  and  in  the  fainting  that  may  attend  diarrhoea. 
The  effect  of  each  cause  is  increased  by  the  action  of  gravitation  in 
the  erect  posture.  (3)  Cerebral  anaemia  has  been  supposed  to  occur 
during  the  exhaustion  after  the  acute  stage  of  febrile  diseases,  and  to 
be  the  cause  of  certain  cerebral  symptoms  that  may  attend  this  stage. 
The  mechanism  is,  however,  uncertain,  since  we  have  learned  that 
such  symptoms  may  be  an  after-effect  of  the  organised  virus  of  the 
disease,  or  a  consequence  of  some  toxic  agent  produced  by  the  virus. 
(4)  The  capacity  of  the  cerebral  capillaries  may  be  diminished  by 
pressure  on  the  brain,  exerted  by  effusions  of  fluid  (hydrocephalus), 
of  blood  (in  cerebral  and  meningeal  haemorrhage),  or  by   growths 


ANEMIA.  369 

within   the   skull.      Symptoms   are   produced   especially    when    the 
mechanism  acts  rapidly. 

Partial  cerebral  ansemia  is  due  to  some  obstruction  to  the  passage 
of  the  blood  through  the  vessels.  To  be  permanently  efficient  such 
obstruction  must  be  situated  beyond  the  circle  of  Willis.  Ligature 
of  one  carotid  causes  immediate  symptoms  of  cerebral  ansemia,  but 
permanent  symptoms  are  not  frequent.  Pressure  on,  or  disease  of, 
one  carotid,  for  the  same  reason,  rarely  gives  rise  to  symptoms.  Ob- 
struction in  certain  arteries  of  the  brain  may  cause  local  anaemia, 
sudden  or  gradual,  temporary  or  permanent,  according  to  its  cause. 
Such  obstruction  may  be  due  to  narrowing  of  the  calibre  of  the  vessel 
by  atheromatous  changes  in  its  wall,  by  syphilitic  disease,  or  possibly 
by  spasm  of  its  muscular  coat ;  but  the  mechanism  of  vaso-motor 
spasm  has  been  extensively  invoked  to  explain  symptoms,  merely 
because  the  origin  of  these  was  obscure.  Complete  ansemia  may  be 
due  to  actual  occlusion  by  embolism  or  thrombosis  ;  it  constitutes 
the  first  stage  of  local  softening,  which  supervenes  after  twelve  or 
twenty-four  hours.  When  the  closure  is  imperfect,  symptoms  of  less 
intensity  result.  The  pressure-effects  of  an  intruding  substance 
within  the  skull  (tumour,  or  clot)  act  most  intensely  in,  and  may 
influence  only,  one  region  of  the  brain. 

Pathological  Anatomy. — The  principal  anatomical  character  of 
cerebral  ansemia  is  pallor  of  the  brain,  observable  chiefly  in  the  paler 
tint  of  the  cortical  substance,  and  the  diminished  number  of  red  spots 
in  the  white  substance.  The  pallor  may  be  partial  or  general.  But 
pallor  of  the  brain  after  death  does  not  by  any  means  necessarily  show 
that  ansemia  existed  during  life.  The  amount  of  blood  in  the  brain 
depends  chiefly  on  the  mode  of  death.  The  membranes  are  usually 
pale  in  ansemia,  but  in  some  cases  of  partial  ansemia  they  are  hyper- 
semic.  In  general  cerebral  ansemia,  effusion  of  serum  in  the  meshes  of 
the  pia  mater  and  between  the  convolutions  may  be  found,  and  it  is 
even  said  that  the  brain-substance  may  be  cedematous,  and  the  nerve- 
cells  changed  in  aspect,  unduly  translucent,  or  unduly  granular.  The 
walls  of  the  minute  vessels  may  also  be  found  degenerated,  thickened 
and  homogeneous  in  appearance,  a  condition  which  may  aid  in  the 
interference  with  function.*  Partial  cerebral  ansemia,  if  absolute,  is 
the  first  stage  of  softening,  in  connection  with  which  its  features  are 
described. 

Symptoms. — The  symptoms  of  this  condition  vary  according  as  the 
ansemia  is  suddenly  or  slowly  produced,  and  as  it  is  general  or  partial. 

(1)  In  sudden  general  ansemia  of  the  brain  the  sufferer  feels 
drowsy ;  the  special  senses  are  dulled ;  noises  in  the  ears  and  vertigo 
are  complained  of ;  the  pupils  are  at  first  contracted ;  sight  may  fail ; 
muscular  power  is  weakened  ;  respiration  is  sighing  ;  the  skin  is  pale, 

*  Knoll,  '  Wien.  med.  Wochenschrift/  1885,  No.  51. 
VOL.   II.  24 


370  BRAIN. 

cold,  and  moist ;  nausea  is  common ;  and  headache  is  rare.  If  the 
anaemia  is  more  intense,  consciousness  is  lost,  there  is  universal 
paralysis  ;  and  general  convulsions  may  occur,  epileptiform  in  cha- 
racter, these  heing  especially  frequent  in  sudden  extensive  loss  of 
hlood  in  strong  subjects.  jSTystagtnus  is  sometimes  observed.  The 
pupils  dilate,*  and  the  coma  may  deepen  to  death.  The  loss  of  sight 
in  cases  which  recover  may  persist  as  permanent  amaurosis  ;  but  this 
is  probably  due  to  an  affection  of  the  retina.  In  syncope  the  patient 
may  lose  his  sight  when  consciousness  persists,  or  may  remain  blind 
for  some  minutes  after  the  mental  functions  are  restored. 

(2)  When  general  anaemia  of  the  brain  is  slowly  produced,  the  state 
of  the  cerebral  functions  is  usually  that  of  "  irritable  weakness."  Their 
action  is  imperfect  in  degree,  but  may  be  excited  with  uudue  facility. 
There  is  mental  dulness  and  drowsiness ;  sometimes,  however,  insomnia 
is  troublesome.  There  are  often  hallucinations  of  the  special  senses, 
and  it  is  said  that  maniacal  attacks  or  melancholic  depression  may 
occur.  Delirium  is  common  in  severe  cases,  as  in  some  forms  of  im- 
perfect blood-nutrition,  the  so-called  "  inanition  delirium."  Headache, 
usually  general,  is  a  common  symptom ;  it  is  often  neuralgic  in 
character,  and  its  dependence  on  this  cause  is  shown  by  its  relief 
in  the  recumbent  posture,  and  (less  surely)  its  removal  by  alcohol. 
Sensory  hyperesthesia,  tinnitus  auriuni  (especially  the  pulsating 
variety),  niuscse  volitantes,  and  vertigo  are  frequent.  Sometimes  the 
sio-ht  is  dim,  or  there  may  be  deafness,  especially  in  the  upright 
posture.  Convulsions  are  rare,  but  muscular  power  is  generally  defi- 
cient. All  these  phenomena  are  more  marked  in  the  erect  than  in  the 
recumbent  posture,  especially  when  the  erect  posture  is  suddenly 
assumed.  It  has  been  remarked  that  some  anaemic  persons  can  think 
well  only  when  lying  down. 

In  young  children,  after  exhausting  discharges,  as  diarrhoea,  sym- 
ptoms referable  to  cerebral  anaemia  sometimes  occur — somnolence  and 
pallor,  with  a  depressed  fontanelle  and  contracted  pupils ;  occasion- 
allv  there  is  strabismus  and  even  rigidity  of  the  neck.  The  somno- 
lence may  deepen  to  coma,  the  pupils  dilate,  losing  their  sensitiveness 
to  light,  and  death  may  occur.  Such  symptoms  have  been  called 
Jiydrocephaloid  (first  by  Marshall  Hall),  from  the  resemblance  to  those 
of  acute  hydrocephalus. 

(3)  Partial  cerebral  anaemia  causes,  if  complete,  loss  of  function  in 
the  affected  area ;  if  it  is  permanent,  necrosis  of  the  cerebral  tissue 
results.  If  incomplete  and  sudden,  there  is  temporary  arrest  of 
function.  Ligature  of  one  carotid,  for  instance,  may  cause  transient 
weakness  and  numbness  in  the  opposite  half  of  the  body.  There  may 
be  at  first  an  over-action  of  grey  matter,  causing,  in  certain  regions, 
unilateral  convulsions.     If   slowly  developed,  as  by  the   disease   of 

*  The  early  contraction  is  probably  due  to  partial  irritation  of  the  third-nerve 
centre,  the  subsequent  dilatation  to  its  paralysis  (see  Mayer  and  Pibrani,  '  Prager 
Zeitschrift  f.  Heilkunde,'  Bd.  v,  p.  15). 


ANEMIA.  371 

arteries,  pain  and  vertigo  are  common,  with  recurring  symptoms,  such 
as  numbness,  tingling,  and  weakness  referred  to  the  limbs,  &c. 

In  all  cases  of  long-continued  cerebral  anaemia,  lasting  damage  to 
the  nutrition  of  the  brain  may  result.  In  the  child,  the  development 
of  the  brain  may  be  arrested,  and  mental  defect  may  increase  to  per- 
manent imbecility,  such  as  is  met  with  after  convulsion's.  In  the 
adult,  loss  of  memory  and  of  general  mental  power  may  be  produced  ; 
they  last  for  months,  and  sometimes  do  not  pass  away.  A  lady,  aged 
thirty-seven,  had  a  prolonged  attack  of  vomiting,  which  kept  her  in 
bed  for  three  months,  in  the  course  of  which  she  became  extremely 
pale,  dull,  and  lethargic,  and  for  a  time  did  not  speak.  On  recovering, 
she  remembered  nothing  of  her  illness,  and  thought  it  had  commenced 
the  preceding  day.  Six  months  later  her  memory  was  good  for 
events  before  the  illness,  but  she  had  no  recollection  of  any  event 
after  it,  even  for  an  bour,  and  exhibited  no  tendency  to  improve.  In 
all  varieties  of  chronic  anaemia  these  symptoms  are  common,  and  some- 
times take  the  form  of  chronic  insanity.  The  simple  failure  usually 
passes  away  sooner  than  definite  derangement,  but  often  not  until 
long  after  the  blood-state  has  improved. 

Pathology. — The  symptoms  are,  as  already  stated,  dependent 
mainly  on  the  defective  quantity  and  quality  of  the  blood  circulating 
in  the  brain.  Some  effect  has  been  ascribed  to  the  diminution  in 
the  blood-pressure  to  which  the  nerve-elements  are  ordinarily  exposed 
(Burrows) — a  mechanical  influence,  of  which  the  possibility  cannot  be 
denied  and  the  probability  cannot  be  proved.  The  precise  cerebral 
disturbance,  on  which  the  symptoms  directly  depend,  is  uncertain. 
Doubtless  the  cortex  is  the  first  to  suffer  in  function,  and  the  mental 
symptoms  are  thus  produced.  The  convulsions  that  result  from 
sudden  anaemia  of  the  brain  are  usually  ascribed  to  disturbance  of 
centres  in  the  medulla  or  pons,  but  the  fact  that  compression  of  one 
carotid,  which  can  affect  only  the  cerebral  hemisphere,  has  caused 
convulsion  in  the  opposite  half  of  the  body,  makes  it  more  probable 
that  the  "  discharge  "  is  from  the  cerebral  cortex.  The  convulsion  is 
preceded  by  tingling  in  the  whole  of  that  side.  That  the  nerve-cells 
should  "  discharge  "  when  the  blood-supply  is  arrested,  is  a  fact  of 
very  great  physiological  interest  as  an  indication  of  the  reserve  of 
force  that  must  be  stored  up  in  the  nerve-cells,  and  of  the  probability 
that  sudden  over-action  is  due  to  diminution 'of  resistance  to  action, 
and  not  to  an  increase  in  the  force- generating  function  of  the  cell. 
Latent  energy  may  be  liberated,  but  new  force  can  scarcely  be 
produced,  under  the  influence  of  sudden  anaemia.  The  disturbance  of 
respiration,  its  sighing  character,  &c,  are  ascribed  to  the  derange- 
ment of  the  respiratory  centre  in  the  medulla,  but  we  cannot  be  sure 
that  this  is  always  the  case.  Such  breathing  has  been  observed  to 
follow  obstruction  of  the  carotids.  It  must  be  remembered  that  our 
consciousness   of   dyspnoea,  due   to   disturbance  of  the   respiratory 


372  BRAIN. 

centre,  must  be  produced  through  related  cerebral  centres,  and  that 
the  respiratory  functions  must  be  -widely  represented  in  the  hemi- 
spheres, so  that  they  easily  manifest  emotional  disturbance. 

The  permanent  impairment  of  cerebral  nutrition  may  be  compared 
•with  the  amaurosis  which  results  from  acute  anaemia  when  no  changes 
in  the  retina  can  be  perceived.  Analogy  suggests  a  permanent  shock 
to  the  nerve-elements  and  their  nutrition. 

Diagnosis. — The  diagnosis  is  not  difficult.  It  rests  on  the  recog- 
nition, in  a  given  case,  of  the  causes  of  cerebral  anaemia,  and  on  the 
exclusion  of  graver  maladies,  such  as  organic  cerebral  disease.  With 
the  latter,  it  should  be  remembered,  ansemia  of  the  brain,  local  or 
general,  often  co-exists.  Some  symptoms  of  hypersemia  of  the  brain 
closely  resemble  those  of  ansemia.  A  common  pathological  state  of 
imperfect  blood-renewal  within  the  capillaries  probably  exists  in  both 
conditions. 

Prognosis. — The  severity  of  the  symptoms,  and  the  extent  to- 
which  the  cause  of  the  anaemia  is  amenable  to  treatment,  and  is  of 
transient  character,  must  determine  the  prognosis.  As  a  rule  this  is 
favorable  when  there  is  no  organic  disease  of  heart,  vessels,  or  brain. 
In  the  so-called  "  pernicious  anaemia  "  the  prognosis  is,  of  course,  far 
more  grave.  Hydrocephaloid  symptoms  in  infants,  if  met  by  prompt 
and  suitable  treatment,  are  usually  recovered  from. 

Treatment. — The  treatment  necessarily  varies  in  the  several  forms 
of  the  affection,  but  it  is  in  the  main  causal.  The  beneficial  effect  of 
the  recumbent  posture  in  affording  immediate  relief  to  the  symptoms, 
and  obviating  permanent  damage  to  the  cerebral  nutrition,  must  be 
always  remembered.  In  acute  anaemia  from  loss  of  blood,  the  head 
should  be  kept  continuously  low,  stimulants  freely  administered,  and 
as  a  penultimate  resort,  bandages,  applied  to  the  limbs  from  below 
upwards,  may  increase  the  proportionate  supply  of  blood  to  the  brain. 
If  this  fails,  tran'sfusion  must  be  had  recourse  to.  In  chronic  anaemia, 
sudden  change  of  posture  should  be  carefully  avoided,  and  ferruginous 
tonics  are  needed.  The  form  of  iron,  I  believe,  matters  much  less  than 
is  usually  supposed.  When  the  corpuscles  are  few,  arsenic  should  be 
given  with  it.  In  severe  cases,  absolute  physical  rest  is  often  advan- 
tageous, but  this  depends  on  the  form  of  the  anaemia.  When  the 
haemoglobin  is  reduced  out  of  proportion  to  the  corpuscles,  physical 
rest  is  of  the  greatest  importance,  greater  even  than  fresh  air.  Cor- 
puscles are  oxygen- carriers  in  proportion  to  the  haemoglobin  they 
contain.  All  muscular  exertion  uses  up  the  oxygen,  and  the  proto- 
plasmic tissues  suffer  in  their  nutrition,  and  are  incapacitated  for  the 
essential  functions  of  digestion,  circulation,  &c.  The  beneficial  effect 
of  absolute  rest  in  bed  in  these  cases  is  often  most  striking.  If, 
on  the  other  hand,  the  corpuscles  are  rich  in  haemoglobin  (and  in 


HYPEREMIA.  373 

pernicious  anaemia  they  may  contaiu  50  per  cent,  more  haemoglobin 
than  normal)  gentle  exercise  may  be  permitted,  because  the  oxygen- 
carriers  have  their  full  functional  capacity,  and  the  nutrition  of  the 
tissues  does  not  suffer ;  if  some  of  the  oxygen  is  used  in  exercise,  the 
supply  to  the  tissues  is  not  impaired  as  it  is  when  every  corpuscle 
contains  far  less  than  the  normal  amount  of  haemoglobin. 

In  the  cerebral  ansemia  of  syncope,  the  recumbent  posture,  stimu- 
lants to  the  skin,  cold  water,  faradisation,  sinapisms,  and  ammonia 
to  the  nasal  mucous  membrane,  assist  the  recovery  of  cardiac  action 
and  the  return  of  consciousness.  In  all  eases,  carefully  regulated  food 
and  stimulants  are  needed ;  beef  tea  should  be  given  in  small  quanti- 
ties at  frequent  intervals. 

The  group  of  symptoms  called  "  hydrocephaloid  "  requires  similar 
treatment.  Its  diagnosis  is  of  the  first  importance,  because  a  routine 
treatment  for  meningitis  would  kill  the  patient.  Warmth  to  the 
surface  of  the  body  and  head  is  of  importance.  Attempts  pre- 
maturely to  rouse  the  child  to  consciousness  are  unadvisable,  but 
when  a  distinct  improvement  has  occurred  in  the  general  state,  and 
especially  in  the  pulse,  some  mental  activity  probably  favours  the 
return  of  a  normal  state  of  the  cerebral  circulation. 

In  the  more  pronounced  mental  symptoms  that  result  from  anaemia, 
opiates  are  of  service  in  adults,  either  opium  by  the  mouth  or  morphia 
under  the  skin.  In  states  of  depression  the  dose  should  be  small 
and  frequent,  ■£%  gr.  of  morphia  three  or  four  times  a  day.  In 
excitement  a  larger  dose  (-|  gr.)  may  be  given  for  its  soporific  effect, 
but  small  doses  should  be  avoided.  Small  doses  of  nitro-glycerine 
may  also  be  given  in  the  method  recommended  for  migraine,' when 
cerebral  symptoms  are  very  marked. 


HYPEREMIA.  OF  THE   BRAIN. 

Of  all  regions  of  cerebral  pathology,  that  of  congestion  of  the  brain 
is  perhaps  the  most  obscure.  We  have  very  little  precise  knowledge 
regarding  it,  and,  as  is  often  the  case,  theory  has  flourished  in  propor- 
tion to  the  deficiency  of  fact.  It  was  long  thought  that  the  state  of 
the  vessels  of  the  brain  after  death  corresponds  with  their  condition 
during  Jife,  and  post-mortem  distension  was  accepted  as  proof  that 
any  preceding  cerebral  symptoms  were  due  to  congestion.  Hence,  an 
extensive  symptomatology  was  elaborated  and  built  up  on  an  erro- 
neous foundation,  and  it  has  to  some  extent  survived  its  evidence. 
The  fact  was  unobserved  or  ignored  that  a  similar  condition  of  the 
brain  is  equally  common  when  there  are  no  cerebral  symptoms  during 
life,  and  depends  chiefly  on  the  mode  of  death.  Moreover,  congestion 
of  organs  seems  to  afford  so  satisfactory  an  explanation  of  derangement 


374  BRAIN. 

of  their  functions,  that  the  temptation  to  assign  the  condition  as 
the  cause  of  symptoms  has  often  been  irresistible.  Even  statistics 
have  been  amassed,  the  value  of  which  may  be  estimated  from  the 
fact  that  in  one  modern  text-book  the  history  of  cerebral  congestion 
has  been  manifestly  written  from  cases  of  pure  hypochondriasis.  On 
the  other  hand,  partly  by  a  reaction  from  this,  some  have  doubted 
even  the  possibility  of  the  condition.  The  truth  lies  between  the  two 
extremes,  but  its  precise  position  is  still  undetermined,  and  there  is 
room  for  wide  difference  of  opinion,  even  among  those  who  strive  to 
keep  their  minds  unbiassed.  It  is  certain,  however,  that  the  cases  in 
which  symptoms  of  definite  character  and  considerable  degree  can  be 
reasonably  ascribed  to  this  cause  are  far  from  frequent. 

The  essential  pathological  condition  of  hyperemia  of  the  brain  is 
an  increase  in  the  amount  of  blood  within  its  capillaries.  This  may 
occur  because  there  is  too  much  blood  in  the  arteries  or  too  much  in 
the  veins  ;  in  the  former  case  too  much  blood  enters  the  capillaries,  in 
the  latter  too  little  leaves  them  ;  in  either  case  they  are  over-distended. 
The  two  conditions  differ  in  their  causes,  nature,  and  effects  ;  the  one 
is  active,  the  other  passive  congestion.  In  the  one  case,  the  supply  of 
arterial  blood  to  the  capillaries  is  excessive ;  in  the  other,  it  is  deficient 
because  the  circulation  in  them  is  hindered.  Hence,  the  state  of 
passive  congestion,  in  which  the  brain  is  under-supplied  with  arterial 
blood,  approaches  that  of  anaemia  ;  in  both  anaemia  and  passive  con- 
gestion there  is  anoxaemia,  but  in  passive  congestion  the  capillaries 
contain  blood  that  possesses  an  undue  amount  of  carbonic  acid  and 
other  products  of  metabolism — an. important  difference  from  pure 
anaemia. 

It  was  at  one  time  thought  that  the  blood  in  the  brain  could  not 
vary  in  amount  because  the  cranio-vertebral  cavity  is  a  closed  space, 
and  this  opinion  is  still  occasionally  put  forward.*  But  the  mobility 
of  the  cerebrospinal  fluid  (which  occupies  not  only  the  intermem- 
branous  space  and  the  ventricles,  bnt  also  the  lymphatic  spaces  around 
the  vessels)  permits  the  vascular  distension  to  vary.  If  the  cavity 
were  hermetically  closed,  the  variation  could  be  only  relative,  not 
absolute.  But  the  numerous  foramina  of  the  cranium  and  vertebral 
canal  are  occupied  by  less  resistent  structures,  which  no  doubt  may 
yield  in  some  degree.  Moreover,  the  large  surface  veins  of  the  spinal 
cord,  and  still  more  the  enormous  plexus  outside  the  spinal  dm-a 
mater,  doubtless  constitute  an  important  means  of  adaptation.  The 
less  blood  these  contain,  the  more  cerebro- spinal  fluid  can  be  in  the 
spinal  canal,  and  the  more  blood  can  be  in  the  cerebral  vessels.  Further, 
the  processes  of  secretion  and  absorption  of  the  cerebro-spinal  fluid, 
always  in  constant  operation,  must  be  influenced  by  the  degree  of 
pressure,  and  may  quickly  vary  with  it.  Although  the  conditions 
during  life  and  after  death  are  widely  different,  yet  we  may  reason- 
ably regard  the  enormous  variations  in  the  total  amount  of  blood 
*  Sen  Moxov.'s  Lectures,  *  Lancet,'  i,  1881. 


HYPEREMIA.  375 

within  the  cranio-vertebral  canal  after  death,  in  different  cases,  and 
the  variations  in  its  distribution  in  the  nerve-centres,  as  evidence  that 
considerable  variations  may  occur  during  life.  Some  are  physiological ; 
in  the  child,  before  the  fontanelles  are  closed,  and  in  the  adult,  when 
a  piece  of  the  skull  is  removed  by  injury,  it  is  seen  that  the  brain 
pulsates  synchronously  with  the  heart,  and  that  its  distension  also 
changes  with  the  respiratory  movements  of  the  thorax. 

Etiology. — The  causes  that  produce  active  and  passive  congestion 
are  widely  different,  and  require  separate  consideration.  Some  acton 
the  brain  alone,  others  on  many  viscera  or  even  on  the  whole  vascular 
system  ;  some  are  transient,  others  are  permanent. 

Active  Congestion. — (1)  Over-action  of  the  heart,  without  corresponding 
contraction  of  the  arteries,  is  one  important  cause.     Whatever  in- 
creases the  force  of  the  heart,  and  at  the  same  time  interposes  no 
obstacle  to  the  flow  of  blood  into  the  capillary  system,  is  a  cause  of 
active  distension  of  the  cerebral  vessels.     Excited  action  is  more  fre- 
quently effective  than  hypertrophy,  because  the  common  cause  of 
hypertrophy  is  an  obstruction  between  the  heart  and  the  capillaries. 
It    may    occur,    however,    from    the    hypertrophy   that    is    due    to 
aortic  regurgitation,  when  obstruction  is  slight  or  absent ;   in  this 
condition  brain  power  is  often  distinctly  above  the  average.     (2)  A 
sudden  contraction  of  the  arterioles  elsewhere — as,  for  instance,  in  the 
skin,  from  exposure  to  cold  or  during  a  rigor — may  cause  transient 
over-filling  of  the  cerebral  vessels  together  with  those  of  other  viscera. 
(3)  Dilatation   of  the   arterioles,  and   consequently  an  increase  of 
the  blood-supply,  may  be  produced  by  certain  toxic  agents,  especially 
by  nitrite  of  amyl,  nitro-glycerine,  and  alcohol.     The  throbbiug  and 
headache  produced  by  nitrite  of   amyl  seems  in  itself  to  prove  the 
possibility  of  active  congestion  of  the  brain.     Morphia  causes  first 
contraction  and  then  dilatation.     Some  of  these  agents  also  quicken 
the  action  of  the  heart,  and  may  thus  further  increase  the  blood- 
supply.     Emotion  may  have  the  same  influence,  although  the  evidence 
of  this  is  inconclusive.*     In  some  diseases  a  similar  mechanism  gives 
rise  to  congestion.     In  exophthalmic  goitre,  for  instance,  vascular 
dilatation  is  associated  with  cardiac  over-action.     In  other  peculiar 
states  of  the  nervous  system,  especially  in  young  neurotic  persons, 
singular  conditions  occur,  sometimes  periodically,  in  which  there  are 
symptoms  of  vaso-motor  paralysis  of  the  cerebral  vessels,  without  other 
cause  than  the  peculiar  neuropathic  disposition,  and  the  tendency  to 
such  disturbance  is  sometimes  distinctly  inherited.     (4)  Active  con- 
gestion occurs  also  as  the  first  stage  of  inflammation,  and  similar  acute 
symptoms  are  occasionally  met  with,  especially  in  children,  which  may 
even  cause  death.     Traces  of  congestion  are  found,  but  no  evidence  of 

*  The  pulsation  of  the  Drain,  observed  in  persons  who  have  lost  a  piece  of  the 
cranial  bone,  is  said  to  be  increased  by  both  intellectual  work  and  emotion  (Mosso^ 
*  Reale  Acad,  dei  Lincei,'  PvOina,  18S0). 


376  BRAIN. 

actual  inflammation.  The  immediate  cause  of  the  condition  is  often 
obscure;  excessive  brain-work,  or  exposure  to  cold,  has  been  supposed 
to  produce  it  in  some  cases.  There  is  no  justification,  however,  for 
referring  all  sudden  cerebral  symptoms  in  children  to  congestion.  Con- 
vulsions, for  instance,  were  once  thought  to  be  always  due  to  this  cause, 
but  there  is  reason  to  believe  that  they  are  very  rarely  produced  by  it. 
(5)  Insolation  is  probably  a  cause  of  active  congestion,  which  may  or 
may  not  go  on  to  inflammation.  The  modern  theory,  which  regards 
the  so-called  sun-stroke  as  really  heat-stroke,  the  result  of  the  over- 
heating of  the  body  and  not  of  the  action  of  the  sun  on  the  head,  is 
probably  too  sweeping.  The  delirium  of  acute  febrile  diseases  was 
formerly  attributed  to  congestion  of  the  brain,  but  it  is  more  probable 
that  the  cerebral  disturbance  is  the  result  of  the  action  of  the  toxic 
blood-state  on  the  cells  of  the  brain,  and  that  any  congestion  is  of 
secondary  origin.  (6)  Active  congestion  is  supposed  to  be  a  cause  of 
transient  general  cerebral  symptoms  in  adults,  especially  after  middle 
life  and  in  the  male  sex.  It  is  believed  to  be  frequent  in  those  of  a 
certain  build,  stout  men  with  thick  necks  and  florid  faces,  and  to  be 
favoured  by  alcoholic  excess,  and  by  the  condition  termed  "  plethora," 
which,  perhaps,  consists  in  an  increase  in  the  total  quantity  of  blood 
in  the  system.  The  symptoms  come  on  suddenly,  and  pass  away  in  a 
manner  that  renders  it  difficult  to  ascribe  them  to  an  organic  lesion,  and 
in  rare  cases  the  absence  of  such  lesion  has  been  demonstrated.  They 
are  said  sometimes  to  follow  the  suppression  of  an  habitual  discharge, 
especially  hemorrhagic,  as  that  from  piles,  or  the  catainenia  in 
women. 

Partial  active  congestion  occurs  in  connection  with  tumours  and 
other  organic  lesions  of  the  brain,  and  also  when  an  artery  is  ob- 
structed, and  the  adjacent  branches  of  the  main  vessel  receive  too 
much  blood.  It  is  possible  that  partial  congestion  occurs  as  a  primary 
condition,  especially  in  certain  parts  of  the  brain,  in  which  limited 
inflammation  is  occasionally  met  with  ;  but  such  inflammation  (as  of 
the  grey  matter  of  the  ocular  nerves,  p.  198)  is  rare,  and  congestion 
must  be  still  more  rare.  Acute  congestion  of  the  medulla  oblon- 
gata has  been  supposed  to  be  an  occasional  cause  of  sudden  death  in 
young  children,  but  if  this  agency  is  really  at  work  in  these  cases  its 
origin  is  altogether  unknown. 

Passive  congestion  is  always  produced  mechanically  by  some  obstruc- 
tion to  the  return  of  blood.  It  occurs  in  heart  disease  which  causes 
over-filling  of  the  venous  system,  although  the  head  suffers  less  than 
parts  that  are  below  the  level  of  the  heart.  It  is  produced  also  by 
pressure  on  the  supei'ior  vena  cava,  or  on  the  innominate  veins,  or  on 
the  veins  of  the  neck,  by  tumours,  &e.  The  obstruction  to  the  flow  of 
blood  through  the  lungs  occasioned  by  the  act  of  coughing,  playing  wind 
instruments,  and  by  other  severe  muscular  efforts  with  closed  glottis, 
is  a  frequent  cause.  Slight  congestion  is  often  produced  by  wearing 
tight  collars,  and  is  shown  by  headache  which  ceases  when  the  pressure 


HYPEREMIA.  377 

is  relieved.  In  death  by  suffocation  such  congestion  occurs  in  very  . 
iutense  degree.  The  horizontal  posture  probably  suffices  to  produce 
some  degree  of  coDgestion,  the  venous  blood  losing  the  aid  that 
gravitation  gives  to  its  return,  and  recumbency  may  intensify  the  in- 
fluence of  other  causes.  Partial  passive  congestion  also  results  from 
pressure  on,  or  thrombosis  in,  one  of  the  cerebral  veins  or  sinuses. 

Pathological  Anatomy. — In  the  strict  sense  of  the  word,  there  is 
scarcely  any  pathological  anatomy  of  congestion  of  the  brain.  Simple 
active  congestion  disappears  after  death  in  every  organ.  No  trace  can 
be  seen,  for  instance,  of  the  congested  areola  around  a  pustule  in  the 
skin.  Only  the  vascular  distension  of  actual  inflammation  persists, 
lessened  in  degree.  The  lesson  of  general  pathology  is,  therefore,  that 
■whenever  we  find  after  death  distension  of  the  minute  vessels,  without 
engorgement  of  _  the  veins,  the  condition  must  be  regarded  as  one  of 
commencing  inflammation,  and  not  of  mere  congestion.  Nor  is  the 
case  otherwise  with  passive  congestion.  Intense  passive  congestion 
occurs  during  death  from  suffocation,  and  yet  the  brain  may  be  found 
anaemic  after  death  (Ackermann,  Jolly).  But  intense  venous  disten- 
sion occurs  after  death  in  those  parts  towards  which  gravitation 
draws  the  blood,  and  hence  in  the  posterior  half  of  the  head,  when 
this  is  not  raised  after  death.  The  influence  of  gravitation  may 
keep  the  blood  in  the  vessels  of  congested  parts,  but  it  is  never 
possible  to  distinguish  the  influence  of  the  ante-mortem  distension  in 
the  presence  of  the  more  powerful  post-mortem  effect.  If  mechanical 
congestion  has  occurred,  not  merely  during  the  act  of  death,  but  for 
many  hours  or  days  previously,  and  gravitation  keeps  up  the  engorge- 
ment after  death,  the  distension  of  the  veins  and  capillaries  is  very 
intense;  the  colour  of  the  grey  substance  is  dark  from  the  more 
abundant  capillaries  in  it,  and  even  the  arteries  may  contain  a  good 
deal  of  blood.  But  if  the  body  is  so  placed  after  death  that  the  blood 
-can  gravitate  from  the  head  into  the  relaxed  vessels  elsewhere,  no 
amount  of  simple  mechanical  congestion  during  life  can  be  traced 
twelve  hours  after  death.  It  is  said,  when  long  continued,  to  render 
the  veins  unduly  tortuous,  but  it  is  doubtful  whether  sufficient  allow- 
ance has  been  made  for  the  degree  of  tortuosity  that  may  be  present 
under  normal  conditions,  and  for  the  influence  of  senile  changes  in 
the  wall  of  the  vessels.  A  slight  degree  of  effusion  into  the  ventricles 
probably  results  from  passive  congestion,  but  it  is  doubtful  whether 
this  is  ever  sufficient  to  cause  flattening  of  the  convolutions,  and  still 
more  doubtful  is  the  occurrence  of  such  swelling  of  the  whole  brain  as 
to  cause  such  flattening,  or  of  any  general  "  hypertrophy  "  or  atrophy 
which  have  been  said  to  occur.  It  is  probable,  however,  that  the 
spaces  around  the  vessels,  which  arise  by  a  dilatation  of  the  peri- 
vascular sheaths,  are  increased  by  mechanical  congestion,  although 
here  again,  apart  from  congestion,  the  variations  met  with  are  so 
great,  and  the  size  of  these  spaces  is  often  so  considerable,  that  the 


37S  BRAIN. 

influence  of  congestion  upon  thein  cannot  be  regarded  as  proved. 
Even  in  young  persons  their  size  is  sometimes  remarkable. 

Microscopical  examination  shows  the  capillaries  to  be  unduly  large 
in  passive  congestion,  and  it  is  probable  that  systematic  measurement 
would  show  that,  after  this  state  has  been  long  continued,  their 
average  size  becomes  larger  than  in  simple  post-mortem  engorge- 
ment. Bulgings  of  the  capillaries  have  been  occasionally  seen. 
After  asphyxial  modes  of  death  it  is  common  to  find  that  minute 
vessels  here  and  there  have  given  way,  so  that  the  lymphatic  sheath 
is  filled  with  blood.  Blood-pigment  in  the  sheaths  has  been  found 
in  cases  of  slighter  long-continued  congestion  (Bastian).  Lastly, 
minute  microscopic  haemorrhages  into  the  cerebral  substance  may  be 
found,  almost  constantly,  in  these  cases. 

While  the  pathological  anatomy  of  congestion  is  thus  to  a  consider- 
able extent  negative,  it  is  important  to  remember  the  fact  that  this 
affords  no  reason  for  doubting  the  occurrence  of  the  condition. 

Symptoms. — The  iuti'oductory  remarks  show  how  great  is  the  diffi- 
culty of  determining  the  symptoms  of  cerebral  congestion,  and  how 
much  caution  is  desirable  in  accepting  the  statements  that  have  been 
made,  founded  for  the  most  part  on  an  elaborate  symptomatology 
that  was  formulated  by  Andral. 

Passive  Congestion. — The  symptoms  produced  by  passive  congestion 
are  much  more  marked  when  this  is  occasional,  than  when  it  is  con- 
stant, uniform,  and  gradually  produced.  This  is  only  one  instance  of 
the  remarkable  tolerance  of  the  brain  to  pressure  if  slowly  developed. 
A  slight  degree  of  mechanical  congestion  causes  dull  headache,  chiefly 
frontal,  sometimes  throbbing,  and  sometimes  accompanied  by  vague 
discomfort,  described  by  some  patients  as  a  "  confused  feeling,"  by 
others  as  a  "  sense  of  fulness."  This  congestive  headache  is  often 
produced  by  coughing.  I  have  known  a  patient  suffering  from 
phthisis  to  seek  relief,  not  on  account  of  the  cough,  but  on  account  of 
headache  which  was  solely  due  to  the  cough.  When  intense,  it  may 
cause  flashes  of  light  in  the  eyes,  or  noises  in  the  ears.  Slight 
general  convulsion  may  even  result,  usually  consisting  only  of  clonic 
spasm,  with  or  without  loss  of  consciousness.  An  elderly  man,  with 
chronic  bronchitis  and  emphysema,  had  severe  paroxysms  of  coughing, 
and  at  the  height  of  each,  when  his  face  was  dusky,  there  was  a  brief 
general  clonic  spasm,  without  loss  of  consciousness.  Occasionally  the 
convulsion  is  more  distinctly  epileptoid  in  its  character,  or  there  may 
be  loss  of  consciousness  without  convulsion.  Persistent  mechanical 
congestion  may  cause  also  somnolence,  mental  dulness,  disturbed 
sleep,  or  even  nocturnal  delirium.  Vague  giddiness  is  often  com- 
plained of,  but  there  is  seldom  distinct  vertigo.  Tingling  in  the 
limbs  and  general  muscular  inactivity  have  been  ascribed  to  this 
cause,  but  it  is  doubtful  whether  unilateral  symptoms  ever  occur. 

With  these  symptoms  are  commonly  associated  the  signs  of  general 


HYPEREMIA.  679 

cephalic  hypersernia,  a  turgid  face,  and  congested  conjunctiva,  often 
with  viscid  secretion.  They  are  increased  by  constipation,  by  stoop- 
ing, by  the  recumbent  posture  with  the  head  low,  by  tight  clothes 
about  the  neck,  by  flexion  of  the  neck,  and  by  all  muscular  effort. 

Active  Congestion. — The  symptoms  of  active  congestion  are  much 
more  variable  and  much  less  certain.  Simple  excitement  of  the 
heart's  action,  such  as  results  from  emotion,  or  from  nitrite  of  amyl, 
will  cause  throbbing  and  pain  in  the  head,  but  in  persistent  over- 
action  of  the  heart,  as  in  exophthalmic  goitre  or  aortic  regurgitation 
with  hypertrophy,  cerebral  symptoms  are  slight  or  absent,  perhaps 
because  the  derangement  is  gradually  induced. 

The  cases  in  which  definite  and  considerable  disturbance  can  be 
referred,  with  most  probability,  to  active  congestion,  are  those  in 
which  there  are  recurring  paroxysms  of  headache,  delirium,  and  some- 
times fever,  preceded  by  throbbing  of  the  vessels,  and  sometimes  by 
reddening  of  the  face — symptoms  of  transient  character  and  uniform 
recurrence.  Thus,  in  a  case  related  by  Nothnagel,*a  man  aged  fifty- 
seven  had  suffered  from  such  attacks  at  intervals  of  a  few  weeks  or 
months  since  the  age  of  fourteen.  At  first  there  was  only  a  sense  of 
fulness,  heat,  and  pain  in  the  head,  always  relieved  by  bleeding  at  the 
nose.  Afterwards  each  attack  began  with  beating  of  the  heart,  heat 
of  head,  spots  before  the  eyes,  and  noises  in  the  ears  ,<  these  symptoms 
were  followed  by  mental  excitement  and  irritability,  screams  and 
tears,  but  no  actual  delusions.  This  condition  would  last  a  few  hours- 
or  a  few  days,  but  was  always  at  once  cut  short  by  venesection.  In 
the  intervals  he  was  perfectly  well. 

Brief  attacks  of  headache  with  delirium  may  be  attended  with  fever 
and  special  heat  of  head,  and  have  been  regarded  as  a  febrile  form  of 
cerebral  congestion.  Whatever  difficulty  there  may  be  in  accepting 
this  explanation  of  such  cases,  it  is  at  present  very  difficult  to  find  any 
other,  especially  when  the  attacks  are  brief  and  recur.  Well-marked 
instances  are  occasionally  seen  in  children.  Thus  a  clever,  precocious- 
girl  of  six  had  been  liable,  since  the  age  of  two,  to  attacks  of  the  fol- 
lowing character,  recurring  at  intervals  of  three  to  nine  months. 
There  was  severe  left- sided  headache,  prostration,  and  elevation  of 
temperature,  reaching  sometimes  103°,  great  heat  of  head,  occasionally 
delirium,  and  often  nausea,  but  no  vomiting.  Each  attack  com- 
menced suddenly  and  lasted  a  few  hours  ;  then  the  child  went  to  sleep 
and  woke  up  perfectly  well.  There  is  some  reason  to  think  that  such 
attacks  in  childhood  may  pass  into  non-febrile  migraine  at  a  later 
period.  Whether  they  are  to  be  ascribed  to  a  primary  vaso-motor 
disturbance  or  to  a  "  nerve  storm,"  the  opinion  that  an  active  cerebral 
congestion  takes  at  least  a  secondary  part  in  the  morbid  process  may 
reasonably  be  maintained  and  cannot  be  disproved.  In  some  cases  of 
migraine  there  is  evidence  of  active  hypersemia  of  the  head  and  face 
during  part  of  the  attack,  but  it  is  probable  that  this  is  of  secondary 
*  '  Ziemssen's  Cyclopaedia/  Bel.  xi,  1,  2  Aufl.,  p.  49. 


380  BRAIN. 

origin,  since  the  attacks  in  which  it  is  most  marked  begin  with  pallor 
only.  The  brief  attacks  of  coma,  pyrexia,  heat  of  head,  and  other 
cerebral  symptoms,  which  occur  during  the  course  of  general  paralysis 
of  the  insane,  are  commonly  regarded  as  of  congestive  nature,  because 
they  pass  away  completely. 

Acute  symptoms  of  brain  disturbance  in  children,  resembling  those 
of  meningitis — headache,  delirium  or  somnolence,  vomiting,  strabis- 
mus, inequality  of  pupil,  various  contractions  and  paralyses,  and  a 
prominent  fontanelle — are  sometimes  rapidly  fatal  without  any  post- 
mortem evidence  of  active  inflammation.  As  already  stated,  if  con- 
gestion of  the  brain  is  the  cause,  it  is  probably  that  which  constitutes 
the  first  stage  of  meningitis. 

The  most  common  severe  attacks  that  are  ascribed  to  cerebral  con- 
gestion are  those  which  occur  in  the  second  half  of  life,  and  are 
-attended  with  sudden  loss  of  consciousness  (the  so-called  "  congestive 
apoplexy  "),  and  sometimes  by  transient  hemiplegia,  passing  away  in 
the  course  of  a  few  days.  The  congestive  nature  of  many  of  these 
cases  is  more  i^han  doubtful,  and  few  physicians  would  now  care  to 
insist  on  the  laboured  description  and  classification  of  the  symptoms 
which  were  current  twenty  years  ago.  We  know  that  an  actual  lesion 
may  occur  in  many  parts  of  the  brain,  a  small  hemorrhage,  or  a  spot 
of  softening,  and  may  cause  only  general  cerebral  symptoms,  or  local 
symptoms  of  indirect  origin  and  very  brief  duration.  We  know,  too, 
that  vascular  obstruction  may  occur  and  cause  no  lasting  symptoms, 
because  there  may  be  sufficient  anastomoses  to  permit  of  an  adequate 
collateral  circulation.  It  is  in  these  cases  that  the  facility  and  reassur- 
ing character  of  the  diagnosis  of  "  congestion  of  the  brain  "  often 
tempts  the  physician  to  an  opinion  which  is,  if  not  erroneous,  at  least 
unwarranted.  But  when  the  attack  is  brief,  passes  away  completely, 
is  attended  with  the  signs  of  what  is  termed  "  plethora,"  and,  especially 
when  it  recurs  more  than  once,  still  without  enduring  symptoms,  the 
diagnosis  of  cerebral  congestion  is  at  least  permissible,  and  it  is  certain 
that,  in  many  cases  of  the  kind,  no  lesion  has  been  found  after  death 
to  account  for  the  symptoms.  It  is  commonly  held,  and  must  be 
admitted  as  possible,  that  cerebral  congestion  may  cause  these  sym- 
ptoms, even  when  there  are  no  signs  of  plethora  or  of  hyperemia  of 
the  external  vessels  of  the  head,  and  no  pallor  of  the  face,  but  still 
greater  caution  should  be  exercised  in  making  the  diagnosis  in  such 
a  state.  As  an  instance  of  the  condition  in  which  the  diagnosis 
seemed  justifiable,  I  may  mention  the  case  of  a  stout,  full-blooded 
mau,  about  fifty-five,  with  a  large  strongly  acting  heart  and  some 
arterial  degeneration,  who,  during  the  preceding  year,  had  had  several 
attacks  of  left-sided  weakness,  each  lasting  only  a  few  hours ;  the  first 
was  attended  with  loss  of  consciousness.  The  day  before  I  saw  him 
he  complained  of  tingling  in  both  hands,  and  a  few  hours  later 
vomited,  went  to  bed,  and  passed  a  stool  into  the  bed ;  then  he  got 
up  and  got  into  bed  again.     His  temperature  was  found  to  be  102°; 


HYPEREMIA.  381 

lie  did  what  lie  was  told,  and  answered  questions,  but  with  imperfect 
articulation.  During  the  next  twenty-four  hours  he  did  riot  speak, 
but  was  restless,  tossing  about  in  bed,  sweating  profusely,  with  a  fall 
of  temperature  to  100  5°.  His  pulse  was  80,  full,  but  not  hard,  face 
flushed,  pupils  rather  small.  He  understood  imperfectly  what  was 
said  to  him.  There  was  no  evidence  of  loss  of  power  or  sensation. 
The  symptoms  all  passed  away  in  the  course  of  a  few  days  without 
the  slightest  indication  of  a  local  cerebral  lesion.  In  connection 
with  the  absence  of  signs  of  cephalic  congestion,  we  should  remember 
that  the  vascular  state  of  the  face  and  brain  may  not  correspond. 

There  is  much  difficulty  iu  reconciling  hemiplegic  symptoms  with 
the  idea  of  congestion  as  their  cause.  In  the  vaso-naotor  inertia  of  the 
old,  the  occurrence  of  active  congestion  of  any  part  is  not  easy  to 
understand,  but  it  is  even  less  easy  to  understand  that  one  hemisphere 
of  the  brain  alone  should  suffer.  It  is  possible,  however,  that  an  ex- 
plauation  may  be  found  in  partial  arterial  degeneration,  which  may 
determine  the  greater  or  less  disturbance  of  one  part -of  the  brain. 

A  "  convulsive  form  "  of  cerebral  congestion  has  been  described,  in 
which  severe  epileptiform  convulsions  are  the  only  symptom.  But 
the  relation  of  these  to  cerebral  congestion  is  very  doubtful.  Formerly, 
as  already  mentioned,  almost  all  convulsions  in  young  children  were 
ascribed  to  such  congestion,  and  the  use  of  the  hot  bath  is  due  to  a 
survival  of  the  opinion  ;  but  it  is  certain  that  simple  convulsions  from 
this  cause  are,  to  say  the  least,  extremely  rare,  and  the  beneficial  effect 
of  the  method  of  treatment  may  not  have  a  simple  significance. 

It  is  doubtful  whether  any  form  of  cerebral  .congestion  is  attended 
by  recognisable  changes  in  the  circulation  within  the  eye,  unless  the 
whole  head  shares  the  morbid  state. 

Diagnosis. — The  most  important  principles  of  diagnosis  have  been- 
already  incidentally  mentioned.  The  chief  points,  disregard  of  which 
causes  the  grossest  errors  of  diagnosis,  are  two  :  (1)  Persistent  focal 
symptoms,  such  as  hemiplegic  weakness,  however  slight,  exclude  mere 
congestion.  (2)  Cephalic  sensations,  whether  vague  or  definite  in 
character,  are  alone  of  no  diagnostic  value.  Such  sensations  ai*e 
especially  common  in  hypochondriacal  patients,  who  often  suffer  much 
from  various  feelings  of  fulness,  tightness,  heat,  burning,  and  especi- 
ally from  a  sensation  of  pressure  on  some  part  of  the  head,  generally 
the  vertex  or  occiput.  These  sensations  are  intensified  by  annoyance 
and  by  brain  work,  and  are  vastly  increased  by  attention.  They 
are  purely  nervous  sensations,  pseudo-neuralgic  in  nature,  and  there 
is  not  the  slightest  justification  for  attributing  them  to  congestion  of 
the  brain.  And  yet  such  patients,  if  they  consult  many  doctors,  as 
they  usually  do,  are  sure  to  be  told  by  some  that  their  symptoms  are 
due  to  congestion  of  the  brain,  or  even  (with  a  precision  that  is  evi- 
dence only  of  profound  ignorance  or  of  actual  charlatanry)  to  "  con- 
gestion of  the  base  of  the  brain,"  a  condition  that  probably  never 


382  BRAIN. 

exists  "but  in  a  pathological  imagination.  The  most  important  diag- 
nostic indication  is  the  increase  of  the  symptoms  by  influences  that 
increase  the  amount  of  blood  in  the  head,  and  their  diminution  by 
their  opposite  influences. 

Prognosis. — The  danger  to  life  in  cerebral  congestion  is  indicated 
only  by  the  intensity  of  the  symptoms.  When  these  are  very  severe, 
and  actual  coma  is  present,  there  may  be  danger,  but  in  most  cases 
tbe  symptoms  pass  away  completely.  They  are,  however,  prone  to 
recur,  and  hence  the  future  is  uncertain,  and  depends  chiefly  on  the 
extent  to  which  the  cause  can  be  discovered  and  its  influence  prevented. 

Treatment. — In  passive  congestion  the  only  effective  treatment  is 
the  removal  of  the  cause  of  the  mechanical  obstruction.  Many  causes 
are  unfortunately  for  the  most  part  beyond  our  control,  but  cough 
can  be  moderated ;  the  heart,  if  necessary,  strengthened  by  digitalis  ; 
and  in  all  cases  many  intensifying  influences  can  be  lessened.  Effort 
should  be  avoided  ;  the  clothes  should  be  loose  about  the  neck ;  the 
patient  should  sleep  with  the  head  well  raised  and  the  shoulders  also 
raised,  so  as  to  avoid  any  flexion  of  the  neck. 

In  active  congestion  a  similar  attention  to  posture,  &c,  is  desirable, 
so  as  to  obviate  any  hindrance  to  the  escape  of  the  blood  from  the 
over-filled  capillaries.  In  other  respects  the  treatment  must  be  varied 
according  to  the  individual  condition.  Its  immediate  object  is  to 
lessen  the  amount  of  blood  in  the  cerebral  arteries,  and  there  are 
three  modes  in  which  ..this  may  be  attempted:  (1)  by  lessening  the 
total  volume  of  the  blood  ;  (2)  by  obtaining  the  dilatation  of  vessels 
elsewhere,  and  so  drawing  the  blood  from  the  head  ;  (3)  by  causing 
the  dilated  cerebral  arteries  to  contract.  Some  of  the  measures 
employed  act  in  more  than  one  way. 

The  most  direct  mode  of  lessening  the  volume  of  the  blood,  vene- 
section, is  applicable  only  to  the  plethoric  form  of  congestion,  in  which 
the  face  is  red  and  turgid,  and  the  pulse  is  full.  The  relief  that  it 
affords  is  immediate  and  great.  If  the  propriety  of  venesection  is 
doubtful,  leeches  may  be  applied,  and  in  children  this  method  alone 
is  permissible.  The  leeches  should  be  applied  over  the  mastoid  pro- 
cess, because  there  is  a  communication  between  the  cutaneous  and 
intra-cranial  vessels  through  the  mastoid  veins.  Thus  we  may  follow 
the  indication  that  is  given  by  nose-bleeding,  which  often  gives 
striking  relief  to  cerebral  congestion  and  has  a  more  direct  influence 
on  the  cerebral  circulation  than  any  other  haemorrhage,  although  the 
induction  of  nose-bleeding  is  impracticable,  on  account  of  the  difficulty 
of  controlling  the  flow  of  blood.  Section  and  subsequent  ligature  of 
the  temporal  artery  has  been  recommended. 

Purgation  and  diuresis  both  act  by  diminishing  the  volume  of  the 
Hood,  and  the  former  at  least  acts  also  by  increasing  the  amount  of 
blood  in  the  capacious  intestinal  vessels,  while  both  alter  the  consti- 


HYPEK^HIA.  383 

tution  of  the  blood  by  removing  from  it  effete  products.  The  degree 
of  purgation  must  depend  on  the  strength  of  the  patient,  but  in  all 
cases  it  is  important  that  the  bowels  should  be  opened,  freely  or 
gently.  Constipation  causes  in  some  way  cephalic  discomfort,  head- 
ache, &c,  and  intensifies  the  symptoms  of  cerebral  congestion.  A 
saline  purge  is  the  most  effective,  with  or  without  a  preceding 
mercurial.  The  saline  should  not  be  too  much  diluted,  and  thus  a 
maximum  osmotic  action  may  be  obtained.  Both  the  liquid  evacua- 
tions, and  the  thirst  which  follows  the  action  of  the  purgative,  afford 
proof  of  the  removal  of  liquid  from  the  blood.  Diuretics  are  also 
distinctly  useful.  A  full  dose  of  nitrous  ether  and  spirit  of  juniper 
may  be  given  every  three  or  four  hours.  Diaphoretics  are  of  doubtful 
value,  unless  the  symptoms  follow  exposure  to  cold — a  questionable 
cause.  Except  pilocarpine,  which  has  not  yet  been  tried  in  this  affec- 
tion, a  hot-air  bath  is  the  only  effectual  diaphoretic,  and  this,  by  raisino- 
the  temperature  of  the  whole  body,  may  have  a  prejudicial  action. 

Blood  may  be  drawn  to  the  limbs  by  immersing  them  in  warm 
water  and  keeping  them  dependent.  Even  in  health,  faintness  may 
be  produced  by  the  long  immersion  of  the  feet  in  hot  water.  "  Junod's 
boot,"  in  which  the  air  is  partially  exhausted  around  a  limb,  was 
formerly  employed  with  this  object,  but  has  fallen  into  almost  entire 
disuse.  General  constriction  of  the  limbs  by  a  bandage,  wound 
round  from  above  downwards,  so  as  to  compress  the  surface  veins  but 
not  the  deeper  arteries,  has  a  similar  effect. 

The  third  object  of  treatment  is  to  obtain  contraction  of  the  arteries 
of  the  brain.  It  is  unfortunately  never  possible  to  ascertain  to  what 
degree  this  object  is  attained,  and  we  can  only  adopt  those  measures 
that  seem  most  likely  to  secure  it.  One  of  these  is  the  application  of 
cold  to  the  head.  This  should  be  continuous,  by  ice  or  an  irrigation- 
tube  cap.  A  mustard  plaster  to  the  neck  is  also  probably  of  service. 
The  application  of  mustard  plasters  to  the  limbs  is  of  doubtful  value  • 
it  is  possible  that,  as  some  think,  they  may  cause  a  reflex  contraction 
of  the  cerebral  arteries,  but  their  supposed  "  derivative  "  influence,  in 
drawing  blood  to  the  surface,  must  be  infinitesimal  unless  the  appli- 
cation is  made  over  a  very  large  area.  It  is  uncertain,  also,  how  far 
pathological  dilatation  of  the  vessels  of  one  part  can  be  influenced  by 
drugs.  Ergot,  for  instance,  probably  would  have  less  influence  on  the 
vessels  that  are  in  a  morbid  state  than  on  those  elsewhere,  and  it 
might  thus  increase  the  congestion.  Digitalis  may  be  beneficial, 
since  it  causes  contraction  of  the  arterioles  ;  it  is  most  important  to 
maintain  the  circulation  as  steady  and  uniform  as  possible,  and  to 
reduce  undue  frequency  of  the  action  of  the  heart.  Eor  these  ends 
perfect  tranquillity  of  mind  and  body  should  be  secured.  Alcohol  and 
morphia  should  be  avoided,  and  insomnia  or  restlessness  treated  with 
bromide  or  other  gentle  sedatives. 


384  BEAIN. 


CEEEBEAL  HJEMOEEHAGE. 

Haemorrhage  may  occur  into  the  substance  of  the  brain,  or  into 
cavities  within  it,  or  into  the  membranes.  The  term  "  cerebral  haemor- 
rhage "  is  sometimes  used  as  a  general  designation  for  all  intra-cranial 
extravasations ;  sometimes  it  is  applied  only  to  hsemorrliage  into  the 
substance  of  the  brain  (including  the  cerebellum,  pons,  and  medulla), 
and  is  distinguished  from  "meningeal  haemorrhage,"  in  which  the 
extravasation  is  into  the  membranes. 

Etiology. — Haemorrhage  is  always  due  to  the  rupture  of  a  vessel. 
The  rupture  may  be  the  result  of  injury,  or  may  occur  "  spontaneously," 
i.  e.  as  a  result  solely  of  internal  causes.  The  vessel  that  bursts  is 
usually  an  artery,  very  rarely  a  vein.  Capillaries  may  also  rupture, 
b.ut  only  minute  extravasations  result. 

The  causation  of  cerebral  haemorrhage  includes  three  subjects  :  (1) 
the  immediate  pathological  conditions  that  lead  to  the  rupture ;  (2) 
the  influences  that  bring  about  this  pathological  condition  ;  and  (3) 
those  that  actually  burst  the  vessel.  These  may  be  distinguished  as 
the  pathological,  remote,  aud  exciting  causes. 

Pathological  Causes. — Putting  aside  traumatic  influences,  the  force 
that  ruptures  an  artery  is  the  pressure  of  the  blood  within  it.  But  as 
long  as  the  walls  of  an  artery  are  in  a  healthy  state,  they  very  rarely 
give  way,  however  great  may  be  the  pressure  to  which  they  are 
exposed.  Healthy  veins  may  give  way  under  extreme  pressure,  as  in 
death  by  suffocation  ;  but  arteries  do  so  seldom,  pehaps  never.  When 
an  artery  ruptures,  it  is  because  the  wall  is  so  changed  as  to  be 
weakened ;  it  may  give  way  without  any  abnormal  degree  of  pressure, 
but  more  readily  if  the  pressure  is  increased.  The  two  factors,  weak- 
ening of  wall  and  increase  of  blood-pressure,  often  coincide,  because 
increased  pressure  leads  to  degeneration  of  the  wall.  The  state  of 
the  wall  is  the  more  important  of  the  two  elements,  and  may  cause 
rupture  when  the  blood-pressure  is  normal. 

When  the  wall  of  an  artery  is  weakened,  it  yields  before  the  blood- 
pressure  and  becomes  bulged.  By  the  extension  it  is  thinned,  and  thus 
is  further  weakened,  until  it  gives  way.  The  bulging  constitutes 
an  aneurism.  The  large  arteries  at  the  base  or  on  the  surface  of 
the  brain  are  occasionally  thus  dilated  and  thus  burst,  but  such 
aneurisms  also  constitute  "  tumours,"  and  are  considered  at  another 
page.  The  vessels  that  give  way  in  the  common  form  of  cerebral 
haemorrhage  are  of  much  smaller  size,  and  are  in  the  substance  of 
the  brain.  In  these  arteries,  also,  bulging  precedes  bursting,  and  the 
rupture  is  of  the  wall  of  a  minute  aneurism.  Such  "  miliary  aneu- 
risms," as  they  are  termed,  are  therefore  always  to  be  found  in  cases  of 
"  spontaneous  "  cerebral  haemorrhage.  Their  constancy  was  proved  by 
Charcot  and  Bouchard,  who  found  them  in  each  of  seventy  seven  con- 


CEREBRAL    HAEMORRHAGE. 


385 


secutive  cases.  They  are  to  be  discovered  by  washing  away  the 
cerebral  substance  under  water,  and  carefully  picking  out  the  tiny 
thread-like  vessels  that  remain.  On  these,  little  red  grains  are  seen, 
■which  a  low  magnifying  power  shows  to  be  minute  aneurisms  (Fig. 
116).  Their  size  varies 
from  y^  to  ¥V  of  an  inch. 
As  many  as  a  hundred 
have  been  found  in  a 
single  brain .  They  are  met 
with  almost  exclusively 
in  the  second  half  of  life, 
and,  although  once  found 
in  a  patient  only  twenty 
years  old,  they  are  as 
rare  under  forty  as  is  cere- 
bral haemorrhage.  Their 
frequency  after  forty  in- 
creases up  to  at  least  moderate  old  age 


Fio.  116. —  Outline  of  miliary  aneurisms  from  the 
brain  in  a  case  of  haemorrhage  j  magnified.  (After 
Eichhorst.) 


The  order  of  frequency 
with  which  they  are  found  in  different  parts  of  the  brain  is,  accord- 
ing to  Charcot  and  Bouchard,  central  ganglia,  cortex,  pons,  cere- 
bellum, centrum  ovale,  middle  cerebellar  peduncle,  crus  cerebri, 
medulla  oblongata — an  order  which  is  not  far  from  that  of  haemor- 
rhage. In  the  aneurisms,  the  muscular  coat  of  the  vessel  has 
disappeared,  the  adventitia  and  intima  are  united.  The  change  is 
said  to  commence  by  the  production  of  new  tissue  elements  in  the 
outer  coat?  (Charcot  and  Bouchard)  or  in  the  inner  coat  (Zenker),  and 
is  called  "  arteritis  "  (periarteritis  or  endarteritis),  but  the  evidence 
of  its  inflammatory  nature  seems  insufficient  to  justify  the  term.  No 
doubt  the  effective  element  in  the  change  is  the  loss  of  the  contractile 
and  elastic  elements  in  the  coat ;  in  consequence  of  this  it  yields  more 
and  more  to  the  pressure  of  the  blood,  any  new  tissue  elements  that 
are  formed  being  extensible  and  inelastic. 

The  common  change  in  the  large  vessels  termed  "  atheroma  "  has 
only  an  indirect  connection  with  haemorrhage.  Atheroma  does  not 
affect  the  small  vessels  within  the  brain,  and  although  it  renders  the 
wall  of  the  vessel  inelastic,  it  also  renders  it  thicker  and  less  disten- 
sible than  normal.  Both  the  miliary  aneurisms  and  atheroma  are 
senile  changes,  and  often  co-exist,  but  each  may  be  found  without  the 
other  ;*  atheroma  often  exists  in  high  degree  without  haemorrhage,  and 
the  latter  may  occur  when  the  vessels  of  the  base  are  perfectly  healthy. 
Nothnagel  has  suggested  that  atheroma  of  the  larger  vessels  may 
facilitate  the  production  of  miliary  aneurisms  by  increasing  the  force 
and  suddenness  of  the  pulse-wave  that  reaches  the  smaller  arteries, 
the  larger  vessels  no  longer  yielding  to  the  pressure. 

Miliary  aneurisms  are  far  more  frequent  in   the  brain  than  else- 

*  Charcot  and  Bouchard  found  atheroma  absent  in  one  quarter  of  the  cases  of 
miliary  aneurisms. 

VOL.    II.  25 


386  BRAIN. 

where,  first  because  the  external  support  of  the  cerebral  arteries  is 
slight  in  consequence  of  the  wasting  of  the  brain  tissue  around  them ; 
secondly,  because  the  strain  to  which  the  vessels  are  exposed  is  greater 
than  in  other  arteries  of  the  same  size,  in  consequence  of  their  origin 
directly  from  large  trunks,  the  pressure  elsewhere  being  more  gradu- 
ally lessened  by  more  gradual  branching  ;  lastly,  because  the  absence 
of  anastomoses  in  many  parts  (as  the  central  ganglia)  deprives  the 
vessels  of  any  relief  to  the  pressure,  and  the  pulse- wave  not  only 
distends  but  also  elongates  them,  and  renders  them  more  tortuous 
(Mendel).  These  conditions  will  facilitate  not  only  the  production 
of  aneurisms,  but  also  their  rupture. 

Remote  Causes. — Hereditary  predisposition  is  sometimes  very  marked, 
and  doubtless  consists  in  a  tendency  to  the  occurrence  of  the  vascular 
change  and  of  such  disease  as  that  of  the  kidneys,  which  lead  to  the 
arterial  changes.  The  influence  of  heredity  is  shown  not  only  by  the 
frequency  of  the  occurrence  of  cerebral  haemorrhage  in  some  families, 
but  by  the  entire  freedom  of  other  families  through  many  long-lived 
generations. 

Sex. — Males  suffer  more  frequently  than  females,  although  the 
difference  is  less  than  is  commonly  asserted.  G-intrac's  figures  of  681 
cases*  (excluding  meningeal  haemorrhage)  yield  a  percentage  of  males 
56-6,  females  43;4. 

Age. — Cerebral  haemorrhage  is  essentially  a  disease  of  the  degenera- 
tive period  of  life ;  at  least  four  fifths  of  the  cases  occur  after  forty 
years  of  age,  and  its  frequency  increases  as  life  advances.  But  it  is 
met  with  occasionally  in  earlier  life,  even  in  childhood  and  infancy. f 
The  most  extensive  statistics  available  on  tbis  point  are  those  of 
Gmtrac,J  although  these,  consisting  of  published  cases,  are  less  satis- 
factory than  a  consecutive  series  would  be,  and  it  is  probable  that  the 
frequency  of  the  disease  in  early  life  is  over-represented.  The  first 
column  of  the  following  table  gives  Grintrac's  figures  of  the  distribu- 
tion of  653  cases  he  has  collected,  and  in  the  second  I  have  reduced 
these  to  a  percentage.  These  two  columns  thus  show  the  relative  fre- 
quency in  each  decade  of  life.  But  since  the  number  of  persons  living 
diminishes  in  each  successive  decade,  such  figures,  as  Sir  George 
Burrows  long  ago  insisted,  convey  an  erroneous  idea  of  the  liability  to 
the  disease.  The  third  column  of  the  table  is  therefore  computed  by 
the  help  of  Farr's  Life  Table,  No.  3,  and  shows  the  number  of  cases 

*  'Maladies  de  l'appareil  nerveux,'  1S69,  tome  ii,  p.  430. 

f  Haemorrhages  into  the  suhstance  of  the  brain,  minute  and  massive,  have  occurred 
in  young  children  during  the  paroxysms  of  whooping-cough.  An  instance  is  recorded 
hy  Marshall,  '  Glasgow  Med.  Journal,'  1885,  p.  24.  It  is  probable  that  the  rupture 
is  generally  of  a  vein.  Many  cases  of  alleged  cerebral  haemorrhage  in  early  life  have 
been  cases  of  extravasation  into  the  substance  of  a  soft  glioma — always  probably 
when  optic  neuritis  has  been  found  soon  after  the  onset  of  the  symptoms  of 
haemorrhage. 

J  Loc.  cit.,  table  on  p.  431,  with  the  exclusion  of  the  cases  of  primary  meningeal 
and  spinal  haemorrhage. 


CEREBRAL    HEMORRHAGE. 


387 


of  cerebral  haemorrhage  in  an  equal  number  of  individuals  in  each 
decade  of  life,  called  1000a;.  It  thus  shows  the  relative  liability  in 
each  decade.  Of  the  real  value  of  x  we  have  no  means  of  judging. 
In  the  last  column  I  have  reduced  the  series  to  a  percentage,  so  that 
the  relative  liability  to  the  disease  at  each  age  maybe  more  conveniently 
compared  with  its  relative  frequency.  Thus  it  is  seen  that  while  the 
disease  is  actually  less  frequeut  between  seventy  and  eighty  than 
between  sixty  and  seventy,  the  liability  to  it  is  greater  in  the  later 
than  in  the  earlier  decade.  Prom  the  second  column  it  appears  as  if 
the  disease  were  only  one  tenth  as  frequent  between  eighty  aud 
ninety  as  between  fifty  and  sixty,  but  the  third  and  fourth  columns 
show  that  the  liability  to  it  is  the  same  in  these  two  decades.  It 
may  perhaps  be  questioned  whether  the  number  of  cases  between 
eighty  and  ninety  are  sufficient  to  justify  the  conclusion  to  which  they 
point,  that  the  liability  is  much  less  between  eighty  and  ninety  than 
between  seventy  and  eighty,  i.  e.  that  in  the  very  old  cerebral  haemor- 
rhage becomes  less  prevalent.  But  I  think  it  probable  that  the 
conclusion  is  correct,  and  that  the  condition  of  tissues  which  permits 
the  attainment  of  extreme  old  age  is  one  in  which  there  is  less  tendency 
to  the  occurrence  of  the  arterial  changes  that  lead  to  cerebral  haemor- 
rhage. 


Age. 

Age  distribution  of  cases. 

Age  distribution  of  liability. 

No.  of  cases  in 
each  decade. 

Percentage  of  cases 
in  eacli  decade. 

Liability ,  number 

of  cases  in  lOOOjr 

persons  living  in 

each  decade* 

Percentage  of 

liability  in  each 

decade. 

1—10 
11—20 
21—30 
31—40 
41—50 
51—60 
61—70 
71—80 
81—90 

15 

20 

38 

71 

97 

129 

159 

112 

12 

2-3 

31 

60 

10-8 

150 

19-8 

24-4 

17-2 

1-8 

1-8 
3 
6 
12 

19 
31 

52 
72 
32 

•8 

1-3 

26 

52 

83 

13-5 

22-4 

32-4 

14 

*  It  may  be  well  to  explain  further  the  manner  in  which  the  figures  of  the  third 
column  are  obtained.  From  Farr's  Life  Table,  No.  3,  the  population  maintained  in 
each  decade  by  10,000  annual  births  was  first  ascertained  (the  decades  being,  of 
course,  reckoned  according  to  the  first  column,  1 — 10,  11 — 20,  &c).  The  figures  in 
the  third  column  for  each  decade  are  the  numbers  that  bear  the  same  relation  to 
1000  as  the  number  of  cases  in  this  decade  (first  column)  bears  to  the  number  of 
persons  living  of  that  age  in  a  population  in  which  there  are  annually  10,000  births. 
The  number  1000  is  arbitrary.  1  might  have  been  taken  instead,  but  1000  must 
be  much  nearer  the  actual  number  than  1  would  be.  The  uncertain  number  to  be 
added  to  1000  is  represented  by  x,  which  may  be  more  or  less  than  1.  The  actual 
number  (i.  e.  the  real  value  of  a;)  could  not  be  known  unless  there  were  a  post-mortem 
examination  in  every  person  dying  in  a  large  and  known  population.  For  the  sake 
of  simplicity,  the  actual  population  at  each  decade  has  not  been  given,  but  one 


388  BRAIN. 

A  certain  physical  conformation  is  popularly  associated  with  a 
liability  to  "  apoplexy  " — a  short  thick  neck,  high  shoulders,  florid 
face  ;  but  it  is  doubtful  whether  this  condition  has  any  relation  to 
cerebral  haemorrhage;  most  of  the  subjects  are  thin  and  spare,  and 
present  almost  the  reverse  of  the  characteristic  "  apoplectic  build." 

Cerebral  haemorrhage  is  said  to  be  more  frequent  in  temperate  than 
in  tropical  climates,  in  winter  than  in  summer,  and  it  is  probably  more 
common  in  civilised  than  in  savage  races. 

Thus  the  degenerative  tendency  incidental  to  advanced  life  is,  in 
the  majority  of  cases,  the  most  powerful  element  in  the  production  of 
cerebral  haemorrhage.  But  this  influence  is  augmented  by  certain 
morbid  states  which  increase  this  tendency.  The  most  important  of 
these  are  chronic  alcoholism,  gout,  and  renal  disease,  especially  the 
common  senile  form,  granular  disease  of  the  kidney.  Charcot  found 
kidney  disease  in  one  third  of  his  cases  of  cerebral  haemorrhage,  and 
this  is  probably  about  the  true  proportion.*  Whatever  be  the  nature 
of  fibroid  disease  of  the  kidney,  whether  the  affection  is  primarily 
local  or  general,  the  minute  vessels  always  suffer;  and  they  suffer 
likewise,  although  to  a  less  extent,  in  other  forms  of  kidney  disease, 
unquestionably  primary.  The  strain  on  the  vessels  from  the  hyper- 
trophy of  the  heart,  whether  it  helps  to  produce  the  degeneration  or 
not,  must  increase  the  tendency  to  dilation  and  rupture.  Bright's 
disease  is  one  of  the  chief  causes  of  miliary  aneurisms  and  cerebral 
haemorrhage  in  persons  between  thirty  and  forty.  I  have  elsewhere 
described  and  figured  a  case  of  Bright's  disease  in  a  woman  aged 
thirty-six,  in  whose  retina  several  miliary  aneurisms  could  be  seen 
with  the  ophthalmoscope,  and  who  died  a  few  days  later  with  all  the 
symptoms  of  a  sudden  cerebral  haemorrhage,  f 

Aneurisms  of  the  larger  arteries  are  frequently  due  to  the  two  other 
instance  may  make  the  principle  of  the  table  clearer.  In  a  population  in  which 
there  are  10,000  annual  births,  the  number  of  persons  living  between  71  and  80  will 
be  (according  to  the  Life  Table)  1547.  The  number  of  the  deaths  from  cerebral 
haemorrhage  in  this  period  (of  the  cases  collected)  is  112.  Supposing  that  number 
of  deaths  from  this  cause  to  occur  among  1547  persons  living  at  that  period,  the 
number  of  cases  in  1000  will  be  72,  and  x  =  1.  But  as  we  do  not  know  the  exact 
number  of  persons,  it  is  termed  1000,r.  In  any  case,  the  figures  represent  the  rela- 
tive liability  throughout  life,  so  far  as  the  cases  collected  by  Gintrac  are  representa- 
tive. They  are  doubtless  not  exactly  representative;  as  before  stated,  the  early 
deaths  are  probably  in  undue  proportion,  because  such  cases  are  more  likely  to  be- 
published.  But,  with  this  exception,  there  seems  no  reason  why  they  should  not 
fairly  represent  the  relation  of  the  disease  to  age,  and  they  have  the  advantage  over 
Registrars'  reports  that  each  case  is  unquestionably  one  of  haemorrhage,  since  in 
every  case  collected  there  was  a  post-mortem  examination. 

*  It  has  been  attempted  to  depreciate  the  influence  of  renal  disease  in  the  pro- 
duction of  cerebral  haemorrhage,  by  demonstrating  the  rarity  of  the  latter  in  a  series 
of  renal  cases.  But  later  adult  life  is  essential  for  the  occurrence  of  the  vascular 
consequences,  and  nothing  is  proved  by  a  series  of  casts  taken  at  all  ages. 

f  '  Medical  Ophthalmoscopy,'  pi.  xii,  fig.  1  (case  42,  p.  326,  of  the  2nd  ed.). 
In  albuminuric  retinitis  capillary  ectases  are  very  common  (ibid.,  fig.  68) ;  but  it  ia 
rare  to  meet  with  aneurisms  on  the  visible  arteries. 


CEREBRAL    HEMORRHAGE.  389 

chief  causes  of  disease  of  the  wall,  syphilitic  disease  and  embolic 
arteritis  (see  "  Intra-cranial  Aneurisms  "),  and  haemorrhage  results 
from  their  rupture.  It  is  not  yet  known  whether  these  processes  also 
cause  miliary  aneurisms.  I  have  once  seen  extensive  haemorrhage 
into  the  "brain  of  a  boy  aged  eight,  with  inherited  syphilis  and 
vascular  disease,  without  any  visible  aneurism.  The  haemorrhage  had 
apparently  commenced  in  the  right  lenticular  nucleus,  or  outside  it, 
and  had  burst  into  the  ventricles.  The  syphilitic  disease  was  chiefly 
in  the  vertebral  and  cerebellar  arteries.  I  do  not  know  of  any  similar 
case  in  a  subject  of  acquired  syphilis,  but  it  is  certain  that  the  small 
arteries  within  the  cerebral  substance  are  occasionally  affe«ted  by 
syphilitic  changes,  and  it  is  possible  that  some  cases  of  intra- cerebral 
haemorrhage  in  early  adult  life  may  have  this  origin.  Aneurism 
results  from  embolism,  especially  when  incomplete,  and  the  plug  is 
from  a  seat  of  inflammation  of  septic  character.  The  altered  wall, 
still  exposed  to  the  pressure  of  the  blood,  yields  before  it.  It  may 
perhaps  also  be  caused  by  the  rapid  disintegration  of  the  embolus,  the 
fragments  of  which  are  driven  on  into  the  minute  arteries.  The  main 
trunk  is  sometimes  pervious  when  there  is  embolic  softening  in  its 
area,  quickly  fatal.* 

Lastly,  in  certain  general  diseases  there  is  a  tendency  to  bleeding, 
which  may  cause  intra-cerebral  haemorrhage.  Thus  it  may  occur  in 
purpura,  scurvy,  pernicious  anaemia,  and  especially  in  leucocythaemia, 
in  which  it  is  a  common  cause  of  death,  and  the  extravasations  are  often 
multiple.  Its  mechanism  is  probably  an  acute  degeneration  in  the 
walls  of  the  vessels.  In  leucocythaemia  it  has  been  thought  to  be  due 
to  obstruction  of  the  vessels  by  accumulations  of  white  corpuscles,  but 
it  is  not  easy  to  see  how  this  mechanism  would  be  effective.  In  these 
diseases  we  do  not  know  whether  the  vessels  rupture  directly,  or 
whether  they  first  dilate  into  miliary  aneurisms. 

Exciting  Causes. — The  actual  rupture  sometimes  occurs  during  some 
temporary  increase  in  the  blood-pressure  from  muscular  effort,  such 
as  straining  at  stool,  lifting  a  heavy  weight,  during  coitus,  vomiting, 
or  violent  cough  (as  whooping-cough),  or  from  excited  action  of  the 
heart  consequent  on  emotion.  But  often  the  vessel  gives  way 
when  the  circulation  is  tranquil,  even  during  sleep.  The  cerebral 
arteries  are  supposed  to  be  contracted  during  sleep,  but  it  should  be 
remembered  that  in  the  recumbent  posture  the  influence  of  gravita- 
tion on  the  return  of  blood  from  the  brain  is  less  than  in  the  upright 

*  A  remarkable  case  is  described  by  Charlewood  Turner  (' Trans.  Path.  Soc.,' 1892), 
I  in  which  extensive  embolic  softening  in  the  central  ganglia  of  one  side,  from 
obstruction  of  the  middle  cerebral,  was  followed,  four  days  later,  by  haemorrhage  in 
the  same  part  of  the  other  hemisphere.  The  heart  was  the  seat  of  ulcerative  endo- 
carditis. Embolism  has  also  been  the  apparent  cause  of  haemorrhage  during  conva- 
lescence from  scarlet  fever  (Dejerine),  and  it  has  even  been  known  to  result  (in  the 
optic  thalamus,  bursting  into  the  ventricle)  from  echinococcal  embolism  of  the 
posterior  cerebral  (Dahnhardt,  '  Xeur.  Cent./  18ii0. 


390  BEA1N. 

posture,  while  the  blood  from  tbe  lower  limbs  returns  more  readily, 
and  thus  the  pressure  in  tbe  arteries  must  be  increased. 

In  extreme  mecbanical  congestion,  such  as  attends  all  asphyxial 
modes  of  deatb,  small  exiravasalions  are  usually  produced,  apart 
from  vascular  disease.  They  do  not  commonly  exceed  a  mustard  seed 
in  size,  and  still  more  minute  haemorrhages  may  often  be  found,  with 
the  microscope,  scattered  through  tbe  cerebral  substance,  and  espe- 
cially numerous  in  the  pons  aud  medulla.  Often  tbe  haemorrhage  is 
only  into  the  perivascular  sbeatb,  which  becomes  distended  with  blood. 

Meningeal  Haemorrhage. — Blood  may  be  extravasated  (1)  outside 
the  dura  mater,  separating  it  from  tbe  bone  (extra-dural  hemor- 
rhage) ;  (2)  beneath  tbe  dura  mater,  into  what  was  regarded  as  tbe 
sac  of  tbe  arachnoid  when  it  was  thougbt  tbat  a  parietal  layer  of  tbe 
arachnoid  lined  the  dura  mater  (subdural  bseniorrhage)  ;  and  (3) 
beneatb  tbe  araebnoid,  between  it  and  the  pia  mater  (subarachnoid 
hsemorrbage).  The  blood  may  come  from  the  arteries  or  veins  or 
sinuses  of  the  dura  mater,  or  from  the  vessels  of  the  pia  mater.  The 
chief  causes  are  as  follows: — (1)  Injury  tbat  causes  fracture  of  tbe 
skull  or  laceration  of  tbe  pia  mater.  Extensive  hsemorrbage  is 
usually  from  the  meningeal  arteries  or  sinuses.  The  blood  may  be 
outside  or  beneath  the  dura  mater.  (2)  Aneurisms  of  the  larger 
arteries  of  the  base  or  surface.  (3)  Tbe  escape  of  blood  from  an 
intra- cerebral  bseniorrhage  in  tbe  ways  to  be  presently  described.  (4) 
Meningeal  haemorrhage  occurs,  apart  from  visible  aneurisms,  under 
tbe  same  conditions  (age,  chronic  kidney  disease,  &c.)  as -hsemorrbage 
elsewhere  in  tbe  brain.  It  is  also  met  with  in  some  chronic  diseases 
witb  hemorrhagic  tendency,  as  purpura,  leucocythseinia,  and  the 
malarial  cachexia.  The  mechanism  of  its  production  in  these  cases 
is  not  known,  but  is  probably  the  same  as  that  which  causes  intra- 
cerebral haemorrhage  in  the  same  conditions.  (5)  It  occurs  in  tbe 
form  termed  "  haeuiatonia "  already  described,  especially  in  the 
insane ;  the  blood  probably  comes  from  a  meningeal  vein.  (6) 
During  birth  it  may  result  from  the  compression  of  the  skull,  espe- 
cially in  cases  in  which  the  head  is  born  last.  The  blood  conies  from 
the  vessels  of  the  pia  mater  or  veins  of  the  dura  mater,  or  even  from 
the  superior  longitudinal  sinus.  These  cases  are  separately  described. 
(7)  It  is  probably  sometimes  excited  by  exertion  in  a  heated  room, 
without  any  traceable  predisposing  cause. 

Subarachnoid  haemorrhage  is  equally  frequent  in  the  two  sexes,  but 
the  subdural  form  is  three  times  as  frequent  in  males  as  in  females 
(Giotrac).  Taking  all  forms  together,  meningeal  haemorrhage  is  far 
more  frequent  both  in  youth  and  in  tbe  middle  period  of  life  than 
intra-cerebral  haemorrhage.  About  one  tenth  of  the  patients  do  not 
exceed  twenty  years  of  age,  and  nearly  half  the  cases  occur  in  the 
first  forty  years  of  life.* 

*  Gintrac's  collection  of  165  cases  (of  which  only  twelve  were  traumatic)  exhibit* 
the  following  distribution : 


CEKEBltAL    U^MOERHAGE.  391 

Primary  ventricular  haemorrhage  is  met  with  in  rave  eases,  one  or 
more  of  the  ventricles  being  filled  with  blood  without  any,  or  with 
only  secondary,  lesions  of  their  walls.  The  blood  usually  comes  from 
the  vessels  of  the  choroid  plexuses,  or  of  the  velum  interpositum, 
rarely  from  a  vein  in  the  wall  of  the  ventricle.  Probably  the  haemor- 
rhage is  due  in  most  cases  to  .the  rupture  of  miliary  aneurisms,  which 
have  been  found  in  the  choroid  plexus,  and  it  is  for  the  most  part 
related  to  the  same  general  conditions  as  intra-cerebral  haeniorrhao-e 
But  it  occasionally  results  also  from  severe  mechanical  congestion,  as 
in  attempted  hanging,  from  convulsions,  or  after  a  severe  concussion, 
sometimes  at  an  interval  of  a  few  clays  or  one  or  two  weeks.*  In 
rare  cases  it  proceeds  from  a  large  aneurism  that  has  perforated  the 
ventricle,or  from  avascular  growth,  or  occurs  in  haemorrhagic  diathesis, 
as  purpura  or  leucocythsemia.  Like  meningeal  haemorrhage,  it  is 
relatively  more  frequent  in  early  life  than  is  the  ordinary  form,  occur- 
ring even  in  cbildhood  and  infancy,  both  during  birth  and  in  the 
eai'ly  months  of  life.  Of  ninety-four  cases  collected  by  Saunders, f 
one  tenth  occurred  in  the  first  year  of  life,  and  one  fifth  were  under 
twenty,  about  a  quarter  under  thirty,  and  one  third  under  forty.  It 
is  rather  more  frequent  in  males  than  in  females  at  all  ages  except 
thirty  to  forty,  when  females  preponderate,  in  consequence  of  the 
influence  of  child-bearing,  and  the  mechanism  of  convulsions  occur- 
ring during  the  pregnant  and  puerperal  states. 

Traumatic  haemorrhage,  the  result  of  blows  and  falls  on  the  head, 
may  occur  at  any  age,  and  is  independent  of  arterial  degeneration.  It 
is  most  common  in  the  meninges,  extra-clural  as  the  result  of  rupture 
of  a  meningeal  artery  or  a  sinus,  or  subdural  or  subarachnoid  in  con- 
sequence of  rupture  of  a  vessel  of  the  pia  mater,  often  as  part  of 
superficial  laceration  of  the  brain.  Occasionally  it  occurs  within  the 
cerebral  substance,  and  may  then  be  multiple  ;  e.  g.  an  extravasation  in 
the  pons  may  co-exist  with  one  or  more  extravasations  into  the  hemi- 
spheres.    Traumatic  ventricular  haemorrhage  is  rare. 

Pathological  Anatomy. — In  the  majority  of  cases  there  is  only 
one  recent  haemorrhage  in  the  brain  ;  occasionally  there  are  two  or 
more,  of  which  one  is  much  larger  than  the  other  and  has  given  rise 
to  the  symptoms.     In  some  constitutional  diseases  with  a  tendency  to 

Note  continued. 


Age. 
0—10        .. 

Cases. 
10       .. 

Percentage. 
6 

Age. 
51—60       . 

Cases. 
..       19 

Perceutii 
11-5 

11—20        .. 

9       .. 

5-5 

61—70       . 

..       26 

..       15-7 

21—30       .. 

19       .. 

11-5 

71—80       . 

..       22 

135 

31—40       .. 

37       .. 

22-4 

81— UO       . 

2 

1-2 

41—50 

21       .. 

123 

*  It  has  been  suggested  that  the  fluid  within  the  ventricles  is  driven  into  the  aque- 
duct and  fourth  ventricle  with  such  force  as  to  injure  the  lining  membrane  and 
induce  disease  of  its  veins  (Bolliuger,  1891). 

T  In  a  careful  study  of  this  form,  published  in  the  'American  Journal  of  Med. 
Science,'  vol.  lxxxii,  1881,  pp.  85,  337. 


392  BKAIN. 

haemorrhage  the  brain  may  contain  many  extravasations.  In  leuco- 
cythaemia  more  than  fifty  small  haemorrhages  have  been  found.  The 
size  of  the  extravasation  varies  from  that  of  a  nut  to  that  of  the 
closed  fist.  It  may  even  have  torn  up  the  greater  part  of  one  hemi- 
sphere, may  have  distended  all  the  ventricles,  and  have  accumulated 
at  the  base.  The  two  hemispheres  are  affected  with  equal  frequency. 
Of  the  several  parts  of  the  brain,  the  central  ganglia  are  the  most 
frequent  seat  of  haemorrhage;  about  half  the  total  number  of  extra- 
vasations commence  in  the  corpus  striatum  or  its  neighbourhood. 
The  clot  often  extends  into  the  optic  thalamus,  but  does  not  often 
begin  in  it.  Next  in  frequency  is  haemorrhage  into  the  centrum 
ovale,  then  successively  the  cortex,  the  pons,  and  the  cerebellum. 
The  frequency  of  haemorrhage  in  the  cerebrum  is  twenty  times  greater 
that  in  the  cerebellum.  Haemorrhage  into  the  medulla  oblongata 
aud  crus  cerebri  is  rare,  although  the  latter  may  be  invaded  from 
above,  and  still  more  so  is  an  extravasation  into  the  corpus  callosum.* 

Within  the  cerebral  substance  the  blood  occupies  a  cavity  formed 
by  laceration  of  the  brain-tissiie ;  rarely,  when  very  small,  by  merely 
separating  the  fibres.  The  blood  is  clotted,  and  reddish  black  in 
colour ;  fragments  of  brain-tissue  are  mingled  with  it.  The  con- 
taining cavity  is  often  very  irregular  in  shape  ;  its  walls  are  uneven, 
present  projecting  shreds  of  lacerated  brain-substance,  and  are  blood- 
stained and  softened — at  first  by  imbibition  of  serum,  and  later  by 
inflammation.  Small  extravasations  are  sometimes  seen  in  the 
neighbourhood  of  a  larger  clot.  The  extravasated  blood  exerts 
pressure ;  the  convolutions  are  flattened ;  the  falx  is  bulged  to  the 
opposite  side,  and  the  rest  of  the  hemisphere  is  ana?mic.  The  effused 
blood  may  tear  its  way  into  the  lateral  ventricle  ;  it  then  speedily 
distends  both  lateivil  ventricles  and  the  third  and  fourth  ventricles, 
and  escaj>es  by  the  openings  at  the  lower  extremity  of  the  fourth 
ventricle,  central  and  lateral,  into  the  subarachnoid  space.  Or  the 
blood  may  tear  its  way  to  the  surface  of  the  convexity,  infiltrate  the 
pia  mater,  and  pass  into  the  subarachnoid  cavity,  often  by  a  very 
small  opening.  It  has  been  known  to  force  its  way  out  of  the  de- 
scending cornu  of  the  lateral  ventricles  by  the  transverse  fissure.  The 
artery  from  which  the  blood  has  escaped  can  often  not  be  detected 
unless  it  is  an  aneurism  of  some  size,  and  even  this  may  be  difficult  to 
discover.  The  miliary  aneurisms  can  often  be  found,  but  not  always 
that  which  has  ruptured. 

After  a  time  the  extravasated  blood  undergoes  changes.  The  clot 
shrinks,  and  gradually  becomes,  first  chocolate,  then  brown,  and  ulti- 
mately a  reddish  yellow  ;  and  it  then  contains  chiefly  fat-globules, 
pigment  and  other  granules,  and  haematoidin  crystals.  The  rapidity 
with  which  it  undergoes  this  change  is  uncertain,  and  certainly  varies. 
It  is  said  that  the  distinctive  blood-colour  has  disappeared  as  early  as 
the  twentieth  day ;  but  it  usually  persists  for  a  much  longer  time. 
*  Eib, '  Vircliow's  Arehiv/  xcvii,  329,  in  a  case  of  cerebro-spinal  meningitis. 


CEREBRAL   HEMORRHAGE.  393 

Meanwhile  the  walls  of  the  cavity  undergo  changes.  The  inflamma- 
tion, in  rare  cases  excessive  and  purulent,  is  usually  conservative,  and 
leads  to  the  formation  of  connective  tissue.  A  firm  wall  is  thus 
developed,  the  inner  surface  becomes  smooth,  and  a  cyst  results  ;  some- 
times it  is  seen  in  thirty  or  forty  days,  but  usually  only  in  the  course 
of  some  months.  It  is  said  that  connective  tissue  may  extend  across 
its  cavity,  and  that  in  rare  cases,  the  fluid  being  absorbed,  the  cyst 
walls  may  unite  and  a  cicatrix  result,  but  this  is  much  more 
frequently  due  to  softening. 

Traumatic  haemorrhage  occurs  into  and  from  a  lacerated  portion  of 
brain,  and  is  most  frequent  on  the  surface,  especially  on  the  convexity 
of  each  convolution.  It  is  most  frequent  in  regions  much  exposed  to 
injury,  direct  or  by  "  contre-coup,"  as  the  convexity,  or  the  temporo- 
sphenoidal  lobe,  on  the  under  surface  of  the  frontal  lobe.  Traumatic 
ventricular  hemorrhage  is  said  to  result  occasionally  from  rupture  of 
a  small  vein  on  the  surface  of  the  corpus  striatum  (Prescott  Hewett), 
or,  at  a  later  period,  by  the  process  already  desci-ibed. 

Soft  tumours  (especially  gliomata)  are  sometimes  the  seat  of 
haemorrhage  wbich  has  been  often  mistaken  for  a  primary  extravasa- 
tion, but  is  distinguished  sometimes  by  the  seat  being  one  in  which 
primary  haemorrhage  is  rare;  and  especially  by  the  presence  of  some 
adjacent  gelatinous-looking  substance,  which  has  characteristic  micro- 
scopic features. 

Other  organs  are  seldom  healthy ;  they  usually  present  (1)  the 
changes  which  indicate  the  predisposing  causes,  of  which  disease  of 
the  kidneys  and  hypertrophy  of  the  heart  are  the  most  frequent,  or 
(2)  alterations  consequent  on  the  cerebral  lesion.  The  lungs  are 
loaded  with  serum  and  mucus.  Occasionally  intense  congestions,  and 
even  haemorrhages,  are  found  in  the  stomach,  &c.  General  conges- 
tion may  be  due  to  the  mode  of  death,  but  in  other  cases  the  limited 
seat  of  the  congestion  and  its  intensity  render  it  probable  that  it  is 
due  to  derangement  of  the  vaso-motor  nerves. 

The  relation  of  haemorrhages  in  various  situations  to  the  vascular 
supply  has  been  carefully  traced  by  Duret.*  Certain  arteries  give 
way  more  frequently  than  others,  and  this  enables  us  to  understand 
the  position  of  the  extravasation.  The  arrangement  of  the  arteries  is 
described  at  p.  60. 

Corpus  Striatum. — The  haemorrhages  into  the  corpus  striatum  may 
be  divided  into  three  series — anterior,  middle,  and  posterior.  The 
anterior  are  situated  in  the  head  of  the  caudate  nucleus,  and  are  due 
to  tbe  rupture  of  the  branches  that  come  from  the  anterior  cerebral 
artery.  They  are  usually  small,  but  often  break  through  into  the 
lateral  ventricle.  The  middle  group  comprehends  those  produced  by 
the  rupture  of  the  lenticular  and  lenticulo-striate  branches  of  the  . 
middle  cerebral,  and  are  the  most  frequent  of  all  cerebral  haemor- 
rhages. These  vessels  may  rupture  anywhere  in  their  course,  outside 
*  '  Arch,  de  Physiologie/  1874,  p.  664. 


394  BRAIN. 

the  lenticular  nucleus,  within  it,  or  in  the  caudate  nucleus.  The 
extravasations  outside  the  nucleus  are  restrained  externally  by  the 
grey  cortex  of  the  insula  and  its  subjacent  layer  of  white  substauce  ; 
they  may  tear  up  or  displace  inwards  the  central  ganglia.  Blood 
within  the  ganglia  often  extends  upwards  and  outwards  in  the  white 
centrum  ovale,  and  may  attain  a  very  large  size.  The  posterior 
haemorrhages  are  due  to  the  rupture  of  the  lenticulo-optic  arteries  of 
the  middle  cerebral,  which  pass  through  the  lenticular  nucleus  into 
the  anterior  part  of  the  optic  thalamus.  The  extravasation  usually 
commences  in  the  thalamus,  or  between  it  and  the  corpus  striatum, 
and  the  blood  is  apt  to  escape  between  the  two  into  the  lateral 
ventricle.  They  often  damage  the  posterior  (sensory)  part  of  the 
internal  capsule.  The  small  arteries  to  the  inner  portion  of  the 
thalamus,  which  pass  from  the  posterior  cerebral,  or  posterior  com- 
municating, sometimes  give  way  and  cause  small  extravasations  near 
the  surface  (internal  thalamic  hemorrhages),  which  are  very  prone  to 
rupture  into  the  ventricle.  The  branches  of  the  posterior  cerebral  to 
the  hinder  part  of  the  thalamus  may  give  rise  to  extravasations  in 
this  situation  (posterior  thalamic  haemorrhage),  which  may  either 
rupture  into  the  lateral  ventricle  or  may  extend  down  into  the  eras 
and  even  into  the  pons. 

Centrum  Ovale.  —  Large  haemorrhages  usually  spread  into  the 
centrum  ovale  from  the  corpus  striatum.  The  vessels  in  the  white 
substance  itself  are  small,  and  give  rise  only  to  small  haemorrhages, 
rarely  larger  than  a  walnut,  and  often  oval,  with  the  long  axis  in  the 
direction  of  the  fibres.  Larger  extravasations  are  sometimes  found 
in  the  white  substance  of  the  occipital  lobe.  These  are  due  to  the 
rupture  of  branches  of  the  calcarine  division  of  the  posterior  cerebral 
artery. 

Cortex — Haemorrhages  limited  to  the  cortex  may  occur  in  almost 
any  position,  but  they  are  rare  and  are  usually  small,  although  they 
sometimes  extend  into  the  white  substance,  and  attain  in  it  a  larger 
size.  This  occurs  chiefly  when  the  membranes  have  been  thickened 
by  chronic  inflammation. 

Crura  Cerebri. — Haemorrhages  into  either  the  corpus  striatum  or 
optic  thalamus  may  extend  down  into  the  crus.  Those  which  com- 
mence in  the  crus  are  usually  small,  and  oval  in  form.  They  may 
descend  into  the  pons,  but  do  not  pass  up  into  the  centi*al  ganglia. 
They  may  be  situated  in  the  inner  part  of  the  crus,  or  in  the  outer 
part  beneath  the  corpora  geniculata,  or  in  the  upper  part  beneath  the 
corpora  quadrigemina. 

Pons. — Haemorrhages  are  most  frequent  near  the  middle  line, 
from  the  rupture  of  the  median  branches  of  the  basilar ;  and  the 
raphe  usually  prevents  their  extension  to  the  other  side.  The  extrava- 
sation often  has  a  spherical  shape,  and  may  be  kept  from  the  fourth 
ventricle  only  by  a  thin  layer  of  tissue  (Fig.  117),  which  may  give 
way,  and  the  blood  may  escape  into  the  cavity.      Sometimes    small 


- 

'-'$& 


CEEEBKAL    HEMORRHAGE.  395 

haemorrhages  extend  in  a  transverse  direction,  and  these  are  due  to 
the  rupture  of  the  small  lateral  branches  of  the  median  arteries. 
Haemorrhages  in  the  lateral  portions  of  the  pons,  from  rupture  of  the 
radicular  arteries,  are  rare.  The  vessel  that  most  frequently  gives 
way  is  the  branch  to  the  root  of 

the  fifth  nerve.  ^     cy.  tf£  "  ^  \ 

Cerebellum. — Large     haemor-  <oJ  'i  j^M ■.■"  ,"':..: 

rhages  are  most  frequently  due  ^*^7U  ■-->-■  xX 

to  the  rupture  of  a  branch  that         ■;;:'„•  x  ii-s-,        -.'      ":[x,- 

the    superior    cerebellar   artery        ;    .'-       '-^^^^       ' 
gives    to   the  dentate   nucleus.       -         ,  |p 

A  small  extravasation  may  oc-      \ 
cupy  the  interior  of  the  dentate 
nucleus,  arising  from  a  branch     '^~-%\      .^Bsb^ 
of   the    same    artery.     Has  in  or-  V         p       fl  I 

rhage  into  the  inner  and  hinder  "^  $11^^?-^ 

part    of    the     hemisphere    may  K^^'iZ~J^'~^K%!:~,. 

occur  from  rupture  of  a  branch 

of  the  posterior  cerebral.  Ex-  ^G-  117.— Haemorrhage  into  the  pons,  on 
,  ,.  .t      p        ,-,  the   left   of  the   middle   line.        f After 

travasations  near  the  fourth  ven-        Carswell.) 

tricle  readily  burst  into  it.     The 

cortex  of  the  cerebellum  offers  much  less  resistance  to  hemorrhage 
than  does  the  grey  matter  of  the  cerebral  convolutions.  The  superior 
and  inferior  cerebellar  peduncles  are  rarely  the  seat  of  haemorrhage, 
but  an  extravasation  sometimes  occurs  in  the  middle  cerebellar 
peduncle,  and,  more  frequently,  a  haemorrhage  in  one  half  of  the 
pons  may  extend  a  short  distance  into  the  peduncle,  passing  in  the 
direction  of  its  fibres. 

In  ventricular  haemorrhage,  whether  primary  or  secondary  (by  rap- 
ture of  an  extravasation  in  the  substance  of  the  brain),  the  blood  fills- 
all  the  ventricles  in  a  third  of  the  cases.  If  slowly  effused,  it  may 
occupy  only  one  lateral  ventricle,  and  such  limitation  is  met  with  in 
about  one  quarter  of  the  cases  of  each  variety.  It  occupies  both  lateral 
ventricles  alone  (not  extending  to  the  third  and  fourth),  more  fre- 
quently in  primary  than  in  secondary  haemorrhage.  It  is  rarely  con- 
fined to  the  fourth,  still  more  rarely  to  the  third.  The  blood  is  usually 
coagulated,  and  if  small  in  amount  the  clot  may  correspond  in  form  to- 
the  ventricular  cavity.  If  the  blood  is  slowly  effused,  the  distension 
of  the  lateral  ventricles  may  be  less  than  that  of  the  third  and.  fourth  ; 
in  the  latter  the  accumulation  of  blood  is  aided  by  the  influence  of 
gravitation  in  the  recumbent  posture.  In  primary  haemorrhage  the 
walls  of  the  ventricles  may  be  intact,  the  choroid  plexuses  are  anaemic 
from  pressure,  and  it  may  be  difficult  to  discover  the  source  of  the 
blood.  Superficial  lacerations  of  the  wall  of  the  distended  ventricle 
may  be  of  secondary  origin,  as  is  shown  by  the  fact  that  there  are 
many  of  similar  aspect.  Sometimes  it  is  difficult  to  say  whether  lace- 
ration is  the  source  of  the  haemorrhage  or  is  produced  by  it.     Occa- 


•396  BfiAIN. 

sionally  there  are  also  separate  extravasations  into  the  substance  of 
the  brain ;  or  a  meningeal  haemorrhage  may  co-exist,  even  when  the 
ventricular  extravasation  is  small. 

The  appearances  in  meningeal  haemorrhage  differ  according  to  its 
seat  and  amount.  There  is  a  layer  of  blood  either  upon  the  arachnoid 
or  in  the  subarachnoid  space,  sometimes  in  both.  The  blood  accumu- 
lates first  in  the  sulci  and  depressions,  and  is  generally  most  abundant 
at,  and  sometimes  confined  to,  the  base.  If  considerable  in  quantity 
over  the  convexity,  the  convolutions  may  be  distinctly  flattened.  Just 
as,  in  ventricular  haemorrhage,  blood  may  escape  from  the  fourth 
ventricle  into  the  meninges,  so  in  extensive  meningeal  haemorrhage 
blood  may  pass  into  the  fourth  ventricle,  and  a  little  may  even  find  its 
wav  into  the  lateral  ventricles.  The  blood  may  also  pass  down  into 
the  spinal  canal,  whether  the  meningeal  haemorrhage  is  primary,  or  ia 
due  to  the  escape  of  blood  from  the  ventricles.  It  often  distends  the 
sheaths  of  the  optic  nerves. 

Symptoms. — The  occurrence  of  cerebral  haemorrhage  is  indicated  by 
symptoms  of  two  classes,  the  one  general  and  transient,  the  other  local 
and  more  or  less  permanent.  Both  sets  of  symptoms  are  usually 
present,  but  either  may  be  so  slight  as  to  be  inconspicuous.  In  addi- 
tion, the  onset  may  be  preceded  by  what  are  termed  premonitory  sym- 
ptoms, and  followed  by  symptoms  outside  the  cerebral  functions, 
alterations  of  pulse,  temperature,  urine,  &c. 

The  premonitory  symptoms,  so  called,  are  on  the  whole  rare.  They 
consist  of  headache,  slight  vertigo,  weakness  or  tingling  in  the  limbs, 
slight  mental  changes,  or  slight  affection  of  speech.  These  symptoms 
may  be  continuous  or  paroxysmal,  coming  on  suddenly,  and  passing 
away  after  a  few  hours  or  days.  It  is  doubtful  how  far  it  is  correct 
to  speak  of  them  as  prodromata  of  haemorrhage.  The  miliary  aneu- 
risms, however  numerous,  cause  no  symptoms  until  they  burst.  The 
more  severe  antecedent  symptoms  are  sometimes  due  to  the  occur- 
rence of  actual  small  haemorrhages,  or  to  the  commencement  of  a 
haemorrhage  that  is  at  first  slight  and  afterwards  suddenly  becomes 
considerable.*  Slighter  "  prodromata  "  may  be  due  to  the  atheroma 
that  often  co-exists  with  miliary  aneurisms,  and  they  are  the  result  of 
interference  with  the  blood-supply  to  certain  parts  of  the  brain. 
They  thus  indicate  merely  an  associated  condition.  Hence  they  are 
far  less  frequent  before  attacks  of  haemorrhage  than  before  attacks  of 
thrombotic  softening,  and  they  are  similar  in  the  two  cases. 

Of  the  general  cerebral  symptoms  the  most  common  is  loss  of 
consciousness;    of  the  local   symptoms,    hemiplegia.      The   loss   of 

*  Thus  a  young  man,  who  had  suffered  from  lead-poisoning,  was  attacked  with 
severe  pain  in  the  right  side  of  the  head,  and  after  this  had  continued  for  ten  days, 
left  hemiplegia  suddenly  came  on,  without  loss  of  consciousness.  He  subsequently 
died,  and  a  haemorrhage  was  found  in  the  right  hemisphere,  which  had  damaged  the 
whole  thickness  of  the  internal  capsule,  hut  had  apparently  occurred  in  two  stages 
{Hardy,  '  Gaz.  med.  de  Paris/  June  11,  1880). 


CEREBRAL    HAEMORRHAGE.  397 

consciousness  usually  comes  on  suddenly,  and  constitutes  the  most 
common  form  of  "  apoplexy."  The  patient  may  fall  senseless, 
•without  any  subjective  symptom.  More  commonly  giddiness,  pain 
in  the  head,  weakness  in  one  side,  or  difficulty  in  speaking,  is  the  first 
indication  of  the  attack ;  and  in  .the  course  of  a  few  minutes,  or 
longer,  the  patient  becomes  unconscious,  and  seems  to  go  to  sleep, 
but  it  is  a  sleep  from  which  he  cannot  be  roused,  the  sleep  of 
"coma."  Occasionally  the  obscuration  of  consciousness  is  incom- 
plete ;  the  patient  can  be  partially  roused,  can  be  made  to  answer  a 
question,  put  out  his  tongue,  &c,  but  lapses  again  into  the  comatose 
state.  In  slighter  cases  he  may  only  seem  confused  or  "  dull." 
Rarely  there  is  not  even  this  interference  with  the  cerebral  functions, 
and  only  the  sudden  onset  of  the  local  symptoms  announces  the  occur- 
rence of  the  haemorrhage. 

In  the  most  severe  cases  the  symptoms  of  apoplexy,  as  described 
in  a  previous  page,  are  present  in  the  most  intense  degree.  The 
muscles  are  relaxed  and  flaccid,  urine  and  faeces  escape,  reflex  action 
is  abolished,  not  only  in  the  limbs,  but  in  the  conjunctiva  and  iris. 
Even  the  knee-jerk  is  lost  by  irritative  inhibition  of  the  spinal  centres. 
Only  the  beating  of  the  heart  and  the  movements  of  breathing  indicate 
the  continuance  of  life,  while  the  irregularity  of  the  former,  and  the 
laboured  character  and  stertor  of  the  latter,  show  how  frail  is  the 
tenure  by  which  life  is  held.  In  this  state  the  patient  may  die  a  few 
hours  after  the  onset,  but  death  occurs  so  rapidly  only  when  the 
haemorrhage  is  into  the  pons  or  medulla,  or  distends  the  fourth 
ventricle,  so  as  to  interfere  with  the  vital  centres,  cardiac  or  respi- 
ratory. In  very  rare  cases  death  has  occurred  within  an  hour,  once  in 
as  short  a  time  as  five  minutes  (Abercrombie).  Often  the  coma,, 
although  complete,  is  less  deep;  the  iris  still  acts  to  light,  liquid 
placed  in  the  mouth  may  still  be  swallowed.  It  is  common  for  the 
muscles  of  one  side  only  to  be  flaccid,  and  on  the  other  muscular  tone 
remains  and  the  raised  arm  falls  less  suddenly.  When  the  irritation 
is  insufficient  to  abolish  the  action  of  the  centres  on  which  the  knee- 
jerk,  &c,  depend,  it  may  arrest  the  controlling  influence,  so  that  there 
is  an  early  excess  of  this  irritability,  and  an  early  foot-clonus  can  be 
obtained  during  the  first  day  or  two.* 

The  aspect  of  the  face  presents  great  variations.  It  may  be  flushed 
and  turgid,  or  pale  and  pinched.  The  surface  of  the  body  is  usually 
wet  with  perspiration.  The  pulse  is  generally  at  first  slow,  often 
small  and  incompressible,  sometimes  quick.  Respiration,  besides  its 
labour  and  stertor,  may  have  the  Cheyne-Stokes  rhythm,  always  of 
evil  omen.  The  urine  may  be  at  first  abundant,  of  low  specific 
gravity,  and  acid  in  reaction.  Occasionally  albumen  is  present  for  a 
few  hours  after  the  onset  when  there  is  no  kidney  disease. 

A  convulsion  may  usher  in  the  attack,  but  is  not  common  unless 

*  The  effect  of  this  difference  in  degree  is  seen  also  after  an  apoplectic  fit,  and  in 
the  action  of  chloroform  and  ether. 


398  BRAIN. 

the  haemorrhage  is  in  the  cortex,  although  haemorrhage  into  the 
corpus  striatum  or  elsewhere  now  and  then  causes  a  general  convul- 
sion. Vomiting  occasionally  occurs,  more  frequently  when  the 
haemorrhage  is  into  the  cerebellum  than  when  it  is  in  other  parts  of 
the  brain.  Its  occurrence  is  probably  influenced  in  part  by  the  condi- 
tion of  the  stomach  ;  if  a  meal  has  been  taken  shortly  before  the  onset, 
the  process  of  digestion  may  be  arrested,  and  the  contents  of  the 
stomach  may  be  vomited. 

The  temperature  usually  falls  within  an  hour  after  the  onset,  and 
may  be  only  97°  or  96° ;  it  may  even  reach  94-4°  in  the  rectum.*  In 
cases  fatal  during  the  first  twelve  hours,  the  fall  may  continue  until 
death.  In  other  cases  the  temperature  may  become  normal  at  the 
end  of  the  first  day,  and  remain  so  in  slight  cases,  or  rise,  in  more 
severe  forms,  to  two,  three,  or  four  degrees  above  the  normal 
(Bourneville).  But  there  is  one  apparent  exception  to  the  rule  of 
initial  depression.  In  cases  of  haemorrhage  into  the  pons  or-medulla, 
the  temperature  may  rise  above  the  normal  within  an  hour  of  the 
onset,  and  during  the  next  hour  may  attain  a  height  of  104°  or  106°, 
and  the  rise  may  go  on  until  death.  It  may  also  rise  above  the  normal 
when  the  haemorrhage  is  into  the  grey  matter  of  the  central  ganglia, 
as  Hale  "White  has  shown,  by  experiment  and  observation. f 

The  duration  of  the  apoplectic  state  varies  much  in  cases  that 
recover  from  it.  At  the  end  of  from  half  an  hour  to  six  hours  reflex 
action  returns  in  the  limbs,  the  patient  gives  some  signs  of  returning 
consciousness,  and  moves  those  parts  that  are  not  paralysed.  Difficulty 
of  swallowing  and  impairment  of  articulation  may  exist  for  a  day  or 
two.  Dull  general  headache  is  usually  felt  as  consciousness  returns, 
and  there  is  occasionally  some  delirium. 

Even  during  the  state  of  apoplexy  some  indications  of  a  unilateral 
lesion  may  be  present;  reflex  action,  if  lost,  returns  on  one  side  only  ; 
on  the  other  it  remains  absent  in  the  foot,  cremaster,  or  abdomen  : 
the  muscular  tone  is  different  in  the  two  arms,  as  already  mentioned, 
and  sometimes  the  affected  side  becomes  rigid.  The  head  and  eyes 
may  be  directed  to  one  side  in  "  conjugate  deviation,"  usually  from 
the  side  on  which  the  limbs  are  affected,  sometimes  towards  it,  accord- 
ing to  the  laws  already  stated  (p.  78).  As  the  general  cerebral 
symptoms  lessen,  the  local  symptoms,  persisting,  become  more  pro- 
minent. The  return  of  movement  in  the  unaffected  limbs  defines  the 
paralysis,  which  is  usually  hemiplegic.  When  the  loss  of  conscious- 
ness is  slight  or  absent,  the  loss  of  power  is  conspicuous  from  the 
first,  and  the  subjective  symptoms,  already  described  as  occasionally 
attending  the  onset  of  apoplexy,  rise  into  greater  prominence. 

The  attack  often  occurs  during  sleep.     The  patient  is  either  found 

*  In  a  case  of  extensive  ventricular  haemorrhage,  due  to  the  rupture  of  an  aneu- 
rism, recorded  hy  Bastian  ('  Trans.  Clin.  Soc.,'  1S83,  p.  18). 

+  A  gradual  rise  to  107"5°  during  the  two  days  life  endured,  occurred  in  a  case 
of  hemorrhage  into  the  lenticular  nucleus,  observed  by  Pasteur  (*  Lancet,'  1889). 


CEREBRAL   HEMORRHAGE.  399 

unconscious  in  the  morning,  or  wakes  unaware  of  what  has  happened, 
and  only  discovers  his  paralysis  when  he  attempts  to  stand.  The 
state  of  sleep  has  been  thought  to  favour  the  occurrence  of  haemor- 
rhage, but  it  is  not  proved  that  the  number  of  cases  occurring  during 
sleep  is  larger  than  corresponds  to  the  proportion  of  existence  spent 
in  that  condition. 

In  all  except  the  slightest  cases,  there  occurs,  two  or  three  days 
after  the  onset,  slight  general  febrile  disturbance,  due  to  inflamma- 
tory changes  about  the  cerebral  lesion.  There  may  be  merely  head- 
ache, loss  of  appetite,  quickening  (sometimes  slowing)  of  the  pulse, 
and  a  rise  of  temperature  of  one  or  two  degrees,  lasting  a  few  days. 
In  other  cases  the  rise  of  temperature  is  greater,  consciousness  may 
be  dulled  or  even  again  lost,  or  there  may  be  some  delirium.  If  con- 
sciousness has  not  been  regained,  the  coma  deepens,  there  is  a  tendency 
to  sloughing  and  vesication  of  the  skin,  swallowing  is  impossible, 
mucus  accumulates  in  the  chest,  and  the  patient  usually  dies.  During 
this  stage  of  inflammatory  reaction,  rigidity  ("early  rigidity")  often 
develops  in  the  paralysed  limbs.  The  urine  becomes  less  abundant, 
and  may  lose  its  acidity. 

Before  the  initial  coma  has  passed  away  it  may  be  suddenly 
deepened,  or  consciousness,  after  being  regained,  may  be  again  suddenly 
lost,  in  consequence  of  the  extravasation  bursting  into  the  ventricles. 
The  symptoms  of  this  occurrence  are  described  further  on. 

As  the  general  cerebral  symptoms  subside,  only  those  remain  that 
are  due  to  the  local  effect  of  the  lesion,  and  consist  in  the  loss  of  the 
functions  subserved  by  the  structures  destroyed.  Since  the  haemor- 
rhage is  usually  in  one  side  of  the  brain,  the  persisting  symptoms  are 
commonly  unilateral  in  distribution.  But  the  unilateral  symptoms 
that  can  be  at  first  recognised  are  much  wider  in  extent  than  those 
that  ultimately  remain.  There  may  be  at  first  an  apparent  loss  of 
function  of  almost  all  parts  of  one  hemisphere,  and  even  of  the  whole 
brain.  There  is  not  only  loss  of  motor  power,  but  there  is  often  loss 
of  sensibility,  and  this  in  cases  in  which  the  ultimate  loss  is  purely 
motor.  Indications  of  hemianopia  may  often  be  found  in  the  early 
stage  ;  if  the  finger  is  brought  suddenly  before  the  eye,  first  from  one 
side  and  then  from  the  other,  it  will  be  fouud  that  the  eyelids  blink 
when  the  finger  comes  from  the  unparalysed  side,  and  not  when  it 
comes  from  the  affected  side.  The  early  conjugate  deviation  of  the 
head  and  eyes,  already  mentioned,  is  sometimes  a  symptom  of  the  same 
character.  These  wide  initial  symptoms  show  that  the  interference 
with  the  function  of  the  hemisphere  extends  at  first  far  beyond  the 
limits  of  the  destruction  wrought  by  the  haemorrhage.  The  effect  is 
probably  partly  due  to  the  influence  of  the  pressure  on  the  adjacent 
nerve-elements,  partly  to  anaemia  produced  by  that  pressure,  partlv  to 
inhibition  by  the  irritative  influence  of  the  acute  lesion.  These  sym- 
ptoms gradually  lessen;  some,  such  as  the  hemianopia,  usually  pass 
away  in  a  few  days,  others  in  a  few  weeks,  until  there  remain  only 


400  BRAIN. 

those  that  are  the  direct  effect  of  the  destruction ;  these  persist  for 
months,  and,  unless  the  loss  is  of  such  a  character  that  it  can  be 
supplemented  by  the  action  of  the  other  hemisphere,  they  continue 
for  the  rest  of  life.  The  pressure  is,  of  course,  greatest  on  the 
structures  nearest  to  the  haemorrhage,  and  the  symptoms  thus 
produced  last  longer  than  do  those  that  result  from  the  slighter 
pressure  on  distant  parts.  The  symptoms  produced  by  these  two 
mechanisms  have  been  distinguished  as  "direct"  and  "indirect" 
symptoms.*  But  the  two  are  the  same  in  character,  and  can  only  be 
distinguished  in  practice  by  the  gradual  disappearance  of  the  one 
and  the  persistence  of  the  other. 

In  some  cases  there  is  a  slight  increase  of  the  local  symptoms 
during  the  period  of  "inflammatory  reaction,"  due,  no  doubt,  to  the 
damage  to  adjacent  structures  by  the  inflammation  around  the  lesion. 

Chronic  Stage. — The  enduring  symptoms,  which  persist  after  the 
initial  stage  is  over,  are  due  to  the  local  interference  with  the  func- 
tions of  the  damaged  part  of  the  brain,  and  are  determined  by  the 
situation  of  the  lesion.  Persistent  general  cerebral  symptoms,  such, 
for  instance,  as  are  so  conspicuous  in  cases  of  tumour,  are  for  the 
most  part  absent  in  haemorrhage.  Headache  is  trifling  ;  optic  neuritis 
is  practically  unknown.  Convulsions  are  rare.  Some  mental  change 
may  be  present,  slight  or  considerable,  and  evidenced  chiefly  by  defec- 
tive memory,  irritability,  and  emotional  instability,  but  is  less  than  in 
atheromatous  softening. 

Local  symptoms,  persistent  in  most  cases,  are  absent  when  the 
lesion  is  so  placed  as  to  spare  the  structures  concerned  directly  in 
motion,  sensation,  &c. 

The  most  common  symptom  is  motor  hemiplegia,  because  haemor- 
rhage is  most  frequent  in  the  region  of  the  corpus  striatum  and 
internal  capsule,  and  the  anterior  part  of  the  hinder  line  containing 
the  fibres  of  the  motor  path  rarely  escapes  laceration  or  compression. 
"When  due  to  damage  to  the  motor  centres  or  path  the  hemiplegia 
gives  the  characters  already  described,  and  is  attended  with  rigidity, 
excess  of  wrist-  and  knee-jerk,  and  with  the  foot-clonus  that  indicates 
secondary  degeneration  in  the  pyramidal  fibres.  Hemianaesthesia  is  less 
common,  because  haemorrhage  is  frequent  near  the  posterior  part  of 
the  capsule,  in  which  the  sensory  tract  is  contained.  But  it  is  not 
uncommon  to  have  some  blunting  of  sensibility,  especially  on  the 
extremities  of  the  limbs  on  the  hemiplegic  side.  Increased  sensitive- 
ness to  pain  is  sometimes  present,  and  may  co-exist  with  tactile 
anaesthesia,  and  be  accompanied  by  spontaneous  pains,  but  these  are 
less  common  than  in  cerebral  softening.  Trophic  disturbances  in  the 
hemiplegic  side  vary  in  frequency  and  degree  ;  there  may  be  persistent 

*  A  not  very  happy  distinction,  since  the  pressure  effects  are  as  much  the  direct 
effects  of  the  haemorrhage  as  is  the  laceration.  Only  the  inhibitory  symptoms  are, 
strictly  speaking,  indirect,  but  these  cannot  be  separated  practically  from  those  that 
are  due  to  pres-ure. 


CEREBRAL    HiEMORRFIAGE.  401 

elevation  of  temperature,  the  muscular  wasting,  and  the  joint  inflam- 
mation described  in  the  chapter  on  hemiplegia.  The  atrophy  of 
the  muscles  varies  in  degree  in  different  cases,  but  it  is  moderate, 
and  is  not  attended  with  any  considerable  change  in  electrical  excita- 
bility, or  any  destructive  degeneration  of  the  ganglion-cells  of  the 
cord. 

The  symptoms  produced  in  each  locality  are  for  the  most  part 
those  that  have  been  described  in  the  chapter  on  "Localisation,"  but  a 
few  additional  facts,  relating. especially  to  haemorrhage,  may  be  here 
mentioned. 

Cortex. — Hsemorrhage  into  the  substance  of  the  cortex  is  very  rare, 
but  occurs  sometimes  from  aneurisms  about  which  there  is  sufficient 
inflammatory  thickening  to  prevent  external  rupture.  This  may  be 
produced  when  embolism  is  the  cause  of  the  aneurism,  and  the  in- 
flammation in  the  wall  of  the  artery  spreads  to  the  tissues  over  it. 
The  onset  is  often  attended  by  convulsions,  which  begin  locally,  and 
may  be  one-sided  if  the  motor  area  is  affected.  Subsequent  para- 
lysis may  affect  only  part  of  one  side.  Hsemorrhage  into  the  centrum 
ovale  causes  symptoms  similar  to  those  due  to  a  cortical  lesion  in 
the  corresponding  situation,  but  without  symptoms  of  irritatiou  of 
equal  degree,  unless  the  lesion  is  just  beneath  the  motor  cortex,  when, 
for  some  reason,  irritation  symptoms  (convulsions  and  rigidity)  may 
be  severe  and  lasting  (Mills). 

Crus  Cerebri  — A  limited  extravasation  may  cause  the  characteristic 
crossed  palsy  of  third  nerves  and  limbs ;  but  often  the  hsemorrhage 
passes  beyond  the  limits  of  the  crus,  either  upwards  into  the  foot  of 
the  internal  capsule  (and  then  causes  well-marked  hemianaesthesia 
as  well  as  hemiplegia)  or  downwards  into  the  pons,  and  may  then 
paralyse  both  third  nerves,  and  the  limbs  on  both  sides.  The  corpora 
quadrigemina  are  never  the  seat  of  limited  haemorrhage. 

Pons  Varolii. — Initial  loss  of  consciousness  may  be  present  or 
absent,  just  as  in  haemorrhage  elsewhere.  Initial  convulsions  are 
especially  frequent,  rarely  unilatei'al,  but  usually  general ;  sometimes 
affecting  the  legs  only,  a  symptom  almost  unknown  from  disease  in 
other  parts.  The  convulsion  is  often  irregular  in  type,  sometimes 
tonic,  or  tonic  varied  with  occasional  clonic  jei-kings.  The  paralysis  is 
often  bilateral,  but  a  small  haemorrhage  may  cause  hemiplegia  from 
the  first.  Bilateral  palsy  may  affect  mainly  the  legs  or  the  arms. 
Anaesthesia  often  accompanies  it,  and  may  even  preponderate.  The 
pupils  are  often  strongly  contracted,  so  as  to  suggest  opium  poison- 
ing, or  they  may  be  diluted  and  motionless, — the  difference  depend- 
ing on  the  irritation  or  paralysis  of  the  nuclei  of  the  third  nerves. 
The  deviation  of  the  head  and  eyes  from  the  side  of  a  unilateral  lesion 
is  occasionally  observed  (see  pp.  318  and  186).  Respiration  often  suffers 
early,  and  may  present  irregularities,  sometimes  almost  convulsive  in 
their  character.  Vomiting  is  frequent.  The  temperature  often  rises 
rapidly  to  a  hyperpyrexia!  degree.  Death  is  usually  more  speedy 
vol.  ii.  26 


402  BKAIN. 

than  in  haemorrhage  into  the  cerebrum ;  it  has  occurred    in   seven 
minutes.* 

Medulla  Oblongata. — A  considerable  haemorrhage  causes  death  very 
quickly,  and  even  instantaneously.  It  is  doubtful  whether  convul- 
sions occur  when  the  extravasation  is  confined  to  the  medulla.  The 
patient  rarely  survives  the  actual  onset ;  if  he  does,  the  symptoms  that 
persist  resemble  those  of  bulbar  paralysis,  but  this  is  extremely  rare  ; 
sudden  apoplectiform  bulbar  paralysis  is  due,  in  the  vast  majority  of 
cases,  to  softening  from  vascular  occlusion,  not  to  haemorrhage. 

Cerebellum. — Loss  of  consciousness  is  as  common  as  in  haemorrhage 
elsewhere,  and  presents  the  same  variations  in  its  degree.  There  is 
often  no  initial  paralysis  ;  sometimes  there  is  hemiplegia,  due  to 
pressure,  and  it  may  be  on  the  same  side  as  the  haemorrhage,  or  on 
the  opposite  side,  according  as  the  pressure  is  exerted  on  the  pons  or 
on  the  medulla.  The  absence  of  hemiplegia  is  more  significant  than 
its  presence.  The  pressure  may  also  cause  various  paralyses  in  the 
parts  supplied  by  the  cranial  nerves  that  arise  from  the  pons  and 
medulla.  The  state  of  the  pupils  varies  ;  vision  is  unaffected.  Vomit- 
ing is  more  frequent  than  in  haemorrhage  elsewhere,  being  met  with 
in"  half  the  cases,  and  it  is  also  more  often  persistent.  It  may  occur 
without,  as  well  as  with,  loss  of  consciousness.  If  recovery  tahes 
place,  the  pressure-effects,  including  the  hemiplegia,  pass  away,  and 
the  only  lasting  symptom  is  cerebellar  unsteadiness,  which  persists  in 
some,  but  not  in  all  the  cases.  Haemorrhage  into  the  cerebellum  often 
bursts  into  the  fourth  ventricle,  causing  fatal  depression  of  the  func- 
tions of  the  medulla.  When  the  middle  cerebellar  peduncle  is  the 
seat  of  haemorrhage,  the  characteristic  symptoms,  forced  lateral  posi- 
tion of  the  head,  difference  in  height  of  the  eyes,  and  a  tendency  to  lie 
on  one  side,  and  even  to  rotate,  is  usually  distinct,  even  sometimes  at  the 
onset  during  the  stage  of  apoplexy,  and  if  the  patient  is  conscious 
there  is  usually  intense  vertigo. 

Ventricular  Haemorrhage. — The  effusion  of  blood  into  the  ventricles 
of  the  brain  is  indicated  by  severe  apoplectic  symptoms,  the  origin  of 
which  is  easy  to  understand.  When,  as  in  the  majority  of  cases,  the 
rupture  is  into  one  lateral  ventricle,  the  blood  rapidly  distends  the 
other  also,  and  the  whole  cortex  is  compressed.  The  blood  soon  passes 
into  the  third  and  fourth  ventricles,  and  compresses  the  important 
structures  that  lie  in  the  floor  of  the  latter.  In  the  rare  cases  in 
which  the  rupture  is  into  the  fourth  ventricle  the  pons  and  medulla 
bear  the  full  force  of  its  pressure,  and  the  grave  symptoms  of  inter- 
ference with  this  part  of  the  brain  are  conspicuous  from  the  first, 
and  resemble  closely  those  produced  by  haemorrhage  into  the  sub- 
stance of  the  pons.  This  is  also  the  case  when  the  rupture  is  into 
the  lateral  ventricles,  and  occurs  slowly  ;  the  fourth  ventricle  may 
then  be  much  more  distended  than  the  lateral  ventricles  (see  p.  395). 
Haemorrhage  into  the  ventricles  is  sometimes  primary,  but  much 
*  Mickle,  '  British  Med.  Journal,'  1881,  ii,  151. 


CEREBRAL    HEMORRHAGE.  40o 

more  frequently  secondary  to  haemorrhage  into  the  cerebral  substance, 
from  which  the  blood  tears  its  way  into  the  cavities.  In  the  former 
case  the  severe  apoplexy  is  primary;  in  the  latter  it  supervenes  on  the 
symptoms  of  the  cerebral  hsemorrhage  already  described.  The  primary 
apoplexy  may  have  passed  away  or  have  lessened,  or  may  be  still  at 
its  height,  when  it  suddenly  returns  or  becomes  deeper.  The  initial 
deviation  of  the  head  and  eyes  ceases,  and  is  of  ten  replaced  by  a  devia- 
tion in  the  opposite  direction.  The  pulse  is  again  slowed,  and  may 
fall  to  50  or  40  beats  per  minute.  The  temperature  may  fall  to  97°  or 
96°.  The  respiration  becomes  more  laboured  and  stertorous.  The 
reflex  action  is  again  lost  in  the  limbs  and  eyes ;  the  pupils  are  some- 
times dilated,  sometimes  contracted  ;  rigidity  often  appears  in  the 
limbs  on  the  hemiplegic  side,  sometimes  in  those  on  the  other  side; 
there  may  be  convulsions,  sometimes  general,  sometimes  affecting  only 
the  un  paralysed  side.  Paroxysms  of  general  and  clonic  spasm,  with 
slight  opisthotonos,  have  been  ol 'served.*  After  a  few  hours  the 
pulse  often  becomes  more  frequent ;  the  temperature  may  remain  low 
or  may  rise,  sometimes  to  104°  or  higher.  The  chest  becomes  filled 
with  rales,  occasionally  with  extreme  rapidity,  even  within  a  couple  of 
hours  of  the  onset ;  the  face  becomes  livid,  respiration  is  increasingly 
difficult,  and  the  patient  dies  from  the  interference  with  breathing. 
In  many  cases  the  blood  escapes  from  the  fourth  ventricle  into  the 
subarachnoid  space  at  the  base  of  the  brain,  and  the  symptoms  may 
be  in  part  due  to  this. 

Primary  ventricular  haemorrhage  causes  symptoms  which  may,  from 
the  first,  closely  resemble  those  of  the  secondary  form,  but  more  fre- 
quently the  onset  resembles  that  of  hsemorrhage  into  the  suUstanceof 
the  brain,  in  the  presence  at  first  of  unilateral  symptoms.  Prodromata 
are  rare,  but  headache  is  occasionally  met  with,  very  variable  in 
seat,  character,  and  duration.  The  onset  may  be — (1)  By  sudden 
apoplexy,  deepening  rapidly ;  death  may  occur  in  a  few  hours.  (2)  By 
apoplexy  with  hemiplegic  symptoms,  or  with  convulsions.  (3)  In  the 
very  rare  slow  haemorrhage,  hemiplegia  first  occurs  alone,  loss  of  con- 
sciousness only  supervening  after  a  few  hours.  Hemiplegia  occurs 
because  the  blood  is  effused  first  into  one  lateral  ventricle,  and  causes 
paralysis  on  the  opposite  side  by  the  compression  of  the  motor  path 
or  centres.  When  the  effusion  is  rapid  and  both  lateral  ventricles 
quickly  become  distended,  the  unilateral  symptoms  quickly  give  place 
to  general  relaxation  of  the  muscles,  and  loss  of  all  reflex  action. 
Bigidity  is  often  met  with,  but  less  frequently  than  in  the  secondary 
form;  it  is  usually  bilateral,  sometimes  one-sided,  and  occasionally 
involves  only  the  muscles  of  mastication:  it  may  be  intermittent. 
Convulsions  are  also  frequent,  occurring  in  at  least  a  third  of  the 
cases,  sometimes  general,  sometimes  affecting  only  the  paralysed  side, 
or  a  part  of  it.  In  cases  of  slow  onset,  speech  is  olten  lost  before 
consciousness.  The  power  of  swallowing  usually  persists  until  the 
*  Bastian,  '  Trans.  Clin.  Sot-.,'  1884,  p  22. 


40-4  BRAIN. 

apoplexy  becomes  profound.  The  temperature  resembles  that  of  other 
forms  of  cerebral  haemorrhage.  The  malady  is  usually  fatal,  but  reco- 
very has  occurred,  shown  by  old  and  altered  clot  in  the  lateral 
ventricles  ;  but  it  is  only  possible  when  the  haemorrhage  is  so  small  in 
quantity  that  the  symptoms  are  slight  and  equivocal. 

Meningeal  Haemorrhage. — The  symptoms  of  meningeal  haemorrhage 
vary  much  according  to  its  cause.  The  rupture  of  a  large  aneurism  at 
the  base  causes  severe  apoplexy,  rapidly  deepening  to  lethal  intensity. 
But  since  slight  haemorrhage  sometimes  occurs  before  the  final  rupture, 
the  loss  of  consciousness  may  be  preceded  by  definite  prodromata, 
and  is  so  preceded  more  frequently  than  is  intra-cerebral  haemorrhage. 
These  prodromata  are  severe  headache  (sometimes  occipital),  giddi- 
ness, and  occasionally  vomiting.  The  attack  itself  is  attended  by 
paralysis  and  atony  of  the  limbs  on  both  sides,  and  sometimes  by  palsy 
of  cranial  nerves  or  by  convulsions. 

When  the  haemorrhage  is  of  traumatic  origin,  the  effect  of  the  injury 
obscures  the  initial  symptoms.  In  these  and  other  cases  in  which  the 
escape  of  blood  is  gradual,  the  patient  may  recover  consciousness  and 
continue  his  occupation  for  some  hours  or  even  for  a  day  or  two,  com- 
plaining only  of  headache,  and  then  gradually  become  somnolent  and 
pass  into  a  state  of  coma. 

In  some  cases  of  meningeal  haemorrhage,  convulsions  are  the  most 
prominent  symptom,  and  they  may  be  either  general  or  unilateral, 
and  in  the  latter  case  may  commence  locally  in  the  face  or  arm,  or 
by  deviation  of  the  head.  Rigidity  of  limb  is  comparatively  rare,  far 
more  so  than  in  meningitis.  In  some  cases  there  is  mental  excitement 
or  delirium,  in  others  there  is  mental  dulness.  The  state  of  the  pupils 
is  very  variable  ;  they  may  be  contracted  or  dilated  or  unequal. 
Sometimes  headache  and  giddiness  are  accompanied  by  tingling  in  the 
limbs  and  weakness  on  one  or  both  sides.  Initial  apoplexy  may  be 
absent,  and  these  symptoms,  commencing  suddenly,  may  increase  until 
consciousness  suffers.  The  variation  presented  by  these  cases  is  thus 
very  great. 

In  some  cases,  in  young  adults,  the  occurrence  of  meningeal  haemor- 
rhage is  probably  indicated  by  intense  pain  in  the  head  at  one  spot, 
soon  followed  by  coma  and  by  convulsions.  The  cases  are  remarkable 
as  occurring  without  other  exciting  cause  than  exertion  in  a  hot  room, 
sometimes  after  a  meal.  The  patient  may  recover  partial  conscious- 
ness in  a  day  or  two,  and  present  for  about  a  week  the  symptoms  of 
slight  meningitis,  but  considerable  mental  dulness  is  apt  to  ensue, 
and  to  continue  sometimes  for  months.  Or  in  this,  as  in  other  forms 
of  meningeal  haemorrhage,  the  patients  may  die  in  the  state  of  coma, 
after  a  few  hours;  sometimes  death  seems  due  to  the  violence  of  the 
convulsions.  Coma  occasionally  passes  away  and  recurs.  The 
frequency  with  wdiich  recovery  occurs  cannot  well  be  estimated. 
The  meningeal  haemorrhage  of  newly  born  children  is  separately 
described. 


CEREBRAL    HEMORRHAGE.  405 

Pathology.- — While  the  rupture  of  the  vessel  is  always  the  result 
of  weakening  of  its  wall,  and  of  the  pressure  of  blood  within  it,  the 
actual  conditions  of  rupture  vary  considerably.  The  variations  relate 
to  the  degree  of  blood-pressure — the  size  of  the  artery,  of  the  aneurism, 
and  of  the  opening  in  it — the  freedom  of  exit  of  the  blood,  or  the 
hindrance  to  its  escape  by  clot  within  the  dilated  part,  and  the  resist- 
ance in  the  tissue  into  which  the  blood  passes,  which  is  less  in  tLe 
grey  than  in  the  white  substance.  The  precise  conditions  in  any  indi- 
vidual case  can  rarely  be  traced,  but  on  them  must  depend  the  size  of 
the  haemorrhage,  and  the  rapidity  with  which  the  blood  is  effused. 
These  two  elements  chiefly  determine  the  symptoms  that  attend  the 
onset.  ~No  doubt  the  occurrence  of  both  aneurism  and  haemorrhage  is 
due  largely  to  the  slightuess  of  the  support  that  the  cerebral  tissue 
affords  to  its  vessels.  This  is  less  in  the  old  than  in  the  young,  on 
account  of  the  larger  size  of  the  perivascular  spaces,  occupied  only  by 
mobile  liquid. 

It  is  a  well-known  law  of  hydrostatics  that  if  a  liquid  passes  into  a 
closed  chamber  by  a  small  opening,  the  total  pressure  within  the 
chamber  is  that  in  the  opening  multiplied  by  the  number  of  times  the 
ai'ea  of  the  wall  of  the  chamber  exceeds  the  opening  in  size.  Thus 
the  total  pressure  within  the  aneurism  must  be  much,  greater  than  in 
the  artery  from  which  it  springs,  and,  at  the  same  time,  the  wall  is 
weakened.  After  rupture,  the  blood  in  the  cavity  formed  by  the  extra- 
vasation will  be  influenced  in  the  same  way;  and  although  the  actual 
condition  and  the  result  are  doubtless  modified,  the  general  law  must 
hold  good  in  some  degree.  We  are  thus  able  to  understand  bow  so 
small  a  jet  of  blood  may  produce  a  cavity  in  the  brain  of  so  large  a  size. 
Doubtless  the  process  is  facilitated  by  the  softening  and  disintegration 
of  the  adjacent  tissue.  On  the  other  hand,  the  transmission  of  the 
pressure  must  be  modified  and  retarded  when  the  blood  begins  to 
coagulate. 

The  most  common  seat  of  haemorrhage  is  the  region  of  the  corpus 
striatum,  because  the  arteries  that  most  frequently  rupture  are  the 
branches  that  come  off  at  right  angles  from  the  middle  cerebral,  in 
the  fissure  of  Sylvius,  and  pass  upwards  through  the  lenticular  nucleus 
and  the  internal  capsule  to  the  caudate  nucleus  and  optic  thalamus 
(see  Fig.  44,  p.  62).  A  large  artery  which  passes  between  the  outer 
part  of  the  leuticular  nucleus  and  the  external  capsule,  then  through 
the  former  to  the  internal  capsule,  is  so  frequently  the  source  of  the 
extravasation  that  it  has  been  termed  by  Charcot  par  excellence  "  the 
artery  of  cerebral  haemorrhage."  A  small  haemorrhage  from  it  simply 
separates  the  external  capsule  from  the  lenticular  nucleus,  occupying 
a  narrow  fissure  thus  formed,  which  may  correspond  to  almost  the 
whole  outer  aspect  of  the  lenticular  nucleus,  but  a  large  haemorrhage 
displaces  inwards  and  erodes  all  the  central  ganglia.  All  these 
branches  of  the  middle  cerebral  pass  to  the  internal  caj:>suie,  and  as 
this  lies  over  the  inner  upper  aspect  of  the  lenticular  nucleus,  it  rarely 


40o  BltAUST. 

escapes  damage — by  pressure  if  tbe  baemorrhage  is  small,  by  lacera- 
tion if  it  is  large.  Hence  hemiplegia,  transient  or  permanent,  is  so 
common  a  symptom.  Tbe  branches  that  have  a  posterior  course,  to 
the  hinder  part  of  the  capsule,  less  frequently  give  way,  and  hence 
lasting  hemianesthesia  is  comparatively  rare.  Tbe  pressuve  in  tbese 
vessels  has  been  found  to  be  little  less  than  tbat  in  the  carotid 
(Mendel), — it  is  supposed  because  they  have  no  anastomoses;  that  in 
tbe  arteries  of  the  cortex  is  far  lower. 

The  meebanism  by  which  the  loss  of  consciousness  and  the  other 
svmptoms  of  apoplexy  are  produced  has  been  previously  considered 
(pp.  99  et  seq.).  It  is  only  necessary  here  to  repeat  that  we  must  recog- 
nise a  double  mechanism,  the  mechanical  effect  of  the  pressure  on  tbe 
cortex,  and  the  inhibition  of  its  ceils  by  the  mechanical  irritation  of 
the  torn  nerve-fibres.  Both  of  tbese  effects  are  tbe  greater  tbe  more 
rapidly  the  blood  is  poured  out,  and  the  larger  its  amount;  wbile  the 
inhibitory  effect  is  doubtless  influenced  also  by  the  position  of  tbe 
lesion,  injury  to  structures  (as  the  fibres  in  the  pons)  that  bave  an 
extensive  connection  with  the  cortex  being  specially  effective. 

Thus  consciousness  is  preserved  at  tbe  onset,  only  wben  the 
haemorrhage  is  smali,  or  the  blood  escapes  very  slowly,  or  when  the 
extravasation  is  so  placed  that  tbe  irritation  basbut  a  slight  influence 
on  tbe  cortex.  When  the  effusion  occurs  slowly  but  the  conditions 
are  unfavorable  to  the  cessation  of  the  flow  of  blood,  consciousness 
may  be  lost,  not  suddenly  at  the  onset,  but  gradually,  as  tbe  haemor- 
rhage attains  a  considerable  size,  giving  rise  to  tbe  "ingravescent 
apoplexy."  As  Broadbent  has  pointed  out,  this  form  is  often  due  to 
rupture  of  the  artery  that  passes  outside  the  corpus  striatum,  although 
even  in  the  case  of  this  vessel  there  is  sudden  initial  apoplexy  much 
more  frequently.  The  difference  is  probably  due  to  the  character  of 
the  rupture  in  the  wall,  whether  it  is  large  or  small.  Ingravescent 
apoplexy  may  also  occur  from  rupture  of  a  vein  (as  is  often  seen  in 
traumatic  haemorrhage)  ;  the  pressure  in  the  vein  is  low,  and  the 
blood  escapes  slowly.  It  may  even  result  from  the  rupture  of  a 
surface  aneurism  into  the  brain  substance,  the  membranes  being 
thickened  and  resistent. 

Diagnosis. — The  diagnosis  of  the  nature  of  the  cerebral  lesion  bus 
to  be  made  under  two  conditions;  first  duiiug  the  initial  apoplexy, 
and  secondly  when  this  has  passed,  and  only  the  enduring  effects  of 
the  lesion  remain.  The  first  is  incomparably  the  most  important, 
since  by  it  the  treatment  has  to  be  determined.  Unfortunately,  it  is 
olten,  of  all  the  diagnostic  problems  presented  to  the  physician,  at 
once  the  most  difficult  and  the  most  urgent. 

The  first  question  in  diagnosis  is  whether  an  attack  of  apoplexy  is 
of  cerebral  origin.  The  chief  points  in  the  differential  diagnosis  have 
been  considered  in  the  account  of  this  condition.  If  cerebral  sym- 
ptoms, such  as  unilateral  numbness  or  weakness,  have  preceded  the 


CEREBRAL    H/EMORKHAGE.  407 

loss  of  consciousness,  or  are  to  be  traced  in  it,  as  by  one-sided  relaxa- 
tion of  limb  or  deviation  of  the  head,  the  cerebral  nature  of  the  attack 
is  clear.  If  these  are  absent,  the  question  must  be  determined  by  the 
considerations  mentioned  at  p.  103.  An  actually  sudden  onset  limits 
the  diagnosis  to  the  distinction  from  syncope,  and  this  should  be  easy. 
If  the  onset  was  gradual,  or,  as  is  often  the  case,  its  character  cannot 
be  ascertained,  the  distinction  has  to  be  made  from  poisonirjo- 
(especially  by  chloral,  opium,  and  alcohol)  and  from  uraemia,  by  the 
indications  already  described  in  the  section  on  apoplexy. 

The  distinction  from  the  apoplectiform  attacks  of  cerebral  conges- 
tion, from  those  of  general  paraly.  is  of  the  insane,  and  from  the  so- 
called  "  simple  apoplexy,"  in  which  there  is  no  sign  of  congestion  and 
after  death  no  lesion  of  the  brain,  is  more  difficult.  In  all  three,  local 
symptoms  are  absent.  In  congestion  the  coma  is  rarely  profound  ; 
the  loss  of  consciousness  is  often  imperfect,  and  is  generally  brief. 
The  only  symptoms  are  general;  there  is  no  local  loss  of  power. 
There  have  usually  been  previous  attacks  of  the  same  character, 
transient,  leaving  no  after  symptoms.  In  a  first  attack,  or  without  a 
history,  the  diagnosis  may  be  impossible.  In  general  paralysis  of  the 
insane  the  preceding  symptoms  are  almost  always  sufficiently  pro- 
nounced to  indicate  the  nature  of  the  apoplectiform  seizure.  The 
attack  lasts  only  a  few  hours,  aud  the  patient  rapidly  recovers  his 
ordinary  state.  They  are  more  readily  confused  with  attacks  of 
simple  congestion  than  with  haemorrhage. 

The  attacks  of  "  simple  apoplexy  "  that  occur  in  the  old,  mysterious 
in  their  nature,  may  resemble  closely  the  apoplexy  of  cerebral 
haemorrhage,  and  it  is  doubtful  whether  a  distinction  between  the  two 
is  possible  in  practice.  The  so-called  "  serous  apoplexy  "  is  merely  a 
variety  of  this  form,  aud  is  important  only  from  ignorance,  and  signi- 
ficant chiefly  of  the  unobserved  facts  that  are  close  at  hand. 

If  the  presence  or  history  of  local  symptoms  makes  it  certain,  or  the 
intensity  of  the  general  symptoms  renders  it  in  high  degree  probable, 
that  the  attack  is  due  to  an  organic  cerebral  lesion,  the  chief  dia- 
gnostic question  is  whether  the  lesion  is  haemorrhage,  or  softening  from 
yascular  occlusion.  If  the  patient  is  under  forty,  the  presence  of 
heart  disease,  or,  in  its  absence,  a  suspicion  of  syphilis,  renders  vascular 
occlusion  far  more  probable  than  haemorrhage,  provided  the  apoplectic 
symptoms  are  of  moderate  severity.  But  these  causal  indications  do 
not  absolutely  exclude  haemorrhage,  even  in  early  adult  life  or  in 
childhood,  since  both  these  conditions  are  undoubted  causes  of 
aneurism  of  the  larger  cerebral  arteries.  The  rupture  of  an  aneurism 
is  probable  if,  under  such  circumstances,  the  apoplexy  is  intense  in 
degree  and  the  coma  rapidly  deepens.  In  a  case  of  heart  disease,  pre- 
ceding symptoms,  headache,  &c,  increase  the  probability  of  aneurism. 

In  the  second  half  of  life,  especially  after  forty-five,  when  miliary 
aneurisms  become  common,  neither  the  presence  of  heart  disease  nor 
a  history  of    syphilis    affords  the  same  strong  presumption  against 


4-OS  BItAlN. 

haemorrhage  that  it  does  in  early  life,  and  their  significance  is  sub- 
ordinate. Thrombotic  softening  from  atheroma  of  the  arteries 
becomes  common  pari  passu  "with  haemorrhage,  and  it  is  only  when 
the  symptoms  make  it  probable  that  the  lesion  is  vascular  occlusion, 
and  not  vascular  rupture,  that  the  heart  disease  or  syphilis  raises  a 
question  as  to  the  cause  of  the  occlusion.  The  older  the  patient  the 
less  weight  do  these  points  deserve ;  because  atheroma  increases  and 
syphilitic  disease  lessens  in  frequency  with  advancing  years,  while 
the  degenerative  valvular  disease  of  the  old  causes  embolism  far  less 
frequently  than  do  the  endocarditic  lesions  of  the  voung. 

Between  thrombotic  softening  and  haemorrhage  the  diagnosis  is 
often  difficult.  The  distinction  is  of  great  importance,  because  the 
treatment  suitable  to  the  two  conditions  is  very  different.  A  probable 
diagnosis  can  be  made  only  by  comparing  the  several  symptoms,  cere- 
bral and  general,  and  balancing  their  indications.  Neither  age  nor 
sex  gives  help,  except  that  in  extreme  old  age,  over  eighty,  there  is  a 
probability  in  favour  of  softening  rather  than  haemorrhage.  The 
conformation  and  nutrition  of  the  patient  are  not  of  much  signifi- 
cance. The  most  important  indications  are  those  drawn  from  the 
state  of  the  heart  and  circulation,  the  presence  of  conditions  favouring 
the  bursting  of  an  artery,  especially  a  pulse  of  high  tension,  and  a 
strongly,  acting  hypertrophied  heart.  The  opposite  conditions  favour 
the  formation  of  a  clot  in  a  degenerated  vessel,  and  therefore  throm- 
botic softening ;  so  also  does  considerable  degeneration.  Irregularity 
of  the  pulse  is  opposed  to  haemorrhage  if  combined  with  feebleness, 
but  is  unimportant  if  there  is  deep  coma  and  the  pulse  is  strong. 
Considerable  degeneration  of  the  arteries  of  the  limbs  is  somewhat  in 
favour  of  softening,  as  Nothuagel  has  pointed  out.  In  Bright's 
disease,  especially  the  granular  kidney,  there  is  a  slight,  but  only  a 
slight,  probability  in  favour  of  haemorrhage,  for  atheroma  and  soften- 
ing are  also  frequent  consequences.  Haemorrhages  in  the  retina  in 
connection  with  albuminuric  retinitis  do  not  render  cerebral  haemor- 
rhage more  probable  unless  they  are  large.  Visible  aneurisms  in  the 
retinal  arteries  probably  do  constitute  strong  evidence  of  cerebral 
haemorrhage,  but  they  are  very  rare.  If  the  attack  was  apparently 
induced  immediately  by  strong  mental  excitement  or  physical  exer- 
tion, the  fact  is  in  favour  of  haemorrhage;  if  by  prolonged  grief,  or 
the  exhaustion  after  physical  exertion,  it  is  in  favour  of  softening. 

Prodromata  of  some  duration  in  the  form  of  numbness,  tingling,  or 
weakness  in  the  side  afterwards  paralysed  are  in  favour  of  atheroma 
and  thromboses,  and  so  also  are  previous  headache  or  slight  attacks 
of  weakness  in  other  parts.  Local  convulsions  at  the  onset  of  the 
attack  are  also  in  favour  of  softening,  because  they  occur  chiefly  in 
cortical  disease,  where  softening  is  more  common  than  haemorrhage; 
a  general  convulsion  suggests  haemorrhage.  The  significance  of 
the  occurrence  of  loss  of  consciousness  at  the  onset  depends  on  other 
associated  conditions.     As  a  general  rule,  loss  of  consciousness  is 


CEEEBLIAL  HiEMOKBHAUE.  409 

more  frequent,  greater  in  degree,  longer  in  duration,  and  occurs  with 
a  smaller  lesion,  in  haemorrhage  than  in  softening.  Its  significance 
depends,  therefore,  on  the  probable  size  of  the  lesion.  If  there  is 
reason  to  think  that  this  is  small,  loss  of  consciousness  is  in  favour 
of  haemorrhage  ;  if  it  is  probably  large,  the  absence  of  apoplexy  is 
strong  evidence  of  softening.  But  it  is  unfortunately  very  difficult 
to  judge  of  the  extent  of  the  lesion  in  the  early  stage.  Partial 
hemiplegia  is,  however,  almost  always  due  to  a  small  lesion,  and  the 
occurrence  of  initial  apoplexy  in  such  a  case  is  in  favour  of  haemor- 
rhage. Deep  and  prolonged  coma  is  always  in  favour  of  haemor- 
rhage, unless  the  general  indications  in  favour  of  thrombosis  are  very 
strong  and  the  symptoms  bilateral,  suggesting  tlrrornbosis  in  both 
hemispheres.  A  considerable  initial  fall  of  temperature,  exceeding 
1°,  or  a  considerable  rise  within  a  few  hours,  is  in  favour  of 
haemorrhage,  provided  the  symptoms  do  not  ndicate  obstruction  of 
the  basilar,  in  which  there  may  be  an  initial  fall  similar  to  that  of 
haemorrhage.  Hyperpyrexia,  with  evidence  of  a  lesion  of  the  pons, 
may  occur  in  either  condition,  but  there  is  then  seldom  sudden 
apoplexy  except  in  haemorrhage.  The  greater  the  secondaiy  inflam- 
matory disturbance,  the  more  probable  is  softening,  especially  if  there 
are  also  secondary  convulsions.  In  the  subsequent  chronic  stage  of 
hemiplegia,  the  most  important  indications  are  that  mobile  spasm 
(athetosis,  post-hemiplegic  chorea,  &c.)  and  recurring  convulsions 
beginning  in  the  paralysed  limb  are  strong  evidence  that  the  lesion 
was  softening,  and  not  haemorrhage.  But  in  this  stage  the  history 
and  the  state  of  the  heart  and  circulation  also  usually  afford  trust- 
worthy guidance.  By  careful  attention  to  these  several  diagnostic 
indications,  and  observing  their  relative  weight,  and  comparing  the 
direction  of  their  significance,  the  cases  are  few  in  which  a  diagnosis 
of  adequate  probability  cannot  be  made.  It  will  often  be  found 
that  all  the  indications  point  in  one  direction,  and,  even  if  not  strong, 
derive  weight  from  their  combination,  or  that  one  important  indica- 
tion is  decided  although  the  others  are  equivocal. 

The  diagnosis  of  secondary  ventricular  haemorrhage  rests  on  the 
occurrence  of  a  second  apoplectic  seizure,  or  on  the  distinct  intensifi- 
cation of  primary  coma,  with  the  extension  to  the  second  side  of  the 
muscular  relaxation  that  was  at  first  unilateral.  But  the  significance 
of  this  depends  on  the  initial  attach  having  the  character  of  haemor- 
rhage* "When  there  is  thrombosis  in  an  artery  of  one  hemisphere,  the 
formation  of  another  clot  in  a  large  artery  on  the  opposite  side  may  be 
attended  with  exactly  the  same  symptoms  as  the  rupture  of  a  haemor- 
rhage into  the  ventricles ;  hence  the  occurrence  of  such  symptoms 
should  not  be  allowed  to  influence  a  diagnosis  of  thrombosis  if  the 
evidence  of  this  was  distinct. 

The  diagnosis  of  a  primary  ventricular  haemorrhage  from  haemor- 
rhage into  the  substance  of  the  brain  is  rarely  possible.  There  is  no 
sy  mptoin  definitely  distinctive  from  haemorrhage  into  the  substance  of 


410  BRAIN. 

the  brain  if  the  initial  symptoms  are  on  one  side,  or  into  the  meninges 
if  they  are  bilateral,  unless  it  be,  in  the  latter  case,  the  suddenness  and 
depth  of  coma. 

In  meningeal  hsemorrbage  the  diagnostic  problem  differs  according 
as  there  is  or  is  not  initial  sudden  apoplexy.  If  there  is,  the  dis- 
tinction is  chiefly  from  intra-cerebral  hemorrhage,  and  this  is  often 
impossible  from  the  symptoms  alone.  If  there  is  no  initial  loss  of 
consciousness,  the  symptoms  are  chiefly  headache,  delirium,  and  con- 
vulsions, and,  developing  gradually,  may  closely  resemble  those  of 
meningitis.  In  all  cases  an  important  elemeut  in  diagnosis  is  the 
condition  under  which  the  disease  occurs.  In  the  young,  in  whom 
alone  the  difficulty  is  likely  to  occur,  meningeal  haemorrhage  very 
seldom  occurs  except  after  injury.  In  the  old,  in  whom  spon- 
taneous haemorrhage  may  be  met  with,  primary  meningitis  is  very 
unlikely. 

Prognosis. — Two  questions  always  present  themselves :  first,  the 
risk  of  death  ;  secondly,  the  prospect  of  recovery  from  the  resulting 
paralysis.  The  initial  danger  is  proportioned  to  the  intensity 
and  duration  of  the  coma.  If  it  has  not  begun  to  lessen  at  the  end 
of  twenty-four  hours  the  probability  is  against  recovery.  Most  cases 
die  in  which  there  is  marked  interference  with  respiration,  indicated 
by  its  sighing  character,  Cheyne-Stokes  rhythm,  or  by  the  accumu- 
lation of  mucus  in  the  lungs.  Bilateral  symptoms  in  the  limbs  are 
also  of  very  grave  significance,  indicating,  as  they  usually  do,  either 
hsemorrbage  into  the  ventricles  or  into  the  pous.  The  lower  the 
initial  temperature  the  graver  is  the  immediate  prognosis.  A  con- 
siderable rise  of  temperature  within  a  few  hours  of  the  onset  is  also 
very  serious,  and  so  is  the  early  appearance  of  albumen  or  sugar  in 
the  urine.  If  the  initial  symptoms  were  severe,  or  the  patient  is  old 
or  feeble,  the  period  of  secondary  inflammation  is  also  attended  with 
danger,  the  indications  of  which  are  considerable  fever,  delirium,  or 
a  tendency  to  the  formation  of  sloughs  and  bedsores.  Most  cases 
die  in  which  a  slough  appears  on  the  buttock  before  the  end  of  the 
first  week.  In  ventricular  haemorrhage  the  prognosis  is  almost 
certainly  fatal.  In  the  few  cases  of  the  primary  form  that  recover, 
the  haemorrhage  is  small  in  amount,  and  the  diagnosis  of  the  condi- 
tion as  a  rule  impossible.  In  meningeal  haemorrhage  with  coma  the 
prognosis  is  exceedingly  grave  ;  but  if  consciousness  is  regained,  there 
is  a  fair  prospect  of  recovery,  especially  in  traumatic  cases,  even 
when  delirium  succeeds.  But  there  may  be  considerable  mental 
impairment  for  weeks,  or  even  for  months. 

The  prognosis  as  regards  the  paralysis  depends  on  whether  it  is  due 
to  direct  destruction  of  the  nerve-elements  by  a  lesion  involving  the 
conducting  path,  or  whether  it  is  due  to  indirect  damage  by  a  lesion 
adjacent  to  it.  It  is  usually  necessary  to  wait  for  a  diminution  in  the 
palsy  before  an  opinion  can  be  formed.     The  parts  in  which  there  is 


CEREBRAL    HEMORRHAGE.  411 

some  return  of  movement  before  the  end  of  a  mouth  will  probably 
recover  useful  power.  Paralysis  that  is  complete  at  the  end  of  three 
months  will  probably  remain  considerable  in  degree  for  the  rest  of  life, 
except  in  those  parts  in  which  the  other  hemisphere  can  compensate 
for  the  loss.  Thus  some  power  always  returns  in  the  leg,  except,  often, 
in  the  flexors  of  the  ankle,  and  it  is  usually  at  last  sufficient  to  enable 
the  patient  to  stand  and  walk.  In  the  shoulder,  also,  there  may  be 
a  return  of  power  when  the  hand  remains  paralysed.  The  development 
of  late  rigidity  in  the  hand  renders  recovery  of  power  unlikely. 

Teeathent. — Little  can  be  done  to  prevent  the  occurrence  of  cere- 
bral haemorrhage  when  miliary  aneurisms,  its  main  cause,  are  once 
formed.  Moreover,  the  degenerative  changes  incidental  to  age,  or  the 
result  of  an  inherited  tendency,  cannot  be  arrested,  and  perhaps  not 
even  retarded.  But  when  the  conditions  likely  to  lead  to  arterial 
dilatation  can  be  recognised,  something  may  be  done  to  prevent  its 
occurrence  by  lessening  its  main  factor,  the  increased  strain  on  the 
wall  that  comes  from  arterial  tension,  and  cardiac  over-action,  constant 
or  occasional.  A  tranquil  life,  as  free  as  may  be  from  severe  exertion 
of  body  or  excitement  of  the  mind,  with  nutritious  but  light  food, 
probably  has  some  tendency  to  effect  these  objects,  and  the  intra- 
arterial pressure  can  be  to  some  extent  influenced  by  occasional 
saline  aperients  and  diuretics,  and  by  the  avoidance  of  alcoholic 
excess  and  "high  living."  We  cannot  recognise  the  good  we  may 
thus  effect,  which  is  probably  often  considerable,  if  the  patient's  life 
is  under  our  control. 

In  the  attack  itself  the  aim  of  treatment  must  be  to  secure  the 
conditions  that  favour  the  arrest  of  the  bleeding,  i.  e.  to  reduce  the 
blood-pressure  within  the  arteries,  especially  that  within  the  cerebral 
vessels,  and,  of  course,  to  avoid  the  conditions  likely  to  increase  the 
pressure.  Physical  rest  is  of  the  utmost  importance.  The  patient 
should  be  laid  down,  but  with  the  shoulders  and  head  well  raised. 
The  clothes  about  the  neck  should  be  loosened,  and  flexion  of  the 
neck  avoided,  so  as  to  prevent  the  hindrance  to  the  return  of  blood 
from  the  head  that  compression  of  the  veins  would  cause.  All  mus- 
cular effort  should  be  forbidden.  It  cannot  be  doubted  that,  in 
many  cases,  the  amount  of  haemorrhage  has  been  greatly  increased  by 
the  patient  walking  about  after  the  onset  of  the  attack.  Even 
passive  movement  should  be  as  little  as  possible. 

Venesection  was  for  long  regarded  as  the  most  important  element 
in  treatment;  and  many  authorities  are  still  of  the  same  opinion, 
although  the  disrepute  into  which  the  lancet  has  fallen  leads  to 
hesitation  in  its  use.  Formerly  the  surgeon  did  not  scruple,  in  any 
case  of  apoplexy,  to  cut  across  the  temporal  artery,  to  obtain  a  free 
flow  of  blood.  No  other  agent  reduces  so  quickly  and  so  considerably 
the  tension  of  the  blood,  and  patients  occasionally  regain  consciousness 
while  the  blood  is  flowing.     On  the  other  hand,  it  has  been  objected 


412  BRAIN. 

that  the  loss  of  blood  may  weaken  the  heart's  action  to  a  degi'ee  that 
would  increase  the  peril  of  an  extensive  haemorrhage  into  the  brain. 
It  is  also  said  that,  in  most  cases  in  which  venesection  is  employed,  no 
distinct  beneficial  influence  can  be  traced.  But  the  absence  of 
immediate  evidence  of  its  utility  is  not  a  consideration  of  much 
weight,  since  the  arrest  of  the  bleeding  does  not,  at  the  moment, 
lessen  any  of  the  conditions  on  which  the  loss  of  consciousness 
depends.     But  if  venesection  is  used,  it  should  be  with  discrimination. 

The  diagnosis  of  haemorrhage  should  be  reasonably  cei'tain,  since  in 
thrombosis  loss  of  blood  will  do  only  harm,  by  weakening  the  heart 
and  favouring  the  extension  of  the  clot.  This  effect,  to  be  desired  in 
haemorrhage,  is  to  be  dreaded  in  softening.  The  indications  for 
venesection  are  a  regular,  strongly  acting  heart,  and  an  incompressible 
pulse.  They  are  strengthened  by  distinct  hypertrophy  of  the  heart, 
by  full  arteries,  strongly  pulsating  carotids,  and  a  turgid  face.  The 
contra-indications  are  softness  of  the  pulse,  irregularity  and  dilation 
of  the  heart.  If  the  apoplexy  is  so  deep  that  the  respiration  and 
heart  are  suffering,  it  is  very  doubtful  whether  venesection  can  do 
any  good.  When  it  is  indicated,  the  sooner  the  blood  is  drawn  the 
better.  A  large  opening  should  be  made  into  the  vein,  and  ten  or 
twelve  ounces  allowed  to  flow  as  quickly  as  possible.  As  a  means  of 
arresting  haemorrhage  from  a  branch  of  the  middle  cerebral,  compres- 
sion of  the  common  carotid  in  the  neck  has  been  advocated  by  Spencer 
and  Horsley,*  on  the  ground  of  the  obserwed  effects,  in  monkeys,  of  a 
diminished  flow  of  blood.  Their  observations  certainly  justify  a  trial 
of  the  method,  but  the  diagnosis  must  be  clear,  since  it  would 
certainly  favour  an  extension  of  the  clot  in  thrombosis. 

An  important  element  is  free  purgation.  This  has  a  powerful 
influence  on  the  cerebral  circulation,  by  filling  the  capacious  vessels 
of  the  intestinal  canal.  It  should  always  be  employed,  but  its  slow- 
ness renders  it  an  inefficient  substitute  for  bleeding  if  the  symptoms 
are  urgent  and  venesection  is  distinctly  indicated.  Croton  oil  or 
calomel  is  the  most  convenient  agent.  With  the  same  object  a 
diuretic  should  be  given. 

To  promote  the  contraction  of  the  cerebral  vessels,  ice  may  be 
applied  to  the  head,  provided  the  patient  is  not  collapsed,  and  a  grain 
of  ergotine  may  be  injected  under  the  skin.  Mustard  plasters  to  the 
nape  of  the  neck  may  be  employed  for  the  same  purpose,  to  induce 
reflex  contraction  of  the  arteries,  if  the  patient's  condition  is  one  of 
pallor  and  collapse.  The  old  practice  of  applying  them  to  the  soles 
and  calves  rests  on  an  intelligible  basis,  since  even  from  these  distant 
parts  an  effect  may  be  produced  on  the  cerebral  vessels,  and  the  dila- 
tation of  the  vessels  of  the  surface  must  aid  in  attracting  the  blood 
from  the  brain. 

Alcohol  should  be  avoided  unless  the  patient's  collapse  and  cardiac 
depression  are  extreme.  If  a  mild  stimulant  is  indicated,  ammonia 
*  <  Brit.  Med.  Journ  ,'  18S9,  i. 


INFANTILE    MENINGEAL    HEMORRHAGE.  413 

may  be  given.  It  is  very  desirable  to  arrest  convulsions  and  vomiting, 
because  these  tend  to  increase  the  bleeding,  In  one  case,  an  injection 
of  thirty  grains  of  chloral  into  the  rectum  appeared  to  stop  the  con- 
vulsions. 

In  all  cases,  but  especially  if  the  coma  is  prolonged,  or  the  secon- 
dary pyrexia  considerable,  the  danger  of  the  occurrence  of  bedsores 
must  he  borne  in  mind,  and  should  be  obviated  as  far  as  possible  by 
extreme  cleanliness,  by  a  water-bed,  and  by  changing  the  position  of 
the  limbs  from  time  to  time,  so  as  to  prevent  long-continued  pressure 
on  the  same  spot.  Hot-water  bottles  should  also  be  employed  with 
great  care,  since  a  degree  of  warmth  that  can  be  borne  with  impunity 
in  health  will  cause  a  blister  and  slough  in  early  hemiplegia. 

In  the  after-treatment  of  these  cases,  when  the  disturbance  of  the 
onset  has  passed  away,  and  slowly  lessening  palsy  remains,  it  is 
important,  with  the  view  of  preventing  a  recurrence,  to  observe  the 
rules  of  life  described  at  the  commencement  of  this  section. 

The  treatment  of  ventricular  and  meningeal  haemorrhage  doijs  not 
differ  from  that  of  the  intra-cerebral  form,  although  little  can  be 
hoped  for  from  any  measures  that  can  be  adopted. 

Infantile  Meningeal  Hemorrhage  (Cerebral  Birth  Palsy). 

Meningeal  haemorrhage  is  occasionally  produced  during  birth ; 
the  accompanying  damage  to  the  brain  may  cause  permanent  sym- 
ptoms, weakness  of  the  limbs  and  of  the  trunk,  inco-ordination,  spon- 
taneous movements,  convulsions,  and  mental  defect.  Tbe  cases  vary 
much  in  degi-ee,  and  it  is  only  in  the  more  severe  forms  that  all  these 
symptoms  are  present.  In  some  cases  the  legs  suffer  chiefly,  and  the 
condition  is  then  termed  "  congenital  spastic  paraplegia,"  a  malady 
that  has  been  already  described  (vol.  i,  p.  441).  When  the  sponta- 
neous movements  constitute  the  most  conspicuous  symptom,  the  state 
has  been  described  as  "congenital  chorea." 

The  relation  of  these  symptoms  to  injury  to  the  brain  during  birth 
was  suggested  by  Dr.  Little,*  and  has  been  clearly  established  by  the 
researches  of  an  American  physician,  Dr.  Sarah  McNutt.f  The  fol- 
lowing account  of  the  symptoms  is  based  on  an  extensive  series  of 
consecutive  cases  that  have  come  under  my  notice,  doubtful  ones,  and 
acquired  lesions,  being  excluded.  J 

The  haemorrhage  that  injures  the  brain  is  almost  always  due  to 

*  *  Nature  and  Treatment  of  Deformities,'  1853  ;  '  Obstetrical  Trans.,'  1862. 

f  '  American  Journal  of  Obstetrics,'  January,  1885,  and  the  '  Am.  Journ.  of  Med. 
Science/  January,  1885.  See  also  a  valuable  paper  by  Dr.  H.  R.  Spencer,  '  Obstet. 
Trans.,'  vol.  xxxiii,  and  Parrot,  '  Clinique  des  Nouveau-nees.'  These  cases  have  also 
been  carefully  studied,  especially  in  their  later  stages,  and  in  conjunction  with  the 
acquired  cerebral  palsies,  by  Osier  ('  Cerebral  Palsies  of  Children,'  18S9),  and  by 
Sachs  ('Journ.  Nerv.  and  Mont.  Dis.,'  1890;  'New  York  Med.  Journ.,'  1891). 

J  Later  observations  fully  confirm  the  conclusions  I  stated  in  a  lecture  on  "  Birth 
Palsies,"  '  Lancet,'  1888. 


414  BRAIN. 

special  difficulty  in  parturition.  In  some  cases  (about  a  fifth)  the 
presentation  is  unnatural,  and  the  bead  is  born  last;  in  such  cases 
intense  mechanical  congestion  accompanies  the  compression,  and  the 
occurrence  of  haemorrhage  is  easy  to  understand.  But  the  same 
svruptoins  follow  cases  of  head  presentation,  when  the  labour  bas  been 
loner  and  difficult,  and  its  immediate  effects  were  shown  by  the 
difficulty  in  getting  the  cbild  to  live,  or  by  distinct  symptoms  of  con- 
vulsions, rigidity,  immobility  of  some  part,  dysphagia,  &c,  present 
from  bir'h  or  coming  on  within  a  few  days.  About  half  the  cases 
are  firstborn,  but  in  almost  all  the  others  the  labour  was  specially 
difficult.  In  some  of  the  cases  the  forceps  was  used,  but  it  is 
probable  tbat,  as  a  rule,  the  lesion  has  been  the  result  not  of  the  use 
of  the  instruments,  but  of  the  conditions  that  made  them  necessary. 
In  rare  cases  the  clumsy  use  of  the  instrument  may  have  produced 
the  injurv,  as  in  one  instance  in  which  a  permanent  indentation 
corresponded  to  tbe  centre  for  the  opposite  arm,  the  part  chiefly 
affected.  But  it  is  most  important  that  the  fact  should  be  clearly 
recognised  that  tbe  result  is  not  usually  due  to  the  instrumental  aid, 
because  parents  are  only  too  ready  to  expand  even  a  question  to  an 
assertion,  that  may  do  great  and  undeserved  barm  to  the  practitioner 
who  attended.  In  one  case,  a  fifth  labour,  the  forceps  was  not  used, 
although  it  had  been  employed  in  each  of  the  preceding  labours,  and 
the  children  had  escaped  injury.  But  I  have  met  with  a  few  cases  in 
which  tbe  condition  was  characteristic,  but  the  labour  unusually  quick 
and  easy,  and  even  premature.  It  is  conceivable  that  the  rapid  birth  of 
a  skull  softer  than  normal  may  cause  the  sameintra-cranial  damage  as 
the  opposite  conditions.  The  affection  seems  to  be  almost  as  frequent 
in  one  sex  as  in  the  other,  the  proportion  of  girls  to  boys  being  as 
five  to  six. 

In  the  majority  of  cases  nothing  particular  is  noticed  in  the  condi- 
tion of  the  child  during  the  first  few  days  or  weeks  of  life.  In  a  few, 
however,  conspicuous  symptoms  attract  attention.  There  may 
be  an  evident  difficulty  in  swallowing;  one  arm  and  leg  are  not 
moved;  sometimes  none  of  the  limbs  are  moved,  but  this  receives  less 
notice  than  does  one-sided  immobility.  Another  frequent  symptom 
is  convulsion,  general  or  unilateral,  and  often  accompanied  by  persis- 
tant rigidity  of  the  limbs,  and  with  inversion  of  the  thumbs.  Barely 
the  head  is  bent  back.  The  convulsions  usually  cease  at  the  end  of  a 
week  or  two  after  birth  ;  deglutition,  if  at  first -impaired,  remains  so 
in  some  degree,  and  there  maybe  a  conspicuous  difficulty  in  support- 
ing the  head,  which  falls  to  one  side  long  after  the  age  at  which 
infants  are  usually  able  to  support  it.  But  these  symptoms  are  often 
disregarded,  and  very  often  it  is  not  until  the  child  is  four  or  five 
months  old  that  a  deficiency  of  movement  attracts  attention;  while 
in  others,  suspicion  is  only  excited  when  the  child  fails  to  stand  and 
walk  at  the  age  at  which  it  should  begin  to  do  so.  Sometimes  the 
first  thing  that  is  noted  is  strong  adductor  spasm  in  the  legs  ;  in 


INFANTILE    MENINGEAL    HEMORRHAGE.  415 

other  eases  it  is  the  inability  to  effect  ordered  movements  with  the 
hands.  In  some  instances  convulsions  are  fhe  most  prominent  sym- 
ptom, and  the  difficulty  in  the  use  of  the  limbs  is  often  ascribed  to 
them. 

The  "weakness,  spasm,  inco-ordination,  and  spontaneous  movements 
usually  increase  during  the  first  two  years  of  life,  being  revealed  by 
the  structural  and  functional  development  of  the  nervous  system. 
Their  distribution  varies,  but  all  four  limbs  are  affected  in  about  two 
thirds  of  the  cases  (twenty-two  out  of  thirty-six),  aud  the  trunk  and 
neck  muscles  are  also  conspicuously  involved  in  about  one  third  (eleven 
cases).  In  a  small  proportion  the  limbs  of  one  side  only  ate  affected 
(seven  cases),  and  in  rather  fewer  (six  cases)  the  legs  alone  suffer  in 
considerable  degree.  Very  rarely  the  symptoms  are  confined  to  a 
single  limb. 

In  the  arms  there  is  weakness  and  some  spasm,  which  varies  in 
character,  but  is  greatest  towards  the  extremity  of  the  limb,  and 
interferes  with  voluntary  movement.  The  elbow  is  generally  flexed, 
sometimes  extended.  The  wrist  is  at  times  bent  at  a  right  angle  to 
the  forearm,  at  other  times  it  is  over-extended.  The  persistent  strong 
flexion  may  even  lead  to  subluxation.  The  thumbs  are  inverted  or 
extended  ;  sometimes  the  metacarpal  bone  is  extended  and  the  pha- 
langes flexed.  The  fingers  are  flexed  at  the  metacarpo- phalangeal 
joints,  and  in  many  cases  they  are  over-extended  at  the  middle  joiut, 
which  may  be  subluxated.  Often,  however,  the  fingers  and  wrist  are 
in  constant  movement,  now  flexed  and  now  irregularly  extended.  The 
movement  is  generally  slow,  like  the  post-hemiplegic  athetoid  spasm 
(p.  86)  ;  sometimes  it  is  quick,  and  may  bear  considerable  resem- 
blance to  the  movements  of  chorea.  In  slight  cases  the  amount  of 
spasm  is  trifling,  and  its  chief  effect  is  the  interference  with  voluntary 
movement,  which  always  exists  in  some  degree.  The  fingers  are 
separated  aud  moved  irregularly  in  an  attempt  to  take  hold  of  an 
object.  It  is  often  impossible  for  the  child  to  pick  up  an  object, 
although  it  can  grasp  firmly  but  slowly.  In  a  severe  case,  when  the 
hand  has  at  last  closed,  it  may  be  very  difficult  for  the  child  to  relax 
the  grasp.  The  condition  of  the  legs  is  that  described  and  figured  at 
p.  446,  vol.  i.  Any  attempt  to  move  them,  and  any  peripheral  im- 
pression, excites  extensor  spasm,  which  renders  the  limbs  rigid,  the 
heel  being  drawn  up  and  the  toes  pointed  down.  There  is  commonly 
some  persistent  contracture  in  the  calf  muscles,  but  this  can  almost 
always  be  completely  overcome  by  steady  pressure  on  the  sole.  Often 
the  feet  are  slightly  inverted,  and  I  have  once  seen  such  extreme 
talipes  varus  that  each  foot  was  turned  in  and  fixed  at  a  right  angle 
to  the  leg.  Occasionally  there  is  some  persistent  contraction  of  the 
flexors  of  the  knee.  There  is  often  also  spasm  in  the  adductors  of 
the  thighs,  which  may  be  sufficient  to  carry  one  leg  in  front  of  the 
other  on  an  attempt  to  stand  or  walk.  The  knee-jerk  is  excessive 
when  the  relaxation  of  the  spasm  permits  its  state  to  be  ascertained; 


416  BRAIN. 

a  foot-clonus  can  seldom  be  obtained.  Spontaneous  movements  of  the 
toes  and  feet  may  occasionally  be  observed,  and  there  are  sometimes 
constantly  repeated  movements  of  flexion  and  extension  of  the  trunk 
or  limbs,  especially  when  the  mind  has  suffered.  In  very  rave  cases 
the  arms  suffer  more  than  the  legs.  The  limbs  that  are  affected  are 
generally  thin,  but  there  is  never  extreme  muscular  wasting.  Dimin- 
ished length  of  limb  may  be  perceptible  when  the  affection  is  one- 
sided, but  if  both  sides  are  involved  no  difference  can  be  found. 

The  muscles  of  the  trunk  are  sometimes  weakened,  so  that  the  child 
has  a  difficulty  in  sitting  up,  and,  if  allowed  to  do  so,  lateral  curvature 
of  the  spine  may  be  produced.  There  is  never  distinct  paralysis  of 
the  face,  but  sometimes  traces  of  spasm  may  be  observed  about  the 
mouth.  Occasionally  difficulty  in  swallowing  and  defective  articula- 
tion exist,  from  paralytic  weakness,  and  sometimes  associated  with 
tremulous  difficulty  in  moving  the  tongue.  The  defective  articulation 
is  due,  in  many  cases,  to  another  frequent  symptom,  mental  defect. 
This  exists  in  at  least  two  thirds  of  the  cases,  from  a  doubtful  amount 
to  complete  idiocy,  with  permanent  inability  to  speak.  In  most  of 
the  cases  in  which  mental  power  is  low,  the  affection  of  the  limbs  is 
considerable,  but  the  opposite  rule  does  not  hold  good;  the  muscular 
affection  may  be  severe  and  general,  although  the  mind  is  nearly  or 
quite  normal.  The  difficulty  in  swallowing  or  mental  defect  or  both, 
often  cause  dribbling  of  saliva,  and  this  seems  sometimes  to  go  on  as 
a  sort  of  habit. 

I  have  once  seen  considerable  defect  of  sight  (associated  with  great 
mental  weakness)  ;  the  ophthalmoscopic  appearances  and  action  of 
the  pupils  were  normal.  Loss  of  sensation  in  the  skin  is  never  to 
be  found. 

The  affection  of  the  two  sides  is  seldom  quite  equal,  and  the  two 
limbs  most  affected  are  always  on  the  same  side.  Occasionally,  as 
already  stated,  one  side  escapes,  and,  if  the  right  limbs  are  those 
involved,  the  child  is  left-handed.  When  the  legs  seem  to  be  alone 
affected,  slight  inco-ordination,  or  at  least  awkwardness  of  movement, 
mav  generally  be  observed  in  one  arm  or  in  both  on  careful  exami- 
nation. 

Convulsive  attacks  occur  only  in  a  small  proportion  of  cases,  and 
they  are  rather  more  frequent  when  the  affection  is  one-sided  than 
when  it  is  general.  They  seldom  date  from  birth  ;  initial  convulsions 
rarely  persist.  Subsequent  fits  begin  generally  during  the  second 
half  of  the  first  year,  sometimes  later ;  they  may  cease  after  lasting  for  a 
short  time,  or  may  recur.  The  occurrence  of  fits  bears  no  relation  to 
the  severity  of  the  limb  symptoms  ;  and,  indeed,  the  latter  may  be 
scarcely  recognisable  when  the  former  are  severe.  If  the  limb  sym- 
ptoms are  one-sided,  so  also,  as  a  rule,  are  the  convulsions.  In  a  case 
in  which  the  legs  only  were  affected,  and  the  leg  centre  alone  found 
damaged,  the  fits  began  in  the  great  toe  of  one  side  or  the  other.* 
*  Ferguson,  'Amer.  -Journ.  of  Obstetrics,'  1891. 


INFANTILE    MENINGEAL    HEMORRHAGE. 


417 


The  subsequent  course  of  these  cases  is  one  of  slow  improvement 
which  is  greatest  when  age  enables  the  will  to  be  brought  to  bear  on 
the  defect ;  but  it  is  only  when  symptoms  are  slight  that  they  approxi- 
mately disappear.  A  peculiar  oscillation  in  walking  is  apt  to  be 
developed,  and  for  a  long  time  the  patient  may  walk  on  the  ball  of  the 
foot,  the  toes  being  over-extended,  or  upon  the  toes  chieflv,  from  the 
talipes  equinus.  The  knees  are  sometimes  imperfectly  extended  even 
in  walking,  and  there  may  be  persistent  inversion  of  the  feet.  These 
conditions  may  lessen,  but  often  remain  in  some  degree,  so  that  a 
peculiarity  of  gait  may  persist  through  life. 


Pathology. — In  many  of  these  cases,  as  we  have  seen,  convulsions, 
rigidity,  and  paralysis  are  observed  immediately  after  birth.  If 
children  die,  who  present  such  symptoms,  meningeal  haemorrhage  is 
invariably  found.  The  extravasation  is  sometimes  over  the  convexity 
of  the  brain,  sometimes  at  the  base.  In  the  former  situation  it  is 
generally  bilateral,  and  is  most  considerable  over  the  central  region 
and  towards  the  middle 
line  (Fig.  118)  ;  it  is 
found  also  on  the  medial 
aspect  of  the  hemisphere 
(Fig.  119)  ;  this  is  pro- 
bably due  to  the  effects  of 
the  overlapping  of  the 
edges  of  the  sagittal  su- 
tures. Sometimes,  how- 
ever, it  exists  only  over 
the  posterior  part  of  the 
convexity.  Where  the 
layer  of  blood  is  thicker, 
the  convolutions  are  much 
compressed,  and  are  some- 
times much  injured,  the 
cerebral  tissue  being 
broken  up  and  infiltrated 
with  blood.  The  haemor- 
rhage at  the  base  is  chiefly 
in  the  posterior  fossa  be- 
neath the  tentorium,  sur- 
rounding the  pons  medulla 
and  cerebellum,  and  it 
generally  proceeds  from  a 
laceration  in  the  cerebellar 
hemisphere.  Dr.  McNutt 
found  that  the  basal  hae- 
morrhage occurred  in  cases  of  head-presentation,  while  the  most 
intense   extravasation  over  the  cerebral  hemispheres  was  found  in 

vol.  ii.  27 


ElG.  118. — Meningeal  haemorrhage  during  birth. 
The  shading  represents  the  extravasation. 


ElG.  119. — Medial  aspect  of  the  hemisphere; 
same  case.     (After  McNutt.) 


418  BRAIN. 

cases  of  foot-presentation.     It  is  probable,  however,  that  the  cortical 
haemorrhage  also  occurs  in  cases  in  which  the  head  is  born  first. 

In  older  children,  who  present  the  symptoms  that  have  been 
described,  the  lesion  found  is  atrophy  of  the  convolutions  in  a  certain 
region  of  the  bi*ain,  generally  the  central  convolutions,  which  may  be 
small  and  indurated,  and  lie  at  the  bottom  of  a  considerable  depression. 


Fig.  121. 


FlG.  120  left,  and  Fig.  121,  right  hemispheres  of  the  brain  of  a  child,  the  subject 
of  bilateral  birth-palsy.     (After  McNutt.) 

This  appearance  agrees  perfectly  with  the  condition  found  in  early 
cases,  since  the  blood  will  be  slowly  removed,  and  only  the  damage  to 
the  cortex  of  the  brain  will  remain.  The  long-continued  compression 
of  the  convolutions  hinders  their  development  where  the  layer  of 
blood  is  thickest,  even  if  they  are  not  actually  damaged  by  the 
compression,  and  a  state  of  atrophic  sclerosis  results  at  the  spot. 

These  conditions  explain,  to  a  large  extent,  the  symptoms  observed. 
The  facts  that  the  thickest  part  of  the  extravasation  is  often  at  the 
motor  region,  and  that  it  is  over  both  hemispheres,  explain  the  dis- 
tribution of  the  symptoms  in  the  limbs,  and  their  bilateral  character. 
It  must  sometimes  be  chiefly  on  one  side,  and  thus  unilateral  effects 
are  produced.  The  frequency  with  which  the  legs  are  involved  in 
considerable  degree  is,  no  doubt,  due  to  the  position  of  the  leg 
centres  near  and  in  the  longitudinal  fissure,  and  it  is  here  that  the 
extravasation  is  most  abundant.  Experiment  refers  to  the  same 
region  the  centres  for  the  trunk  muscles,  which  are  also  often  weak- 
ened, while  the  extension  of  the  haemorrhage  in  front  of  the  central 
convolutions  may  explain  the  frequent  difficulty  in  supporting  the  head. 
The  persistence  of  some  nerve-cells  only  slightly  damaged  may  explain 
the  occurrence  of  the  convulsions,  and  perhaps  also  the  spontaneous 
movements.  The  spasm  may  be  connected  in  part  with  the  arrested 
development  of  the  pyramidal  fibres,  which  are  fewer  than  normal.  The 
spasm  in  the  legs  resembles,  in  its  main  features,  that  which  follows  a 
lesion  of  the  pyramidal  tracts  in  the  spinal  cord,  and  any  differences 
are  no  doubt  due  to  the  occurrence  of  the  disease  during  the  stage  of 
development.  Whether  any  more  complex  mechanism  may  be  con- 
cerned in  producing  the  inco-ordination,  such  as  the  deficient  control 
and  balance  of  other  cerebral  centres,  we  cannot  say.  The  extent  of 
the  damage  to  the  cortex  of  the  brain  is  a  sufficient  explanation  of  the 


INFANTILE    MENINGEAL    HjEMOBBHAGE.  419 

mental  defect  that  so  often  co-exists ;  and  the  fact  that  it  is,  in  rare 
cases,  chiefly  over  the  occipital  lobes,  enables  us  to  understand  the 
impairment  of  sight  occasionally  observed. 

We  are  not  at  present  able  to  say  what  symptoms  are  due  to 
haemorrhage  about  the  pons  and  medulla.  It  seems  reasonable  to 
ascribe  to  this  the  weakness  of  the  neck  and  the  symptoms  in  the 
region  of  the  bulbar  nerves.  Nevertheless  it  is  possible  that  these 
may  be  due  to  symmetrical  lesions  in  the  cerebral  hemispheres  in  the 
lower  parts  of  the  central  convolutions,  and  the  prefrontal  lobe 
adjacent  to  them,  over  which  the  haemorrhage  is  apt  to  extend,  as  the 
figures  show.  It  is  unlikely  that  any  limb  symptoms  are  due  to 
injury  to  the  anterior  pyramids  of  the  medulla,  because  the  symptoms 
are  similar  in  all  cases,  and  are  certainly  generally  due  to  the  cortical 
lesion.  That  they  are  the  same,  whether  or  not  there  is  weakness  of 
the  neck,  is  a  fact  that  suggests  the  cortical  origin  of  the  latter  sym- 
ptom also. 

Diagnosis. — In  a  well-marked  case,  in  which  the  symptoms  are 
general,  the  recognition  of  the  disease  is  easy  if  its  occurrence  is 
known.  Some  difficulty  is  presented  by  cases  in  which  the  symptoms 
are  one-sided,  or  in  which  the  legs  only  are  affected.  The  most 
important  distinctions  from  other  cerebral  diseases  are,  first,  that  the 
condition  is  stationary  and  not  progressive ;  and  secondly,  that  there 
is  no  history  of  a  distinct  onset  at  some  period  subsequent  to  birth. 
Symptoms  of  similar  character  are  occasionally  caused  by  a  tumour 
of  the  brain,  but  then  gradual  development  and  steady  increase  show 
the  existence  of  a  progressive  lesion.  Similar  stationary  symptoms 
may  succeed  an  acute  lesion ;  there  is  then  a  clear  onset  to  be  traced, 
often  with  severe  symptoms,  and  preceded  by  perfect  freedom  from 
any  similar  affection.  In  the  case  of  birth-palsy,  if  the  derangement 
of  movement  was  first  noticed  at  a  certain  period,  it  is  generally 
evident  that  attention  had  not  been  specially  given  to  the  state  of 
the  limbs.  A  distinct  difficulty  in  birth,  or  an  unnatural  presenta- 
tion, can  generally  be  ascertained ;  and  in  many  cases  there  is  a 
history  of  convulsions,  &c,  immediately  after  birth,  to  confirm  the 
diagnosis.  When  the  legs  suffer  chiefly,  the  case  is  often  thought  to 
be  disease  of  the  spinal  cord.  As  already  mentioned,  however,  slight 
derangement  of  movement  in  the  hands  can  generally  be  detected,  and 
it  should  be  remembered  that  primary  chronic  disease  of  the  cord  in 
young  children  is  almost  unknown.  In  any  case  of  spastic  paraplegia 
in  a  child,  in  whom  there  is  no  bone  disease,  a  cerebral  cause  is  always 
probable. 

The  greatest  diagnostic  difficulty  is  the  distinction  of  the  cases  from 
those  in  which  the  brain  has  suffered  before  birth,  either  from  disease 
or  developmental  defect.  In  such  cases  the  birth  is,  as  a  rule,  easy, 
although  it  is  doubtful  whether  the  distinction  is  absolute  (see  above). 
The  limbs  do  not  present  the  inco-ordination  or  rigidity,  and  there 


420  BRAIN. 

are  no  acute  symptoms  immediately  after  birth,  or  indication  that  the 
child  has  suffered  during  the  process.  On  the  other  hand,  there  is 
usually  grave  mental  defect,  and  often  a  history  of  a  tendency  to 
idiocy  or  nervous  maladies  in  the  family. 

Prognosis. — As  the  damage  to  the  brain  is  necessarily  permanent, 
so  are  its  effects.  But  when  there  is  no  considerable  mental  defect, 
the  disorder  of  movement  lessens  in  later  childhood,  because  the  will 
gradually  acquires  more  power  over  the  movement  of  the  limbs,  and 
is  able,  to  some  extent,  to  counteract  the  influence  of  the  spasm.  In 
all  except  the  most  severe  cases  the  child  ultimately  acquires  some 
ability  to  stand  and  walk,  although  it  may  be  only  at  the  age  of  six 
or  eight.  As  already  stated,  the  gait  is  often  permanently  peculiar. 
The  mental  condition  also  slowly  improves.  In  every  case,  however, 
the  prognosis  must  depend  on  the  severity  of  the  symptoms  ;  what 
state  the  improvement  will  ultimately  leave  must  depend  upon  the 
amount  of  defect,  motor  and  mental,  and  upon  the  signs  of  improve- 
ment that  can  be  discerned.  It  must  be  remembered  also  that,  as  a 
rule,  the  greater  the  defect,  the  later  does  improvement  occur. 

Treatment. — Drugs  have  no  influence  on  the  morbid  state,  and 
but  little  on  the  symptoms.  Even  in  the  early  stage,  soon  after 
birth,  it  is  doubful  whether  any  treatment  can  influence  the  process 
by  which  the  brain  is  damaged.  The  meningeal  hemorrhage  probably 
occurs  during  birth  only,  and  there  is  no  evidence  of  auy  subsequent 
increase  in  the  extravasation.  No  agents  can  be  expected  to  facilitate 
the  removal  of  the  compressing  blood,  which  is  only  slowly  absorbed 
after  permanent  tissue-changes  have  occurred  in  the  cortex.  Doubt- 
less it  could  be  removed  by  a  surgical  operation,  but  this  would  have 
to  be  severe,  and  the  diagnosis  would  require  a  degree  of  certainty 
that  could  scarcely  be  obtained  until  changes  had  occurred  in  the 
brain,  from  which  recovery  would  be  doubtful.  The  slow  diminu- 
tion in  the  symptoms  cannot  be  ascribed  to  the  recovery  of  the 
damaged  structures,  since  they  must  have  passed  into  a  stationary 
cicatricial  condition  long  before  improvement  commences.  It  must 
be  due  rather  to  the  functional  education  of  those  parts  that  are  only 
slightly  injured,  and  to  the  compensation  effected  by  undamaged 
parts.  Treatment,  as  far  as  it  is  possible,  must  consist  in  promoting 
this  by  training  the  motor  power  that  remains,  and  increasing  the 
use  that  it  can  afford,  by  a  process  of  muscular  education,  and  espe- 
cially by  rhythmical  movements  of  the  limbs,  fingers,  &c.  When  the 
inco-ordination  is  slight,  and  the  child  is  old  enough,  a  key  type- 
writer is  a  useful  means  of  muscular  and  mental  education.  As  soon 
as  the  child  becomes  able  to  stand,  the  attempt  to  walk  is,  in  itself,  a 
valuable  training.  Instruments  sometimes  enable  it  to  stand  some 
time  before  this  would  otherwise  be  possible,  and  they  may  thus 
distinctly  accelerate  improvement.     It  is  useless,  however,  to  employe 


ACUTE    SOFTENING.  421 

instruments  until  there  is  enough  voluntary  power  and  control  to 
enable  the  child  to  stand  alone  with  their  aid.  Electricity  in  all 
forms  is  useless  ;  its  prolonged  use,  in  cases  under  my  care,  has  shown 
that  it  has  no  influence  over  either  the  weakness,  the  spasm,  or  the 
inco-ordination.  The  treatment  of  convulsive  attacks  is  similar  to 
that  of  other  forms  of  epilepsy,  but  they  are  less  readily  influenced 
by  drugs. 


SOFTENING-   OF  THE   BEAIN. 

Softening  of  the  brain*  is  the  common  result  of  many  morbid  pro- 
cesses. The  diminution  of  consistence  is  due  to  the  breaking  up  of  the 
nerve  elements ;  the  resulting  particles  become  separated  by  serum, 
so  that  a  soft  pulp  replaces  the  original  firm  tissue.  It  is  the  charac- 
teristic effect  of  inflammation  of  the  brain, — and  not  long  since  all 
forms  of  softening  were  thought  to  be  inflammatory.  We  now  know 
that  most  cases  of  acute  softening  are  due  to  a  very  different  cause, 
to  the  arrest  of  the  blood-supply  by  occlusion  of  an  artery.f  In  the 
part  supplied  by  the  occluded  vessel,  the  nerve  elements,  deprived  of 
nutrition,  at  once  lose  their  functional  powers,  and  quickly  undergo 
degeneration.  In  many  parts  of  the  brain  there  is  not  sufficient  com- 
munication between  the  terminal  arterial  twigs  to  permit  of  the  re-esta- 
blishment of  the  circulation,  and  structural  degeneration  occurs  in  the 
delicate  nerve  elements  with  great  rapidity  ;  in  other  parts,  anastomoses 
enable  the  blood-supply  to  be  re-established,  and  the  function  returns 
after  transient  arrest.  A  similar  result  may  follow  occlusion  of  a  vein  : 
if  the  venous  communications  are  insufficient  to  allow  the  blood  to 
escape  by  some  other  channel,  the  circulation  in  the  part  is  at  an  end, 
and  the  nerve  elements  break  up ;  but  the  venous  anastomoses  are 
generally  sufficient  to  prevent  complete  necrosis  of  the  part.  In  rare 
instances  there  is  softening  that  cannot  be  referred  to  either  of  these 
processes,  but  it  is  then  always  chronic,  never  acute.  Thus  we  may 
distinguish,   as  pathological  varieties  of  softening,  Acute  Softening 

*  It  should  be  remembered  that  there  is  a  considerable  difference  between  the 
popular  and  the  medical  uses  of  the  term  "  softening  of  the  brain."  The  general 
meaning  attached  to  the  term  is  chronic  mental  failure,  and  the  disease  most 
frequently  thus  designated  is  general  paralysis  of  the  insane.  In  medical  use  the 
term  is  restricted  to  the  condition  in  which  the  physical  state  actually  exists.  Some 
■care  must  therefore  be  exercised  in  using  the  term,  lest  it  convey  an  erroneous 
impression  of  the  nature  and  course  of  the  disease. 

f  The  relation  of  senile  softening  to  degeneration  of  the  arteries  was  first  clearly 
recognised  by  Rostan  in  1823,  and  soon  afterwards  by  Abercrombie,  Carswell,  and 
others.  That  embolism  is  a  frequent  cause  of  softening  was  first  pointed  out  by 
Tirchow  (in  the  first  volume  of  his  '  Archives'),  and  in  this  country  by  Kirkes,  who 
in  an  admirable  paper  ('  Medico-Chir.  Trans.,'  1852,  p.  281)  brought  our  knowledge 
of  the  subject  within  a  measurable  distance  of  its  present  position,  and  he  did  so 
apparently  without  being  acquainted  with  the  earlier  paper  of  Virchow. 


422  BRAIN. 

from  (1)  inflammation,  (2)  arterial  occlusion,  (3)  venous  occlusion, 
and  Chronic  Softening.  The  first  of  these  varieties  will  be  described 
in  the  chapter  on  inflammation  of  the  brain,  and  the  last  among  the 
degenerations.  Softening  also  results  from  pressure,  but  is  a  secon- 
dary and  unimportant  form. 

Softening    from    Arterial   Occlusion    (Necrotic    Softening  ; 
Encephalohaeacia)  . 

Softening  from  arterial  occlusion  is  not  only  far  more  common  than 
all  the  other  forms  of  softening  put  together,  but  it  is  one  of  the  most 
frequent  diseases  of  the  brain,  perhaps  exceeding  in  frequency  cere- 
bral haemorrhage.* 

General  Etiology  and  Pathology. — Two  pathological  pro- 
cesses may  cause  the  occlusion  of  an  artery ;  a  plug  coming  from  a 
distance  may  be  carried  into  it  by  the  blood  (embolism),  or  a  plug 
may  be  formed  in  it  by  coagulation  (thrombosis).  There  is  an 
important  difference  in  the  pathological  relations  of  these  two  pro- 
cesses. Embolism  is  the  result  of  a  morbid  process  elsewhere  in  the 
circulation,  commonly  in  the  heart.  Thrombosis  is  usually  the  result 
of  local  disease  of  an  artery  of  the  brain,  by  which  either  its  calibre 
is  narrowed,  or  its  inner  surface  is  changed,  so  as  to  cause  coagula- 
tion ;  often  both  these  conditions  coincide.  The  chief  pathological 
processes  that  cause  these  changes  are  atheroma  and  syphilitic 
disease.  A  change  in  the  constitution  of  the  blood,  rendering  it  prone 
to  coagulate,  and  slower  movement  of  the  blood,  from  feebleness  of 
the  heart,  often  aid  the  effect  of  the  arterial  disease  in  producing 
thrombosis,  and  sometimes  cause  it  when  the  arteries  are  free  from 
disease. 

Although  the  primary  processes  of  thrombosis  and  embolism  are 
thus  distinct,  and  usually  occur  under  veiy  different  conditions,  they 
are  often  conjoined  in  a  secondary  manner.  If  an  artery  is  obstructed 
by  embolism,  the  stagnant  blood  in  it  may  clot,  extending  the  occlu- 
sion. If  a  clot  forms  in  an  artery  it  may  be  detached  (as  Laborde 
has  shown),  and  may  obstruct  the  vessel  further  on  by  a  process  which 
is  actually  embolism.  But  the  process  is  regarded  according  to  its 
general  and  primary  character,  and  the  distinction  between  them 
should  always  be  kept  clearly  in  view. 

Embolism. — The  source  of  the  plug  must  be  somewhere  between 
the  lungs  and  the  brain, — in  the  pulmonary  veins,  the  left  side  of 
the  heart,  the  commencement  of  the  aorta,  or  the  large  arteries  of  the 
neck.  It  is  possible  that  septic  material  may  pass  through  the  lungs 
and  lodge  in  the  brain,  but  only  capillaries  can   be  obstructed   by 

*  This  is  the  common  opinion,  and  is  very  likely  correct,  although  the  evidence 
is  not  conclusive.  In  the  post-mortem  room,  haaniorrhage  is  the  more  frequent 
lesion,  but  haemorrhage  is  more  often  quickly  fatal  than  softening  is. 


ACUTE    SOFTENING.  423 

particles  that  can  pass  through  the  capillaries  of  the  lungs,  and  any 
local  softening  of  the  brain  thus  produced  is  usually  purulent,  a 
cerebral  abscess  or  minute  points  of  suppuration.  "When  an  artery 
has  been  plugged  in  consequence  of  septicemic  processes  in  the 
general  system  (as  uterine  phlebitis),  there  has  usually  been  either 
a  pulmonary  abscess  or  endocarditis  to  furnish  the  embolus.  In 
most  cases  the  plug  comes  from  the  heart,  and  its  source  is  either 
diseased  valves,  "  vegetations  "  from  which  are  separated  and  carried 
along  with  the  blood,  or  a  coagulum  in  the  left  auricle,  a  fragment  of 
the  clot  being  detached.  It  is  rather  more  common  in  cases  of  recent 
endocarditis,  rheumatic  or  "  ulcerative,"  than  in  chronic  disease.  A 
fresh  attack  of  endocarditis,  in  valves  previously  diseased,  is  especially 
likely  to  give  rise  to  embolism.  The  plug  may  come  from  either  the 
aortic  or  mitral  valves,  but  comes  from  the  latter  much  more  often 
than  from  the  former.  The  most  frequent  cause  is  mitral  constriction, 
in  which  several  conditions  probably  favour  the  occurrence  ;  the  slow 
flow  through  the  narrow  orifice  during  diastole  permits  the  aggrega- 
tion of  white  corpuscles  on  the  valve,  and  the  quick  flow  during  the 
auricular  systole  tends  to  detach  the  masses  thus  formed.  Moreover,  in 
this  disease  there  is  often  great  dilatation  of  the  auricle,  and  clot  forms 
in  the  auricular  appendix;  fragments  of  this  clot  are  apt  to  be 
detached,  or  softening  occurs  within  it,  and  the  particles  pass  into 
the  blood.  The  softened  clot  often  contains  organisms,  and  in 
ulcerative  endocarditis,  also,  the  particles  detached  (usually  small) 
may  carry  infective  micrococci  into  the  cerebral  arteries.  Hence  in 
both  these  conditions  thei'e  is  often  plugging  of  minute  vessels,  and 
inflammation  in  the  walls  of  the  vessels  and  the  adjacent  tissue. 

Outside  the  heart,  the  plug  comes,  occasionally,  from  the  lungs.  Less 
rarely  it  comes  from  the  aorta ;  when  its  wall  is  the  seat  of  atheroma, 
fragments  of  degenerated  tissue  or  of  clot  may  be  carried  away  by 
the  blood.  I  have  once  known  the  plug  to  come  from  the  interior 
of  an  aneurism.     Echinococcal  embolism  has  been  once  observed. 

Embolism  occurs  with  equal  frequency  in  both  sexes.  It  is  met 
with  at  all  periods  of  life,  but  is  most  frequent  between  later  child- 
hood and  middle  life.  In  the  old  it  is  less  frequent,  both  absolutely 
and  in  comparison  with  thrombosis.  The  subjects  of  it  have  usually 
suffered  from  those  diseases  that  are  attended  with  endocarditis — 
rheumatic  fever,  chorea,  scarlet  fever,  in  this  order  of  frequency.  It 
may  occur  in  the  course  of  these  diseases,  or  succeed  them  at  any 
interval  of  time.  At  the  time  of  the  embolism,  or  soon  afterwards, 
the  signs  of  organic  heart  disease  are  almost  always  to  be  recognised. 
It  occurs  also,  although  very  rarely,  as  a  result  of  other  acute  specific 
diseases,  any  one  of  which  is  occasionally  attended  with  endocarditis. 

An  immediate  exciting  cause  is  rarely  to  be  traced.  I  have  met 
with  one  instance  in  which  the  obstruction  followed  immediately  a 
severe  fright,  which,  by  exciting  the  action  of  the  heart,  may  have 
effected  the  detachment  of  the  plug.     Increased  coagulability  of  the 


424  BEAIN. 

blood  sometimes  co-operates  by  causing  an  increase  of  deposit  on 
diseased  valves,  or  the  formation  of  a  separate  clot  in  a  feeble  heart. 
Hence  embolism  often  occurs  a  week  or  two  after  childbirth.  This  is 
a  point  of  some  practical  importance  :  conditions  favouring  thrombosis 
do  not  necessarily  render  embolism  less  probable. 

Thrombosis. — As  we  have  seen,  thrombosis  may  be  due  to  atheroma, 
to  syphilitic  disease  of  the  arteries,  to  disease  of  their  wall  by  adjacent 
inflammation,  compression,  or  invasion  by  new  growth,  or  to  a  change 
in  the  blood. 

Atheroma. — The  larger  arteries  at  the  base  of  the  brain  are  very 
common  seats  of  the  thickening  of  the  inner  coat,  called  by  Virchow 
"  Endarteritis  deformans,"  which,  when  fattily  degenerated,  con- 
stitutes "  atheroma."  Opaque  yellow  thickenings,  sometimes  calcified, 
are  the  result.  Only  one  or  two  of  these  may  be  present;  but  the 
change  usually  involves  many  of  the  larger  vessels  at  the  base,  and 
extends  for  a  considerable  distance  along  the  chief  branches.  Its 
distribution  may  be  symmetrical.  A  similar  change  may  exist  in 
arteries  elsewhere,  or  it  may  be  confined  to  those  of  the  brain.  The 
exciting  cause  of  this  disease  is  probably  the  strain  to  which  these 
arteries  are  exposed  in  consequence  of  their  proximity  to  the  heart 
and  their  deficient  external  support.  It  is  not  easy  to  explain  their 
occasional  freedom  from  atheroma  when,  this  is  abundant  elsewhere. 
The  result  of  the  degeneration  is  to  abolish  the  elasticity  of  the  vessel, 
to  change  its  calibre,  sometimes  to  lessen  it  or  to  close  it  altogether, 
sometimes  to  enlarge  it.  Alterations  in  the  lining  membrane  lead 
to  the  formation  of  clot  upon  it,  as  on  a  foreign  body.  Where  the 
calibre  of  the  vessel  is  increased  the  current  is  retarded,  and  this  also 
facilitates  coagulation.  The  smaller  arteries  in  the  cerebral  substance 
do  not  suffer  in  the  same  degree  ;*  but  the  orifices  of  branches  coming 
off  from  an  atheromatous  vessel  are  often  narrowed  or  closed,  although 
the  main  trunk  is  pervious,  and  thrombosis  may  be  confined  to  these. 

Atheroma  is  common  after  middle  life,  and  increases  in  frequency 
with  age.  It  occasionally  occurs  before  forty,  chiefly  in  association 
with  chronic  Bright' s  disease,  in  which  the  arterial  tension  increases 
the  strain  on  the  vessels.  Grout  also  induces  early  degeneration. 
Softening  from  atheroma  shows  a  corresponding  relation  to  age.  It 
increases  in  frequency  as  life  advances,  and  the  increase  continues,  if 
due  correction  is  made  for  the  diminished  population,  to  extreme 
senilitv,  exhibiting  in  this  respect  a  contrast  to  haemorrhage  (see 
p.  387).  The  occurrence  of  atheroma,  and  therefore  of  softening,  is 
facilitated  by  chronic  alcoholism.  A  cachectic  state  of  the  system,  or 
some  cause  (such  as  prostrating  illness  or  grief)  that  alters  the 
constitution  of  the  blood,  and  weakens  the  action  of  the  heart, 
often  concurs  in  producing  the  thrombosis.  The  gouty  diathesis 
may  thus  co-operate,  and  even  cause  premonitory  thrombosis  elsewhere. 

*  Fatty  degeneration  of  the  cells  lining  the  perivascular  sheaths  of  the  minute 
arteries  is  very  common  even  in  the  young,  but  is  without  pathological  significance. 


ACUTE    SOFTENING.  425 

Syphilitic  disease  is  a  common  cause  of  softening.*  It  is  chiefly  a 
■consequence  of  acquired  syphilis,  and  so  occurs  in  adult  life.  About 
half  the  sufferers  are  between  thirty  and  forty  at  the  time  of  the 
attack,  one  third  between  twenty  and  thirty,  and  most  of  the  remainder 
between  forty  and  fifty  ;  under  twenty  and  over  fifty  it  is  very  rare. 
The  period  after  infection  at  which  it  is  developed  varies  much,  but  in 
the  majority  of  cases  is  from  one  to  twelve  years.  I  have  met  with  it 
as  early  as  six  months  and  as  late  as  nineteen  years  after  the  primary 
sore.  Fifty  cases  in  which  the  diagnosis  was  practically  certain,  and 
the  period  after  infection  could  be  definitely  ascertained,  were  dis- 
tributed as  follows  : — In  a  quarter  the  onset  was  during  the  first  two 
years  after  infection,  and  the  remainder  were  distributed  thus : 
2 — 3,  nine  cases ;  3 — 5,  seven  cases  ;  6—710,  nine  cases  ;  11 — 15,  eleven 
cases ;  16 — 20,  four  cases.  The  longest  intervals  were  18  and  19  years, 
the  shortest  6  months  (except  a  doubtful  case  at  3  months).  No 
•cases  in  married  women  are  available  for  comparison  because  the  date 
of  infection  cannot  be  ascertained  ;  many  other  cases  are  not  available 
because  the  individual  has  had  more  than  one  sore.  The  above 
twenty-six  cases  are  all  that  could  be  employed  for  this  purpose  out  of 
about  a  hundred  of  which  I  have  notes,  in  which  the  diagnosis  was 
reasonably  certain.  It  has  been  met  with  in  characteristic  form  as 
a  result  of  inherited  syphilis,  between  birth  and  the  tenth  year. 

As  an  isolated  change  (apart  from  massive  syphilitic  growths)  it  is 
almost  confined  to  the  larger  arteries  of  the 
base.     The  vessels  most  commonly  affected     — ^^^ 
are  the  internal  carotid,  middle  cerebral,     ■S^--.  ^  ■""'■---.- -^^-ry 

vertebral,   basilar,   and  posterior   cerebral.     ^  '/• __~f\J 

One  or  many  vessels  maybe  affected.     The 
distribution  of  the  change  is  commonly  ir- 
regular, but   sometimes  it  is  symmetrical. 
The  change  may  proceed  to  the  obliteration 
of  the  vessel,  but  more  frequently  when  the 
lumen  is  considerably  narrowed  a  clot  forms 
within  it  and  suddenly  arrests  the  circula- 
tion, or  forms  in  branches  arising  from  the    ;;  . ■'■■■''■■..->    / 
affected  part.  The  disease  consists  in  a  fibro-     v      ,  /    t ,'  \  * .  "> 
nuclear  growth  in  the  wall,  which  causes  a          //;.,:      V=!k 
nodular    projection   on    the  exterior  (Fig.          \v  • '"  % 
122),  and  diminishes  also  the  calibre  of  the   PlG.  122.— Syphilitic  disease 
vessel.    The  projections  are  more  nodular,       of  the  basilar  and  vertebral 
irregular,  and  less  opaque  than  in  atheroma.       J^Jj^  thrombosis  of  left 
The  structure  of  the  growth  resembles  that 

of  syphilomata  elsewhere.  It  generally  begins  by  a  nuclear  pro- 
liferation between  the  inner  coat  and  the  elastic  lamina,  or 
outside  the  latter :  in  the  former  case  the  elastic  lamina  is  pushed 
outwards  ;  it  may  undergo  degenerative  softening,  and  a  thrombus 
*  See  also  the  writer's  •  Syphilis  and  the  Nervous  System,'  1893,  Lect.  II. 


426  BRAIN. 

may  form  on  the  altered  inner  surface.  Antisyphilitic  treatment 
usually  induces  a  fibroid  cicatricial  change,  which,  causes  the  nodular 
projection  to  he  slight,  and  the  aspect  may  resemble  that  of  early 
atheroma.  If  the  elastic  and  muscular  elements  are  replaced  by  dis- 
tensible fibroid  tissue,  the  wall  may  bulge  into  an  aneurism. 

Other  forms  of  arterial  disease  causing  thrombosis  are  very  rare. 
Occasionally  pressure  on  an  artery  so  narrows  it  that  coagulation 
occurs.  Secondary  arteritis  may  result  from  inflammation  of  the 
membranes,  especially  from  traumatic  meningitis.  The  outer  coat 
of  the  vessels  becomes  thickened,  and  degenerative  changes  may 
be  set  up  in  the  middle  and  inner  coats,  and  may  lead  to  thrombosis 
months  or  years  after  the  primary  mischief,*  from  which  the  patient 
may  have  apparently  recovered.  In  the  course  of  tubercular  menin- 
gitis, a  tubercular  or  inflammatory  infiltration  of  the  walls  of  the 
arteries  has  been  met  with,  especially  in  small  vessels,  and  has  pro- 
duced thrombosis.  This  occurs  chiefly  at  the  convexity,  and  may 
precede  definite  symptoms  of  inflammation,  especially  in  adults  suffering 
from  phthisis.  The  inhalation  of  carbonic  oxide  has  caused  arterial 
degeneration  and  softening,  even  in  young  adults.f  Lastly,  it  may 
be  mentioned  that  ligature  of  the  carotid  occasionally,  although 
rarely,  causes  necrotic  softening  of  the  brain.  Usually  the  collateral 
circulation  is  sufficiently  free  to  prevent  this. 

Blood-states ;  Simple  Thrombosis. — In  certain  conditions  of  the  blood, 
coagulation  occurs  with  undue  readiness.  These  states  accompany 
childbirth,  acute  diseases,  cancer,  gout,  tuberculosis,  and  general 
malnutrition  at  all  periods  of  life,  but  especially  in  young  children 
and  old  persons.  Coinciding  with  disease  of  the  arteries,  it  exerts  a 
powerful  influence  on  the  occurrence  of  thrombosis  in  them.  In  the 
old  this  influence  is  often  seen ;  the  accident  follows,  for  instance, 
some  general  illness  or  some  depressing  emotion.  Arterial  throm- 
bosis may  occur  also  from  this  cause  when  there  is  no  arterial  disease, 
or  the  clot  may  form  in  a  vein  or  sinus.  This  occurs  occasionally  in 
adults,  as,  for  instance,  in  the  course  of  phthisis.  It  has  even  been 
known  to  occur  in  chlorosis.  J  Sudden  hemiplegia  sometimes  occurs 
under  conditions  of  impaired  general  health  in  young  adults,  in  whom 
syphilis  and  heart  disease  can  both  be  excluded ;  spontaneous  throm- 
bosis seems  the  most  probable  cause,  since  it  has  been  observed  in 
external  veins  at  twenty-one,  twenty-three,  and  twenty-four  years 
(Angelucci).  A  sudden  cerebral  lesion  frequently  occurs  in  children, 
and  is  probably  due  in  most  cases  to  thrombosis  in  a  vein  or  artery, 
but  it  is  occasionally  the  result  of  endocarditis  and  embolism.  These 
cases  are  separately  described. 

Cardiac  Weakness. — The  slower  the  blood-current,  the  more  readily 
does  coagulation  occur.     Hence  feebleness  of  the  heart's  action  is  a 

*  «  Med.  Ophthalmoscopy,'  Case  4,  2nd  ed.,  p.  270. 
+  Poelchen,  '  Virchow's  Arch.,'  Bd.  cxii. 
X  Skerritt,  Clin.  Soc,  1885. 


ACUTE    SOFTENING.  427 

powerful  factor  in  the  production  of  thrombosis.  The  weakness  may 
be  due  to  cardiac  disease,  especially  to  dilatation  of  the  left  ventricle, 
or  it  may  be  due  to  general  causes,  prostration  from  acute  or  chronic 
illness,  and  the  like.  Many  of  the  general  causes  of  thrombosis  act 
as  much  or  more  by  weakening  the  heart  as  by  altering  the  blood. 

Pathological  Anatomy. — Embolism. — The  plug  may  consist  of 
fibrin,  usually  decolourised ;  of  vegetation,  soft  or  firm,  from  a  cardiac 
valve ;  sometimes  of  a  calcareous  mass  from  a  valve  of  the  heart  or 
the  wall  of  an  artery ;  and  sometimes  of  minute  fragments  resulting 
from  the  breaking  down  of  clot  or  atheromatous  material.  In  the 
latter  case  minute  vessels,  even  capillaries,  may  be  plugged ;  in  the 
former  case  a  large  vessel  is  usually  obstructed.  Occasionally  a  plug, 
after  obstructing  a  large  vessel,  breaks  up,  and  the  fragments  pass 
on  into  the  smaller  branches.  The  embolus  is  usually  arrested  where 
the  artery  is  narrowed  by  giving  off  a  large  branch,  very  often  at  a 
bifurcation  (Fig.  123).  If  firm,  it  may  retain  its  original  shape; 
but  if  soft,  it  may  be  moulded  to  the  form  of  the  vessel  by  the  pressure 
of  the  blood.  A  coagulum  usually  forms  beyond  the  plug,  and 
extends  into  the  distal  branches,  and  another  often  forms  on  the 
cardiac  side  of  the  plug  as  far  as  the  origin  of  a  large  branch.  The 
secondary  clot  is  red,  and  from  it  the  paler  embolus  can  usually  be 
distinguished  without  difficulty  (Fig.  123,  L.  v.).  Sometimes  the  distal 
part  of  the  vessel  is  empty  and  contracted.  The  obstructing  plug  may 
break  up  and  pass  on  into  the  minute  branches  before  coagulation 
occurs.  Hence  we  cannot  always  find  an  obstructed  artery  even  when 
extensive  softening  has  occurred. 

The  middle  cerebral  arteries  and  their  branches  are  the  most 
frequent  seat  of  embolism,  because  they  are  the  direct  continuation  of 
the  carotid,  and  from  the  mode  of  origin  of  the  left  carotid  the  left 
middle  cerebral  is  rather  more  frequently  plugged  than  the  right. 
But  the  difference  between  the  two  is  less  than  is  often  stated,  the 
proportion  being  as  six  to  five.*  Both  middle  cerebral  arteries  have 
been  obstructed  in  rare  instances. f  Yery  seldom  the  internal  carotid 
is  obstructed,  but  the  circulation  in  its  branches  is  usually  maintained 
by  the  circle  of  Willis.  Next  in  frequency  is  the  posterior  cerebral, 
and  then  the  vertebral.  The  left  vertebral  is  more  often  plugged  than 
the  right,  for  the  reason  mentioned  on  p.  60  ;  but  the  two  posterior 
cerebrals  are  affected  with  equal  frequency,  the  plug  having  to  pass 
through  the  common  basilar.  The  anterior  cerebrals,  the  cerebellar 
arteries,  and  the  basilar  are  rarely  the  seat  of  embolism.  Embolism 
of  the  basilar  has,  indeed,  been  thought  to  be  impossible, £  but  it 

*  Gelpke,  left  64  (49  per  cent.),  right  54  (41  per  cent.) — '  Arch,  der  Heilkunde,' 
1875. 

f  As  in  a  case  of  ulcerative  endocarditis  recorded  by  Carrington,  '  Path.  Trans.  * 
vol.  xxxv,  1884,  p.  108. 

X  Nothnagel,  '  Topische  Diagnose/  &c,  1879,  p.  105 ;  Leyden,  « Zeitsch.  f .  kU 
Med,'  Bd.  v,  1882,  p.  175. 


•428 


BRAIN. 


•certainly  occurs,  as  Fig.  123  shows.  A  plug  too  large  to  be  arrested 
in  the  vertebral,  and  too  small  to  enter  the  posterior  cerebral,  must  of 
necessity  be  arrested  in  the  anterior  extremity  of  the  basilar,  and  the 
adjacent  figure  is  an  example  of  this.*     Barest  of  all  is  embolism  of 

the  cerebellar  arteries, 
doubtless  in  conse- 
quence of  the  angle 
at  which  they  arise 
from  the  larger  trunks. 
More  than  one  artery 
may  be  plugged,  but 
usually  at  different 
times,  rarely  at  the 
same  time.  When 
the  plug  comes  from 
a  septic  source,  as  in 
ulcerative  endocardi- 
tis, a  secondary  arte- 
ritis may  occur  at  the 
obstructed  part,  and 
sometimes  the  inflam- 
mation   may    extend 

to    the   neighbouring 
Fig.  123. — Embolism  of  basilar  artery  and  of  left  ver-  °  .     ° 

tebral.  The  latter  is  shown  cut  open  at  L  V.  The  structures.  Occasion- 
paler  embolus  can  be  distinguished  from  the  secon-  a]]y  £ue  artery  behind 
dary  clot  behind  it.     E  is  the  plug  e  from  the  extremity    .-,         -,  i        +i 

of  the  basilar,  moulded  by  pressure  into  the  shape  tne  Pmg;  or  wnen  tne 
of  the  vessel,  with  projections  corresponding  to  the  obstruction  is  imper- 
branches  There  is  a  secondary  thrombus  in  the  left  fect  ig  ^^  ^  &n 
post,  cerebral,  l.p.c.  . 

aneurism ;  the   walls, 

changed  by  the  inflammation  and  rendered  inelastic,  yield  before  the 
pressure  of  the  blood. 

Thrombosis  from  Atheroma. — Many  arteries  of  the  base  are  usually 
affected  by  atheroma,  and  thrombosis  may  occur  in  any  of  them; 
sometimes  in  two  vessels  simultaneously,  more  often  in  succession. 
It  is  most  common  in  the  internal  carotid,  middle  cerebral,  basilar, 
vertebral,  and  posterior  cerebral.  It  may  occur  in  the  branches  that 
come  off  from  the  diseased  and  thickened  part  of  the  vessel,  although 
the  trunk  remains  pervious.  The  branches  given  off  by  the  basilar  to 
the  pons  may  be  thus  obliterated,  and  softening  of  the  pons  may 
occur  In  the  same  way  the  branches  of  the  middle  cerebral  to  the 
central  ganglia  may  become  closed.  When  a  clot  forms  and  obstructs 
the  vessel,  it  usually  expends  into  its  distal  branches.  This  is  true 
of  the  internal  carotid,  thrombosis  in  which  usually  extends  into  the 
middle  and  anterior  cerebrals,  and  even  to  the  ophthalmic  artery.  In 
this  respect  thrombosis  of  the  internal  carotid  presents  a  contrast  to 
■embolism,  and  has  much  more  serious  consequences.  A  clot  in  the 
*  '  Brain/  vol.  i,  1882. 


ACUTE    SOFTENING.  429: 

vertebral  may  extend  into  the  basilar,  or  the  circulation  in  this  may 
be  maintained  by  the  other  vertebral. 

A  clot  usually  obstructs  the  vessel  where  it  is  formed,  but  occa- 
sionally, as  already  stated,  a  clot  that  has  formed  on  the  side  of  a 
vessel  may  become  detached,  and  may  be  arrested  at  a  narrower  part 
of  the  vessel  a  little  farther  on  (Laborde).  This  mechanism, 
although  probable,  can  rarely  be  proved.  When  the  clot  is  in  the 
place  at  which  it  was  originally  formed,  it  is  adherent  to  the  wall, 
pale,  and  often  laminated.  In  a  recent  case  the  secondary  coagulum 
that  forms  in  the  distal  part  of  the  artery  is  usually  red  and  adherent. 
After  a  time  it  undergoes  changes,  may  become  organised,  or 
degenerate,  and  even  calcify.  The  artery  may  become  transformed 
into  a  fibrous  cord.  Very  rarely  a  thrombus  breaks  down,  or  is- 
pushed  on  before  distal  clotting  occurs,  and  the  circulation  is  thus 
partially  or  entirely  re-established,  or  the  distal  thrombus  (especially 
in  the  cortex)  only  extends  towards  the  periphery  a  short  distance, 
a  collateral  circulation  being  maintained  in  the  smaller  arteries. 

Syphilitic  Disease. — The  disease  narrows  the  cavity  of  the  vessel  to 
a  greater  extent  than  does  atheroma,  and  hence  thrombosis  plays  a 
smaller  but  still  effective  part  in  producing  the  final  occlusion.  The 
branches  coming  off  from  the  vessel  are  obstructed  without  occlusion 
of  the  trunk,  even  more  frequently  than  in  atheroma.  Otherwise  the 
two  conditions  produce  very  similar  pathological  effects. 

Anatomical  Consequences. — The  first  effect  of  arterial  obstruction  is 
to  cause  the  arrest  of  the  arterial  blood-supply  to  the  region  supplied. 
There  is  generally  arterial  anaemia ;  sometimes  the  capillaries  may 
become  distended  with  blood  from  the  veins,  and  may  give  way  in 
places,  so  that  the  area  may  be  infiltrated  with  hsemorrhagic  points. 
For  the  first  twenty-four  hours  there  is  little  change  in  the  consistence 
of  the  part,  and  if  the  vessels  are  empty,  it  is  difficult  to  distinguish 
the  affected  area  from  the  rest  of  the  brain,  the  only  difference  being 
its  paler  tint.  After  the  first  twenty-four  or  thirty-six  hours  the 
consistence  of  the  tissue  rapidly  lessens  ;  the  nerve-elements  break 
down,  and  their  fragments  are  separated  by  effused  serum,  so  that  an 
area  of  softening  results.  The  serum  comes  no  doubt  partly  from 
the  blood,  and  partly  from  the  lymphatic  sheaths,  in  which  the 
lymphatic  fluid  must  collect  if  the  vessels  collapse.  The  tint  of  the 
softened  area  depends  on  the  amount  of  blood  within  it,  and  may  be 
white,  yellow,  or  red  from  the  beginning.  The  blood-corpuscles 
escape  into  the  softening  tissue,  partly,  perhaps,  by  diapedesis,  and 
partly  by  the  rupture  of  the  capillaries,  the  walls  of  which  undergo 
rapid  degeneration.  The  red  colour  changes,  in  the  course  of  a  few 
weeks,  to  yellow,  by  transformation  of  the  blood-pigment.  Thus 
three  forms  of  softening  are  distinguished — white,  red,  and  yellow, 
but  these  do  not  correspond  to  pathological  varieties.  In  all  forms 
the  process  of  destruction  of  the  nerve-elements  proceeds  to  the 
formation  of  fine  fatty  granules,  in  part  aggregated  into  "  granule 


430  BEAIN. 

corpuscles."  These  constitute  a  distinction  from  post-mortem 
softening,  in  which  the  segmentation  of  the  nerve-tubes  does  not  form 
such  small  fragments,  and  granule  corpuscles  are  absent. 

Red  softening  is  found  chiefly  in  the  grey  substance,  where  the 
vessels  are  numerous,  especially  in  the  cortex  and  central  ganglia. 
The  tint  varies;  the  red  colour  is  usually  punctiform,  or  mingled 
with  yellow  and  white.  If  the  extravasations  are  large  and  numerous, 
"  capillary  apoplexy  "  results.  The  diminution  of  consistence  is 
usually  moderate.  According  to  the  amount  of  effusion  of  serum 
and  blood,  there  is  swelling,  and  the  diseased  area  may  project  above 
the  cut  surface.  Inflammatory  changes  result  from  the  vascular 
distension,  and  in  proportion  to  these,  increase  in  the  nuclei  of  the 
neuroglia  is  found.  From  this  cause,  and  from  the  migration  of 
white  corpuscles,  pus-like  cells  appear.  The  vessels  are  dilated,  and 
may  present  a  moniliform  appearance.  Their  perivascular  sheaths 
are  often  distended  with  blood.  Commencing  degeneration  of  the 
effused  blood  may  cause  a  brown  tint. 

Yellow  softening  results  from  red  softening,  by  degenerative  changes 
in  the  blood  effused.  It  has  a  similar  seat,  being  frequently  met 
with  in  the  convolutions,  where  it  constitutes  the  plagues  jaunes  of 
the  French.  Its  consistence  is  usually  slight,  its  aspect  granular. 
The  colour  depends  on  the  presence  of  minute  pigment  granules, 
diffused  colouring  matter,  and  hsematoidin  crystals. 

White  softening  has  the  tint  of  the  normal  cerebral  substance,  and 
is  chiefly  found  in  the  white  substance.  In  consistence  it  varies ;  it 
may  be  only  a  little  below  that  of  the  brain  tissue,  or  it  may  be  difflu- 
ent. Its  aspect  is  uniform,  or  white  flakes  are  scattered  through  it. 
The  limits  are  usually  gradual.  Under  the  microscope  it  presents 
the  detritus  of  nerve-elements,  a  few  nuclei  from  the  connective 
tissue,  granule  corpuscles,  and,  ultimately,  corpora  amylacea.  It 
occasionally  has  a  gangrenous  odour,  and  then  may  be  found  in  the 
white  or  in  the  grey  substance,  probably  resulting  from  the  obstruc- 
tion of  capillaries  by  septic  material. 

The  process  of  softening  is  attended  with  inflammatory  changes 
around  the  affected  area,  and  the  adjacent  nerve-elements  often  suffer 
permanently  in  nutrition  and  function  from  this  cause.  It  is  import- 
ant, in  regard  to  the  symptoms,  to  remember  that  the  destroyed  area 
is  surrounded  by  a  zone  of  slighter  damage. 

Ultimate  Changes. — White  and  yellow  softening  may  remain  for 
years  unchanged.  Sometimes  the  alterations  in  the  elements  of  the 
neuroglia  and  the  extravasated  white  corpuscles  result  in  the  forma- 
tion of  a  considerable  quantity  of  connective  tissue,  consisting  of  fine 
fibre-cells  and  fibres,  most  abundant  in  the  margins  of  the  softened 
area,  which  become  firm  and  dense,  and  trabeculse  of  connective  tissue 
may  cross  the  cavity.  After  a  time  the  fluid  may  be  absorbed,  the 
fat  removed,  and  a  sort  of  cicatrix  results.  In  other  cases  the  walls 
alone  are  thus  altered,  the  solid  particles  are  removed  from  the  soft- 


ACUTE    SOFTENING.  431 

ened  tissue,  and  a  cyst  is  formed.     The  outer  portion  of  the  cyst  or 
cicatrix  may  be  limited  by  a  zone  of  dilated  blood-vessels. 

Seats  of  Softening. — There  is  no  part  of  the  brain  in  which  softening 
has  not  been  found,  but  its  most  frequent  seats  are  the  cortex,  the 
corpus  striatum,  and  the  optic  thalamus.  It  is  also  frequently  found 
in  the  pons,  and  occasionally  in  the  medulla  and  cerebellum.  An 
example  of  softening  of  the  pons  is  shown  in  Fig.  59,  p.  72.  Its 
occurrence,  position,  and  characters  depend  on  the  distribution  of  the 
vessels.  The  small  arteries  of  the  corpus  striatum  and  optic  thalamus 
are  "terminal  arteries,"  having  only  capillary  communications  with 
other  vessels.  The  arteries  to  the  surface  of  the  brain  are  also 
sometimes  terminal,  but  usually  possess  anastomoses  with  other 
branches  which  vary  in  degree  and  disposition.  Hence  obstruc- 
tion in  the  central  arteries  leads  invariably  to  softening ;  obstruc- 
tion in  the  superficial  arteries  often  causes  softening,  which  involves 
the  grey  substance  of  the  convolutions  and  some  of  the  subjacent 
white  centre  to  which  the  vessels  penetrate ;  but  frequently  the 
anastomoses  of  the  superficial  vessels  are  so  free  that  softening  does 
not  result,  or  only  occurs  in  parts  of  the  area  of  the  artery  occluded.* 
Obstruction  of  a  main  trunk  (as  the  middle  cerebral)  may  thus  lead 
to  softening  of  the  central  region  (corpus  striatum),  while  the  convo- 
lutions escape,  or  both  may  suffer.  Some  parts  of  the  cortex  escape 
more  frequently  than  others ;  the  convolutions  about  the  fissure  of 
Sylvius  are  often  destroyed  by  obstruction  of  the  middle  cerebral 
when  the  higher  regions  of  the  cortex  are  intact  (see,  for  instance, 
the  softening  figured  on  p.  23) . 

The  changes  thus  described  are  met  with  in  all  forms  of  vascular 
obstruction.  The  causes  that  determine  the  amount  of  blood  in  the 
softened  part  are  not  all  understood,  but  the  amount  seems  to  be  larger 
in  the  young  than  in  the  old,  and  perhaps  in  embolism  than  in  throm- 
bosis. Cohnheim  and  Litten  have  proved  that  embolism  in  any  organ 
is  usually  attended  with  distension  of  the  veins  and  capillaries  in  the 
infarcted  area,  and  with  abundant  effusion  of  serum.  It  is  surprising 
that  such  distension  is  not  more  constant  in  the  brain. 

Symptoms. — The  symptoms  produced  by  the  occlusion  of  an  artery, 
and  consequent  necrotic  softening  of  the  brain,  resemble  those  of 
cerebral  haemorrhage  in  being  of  two  classes,  one  transient,  the  result 
of  the  sudden  interference  with  the  functions  of  the  brain,  the  other 
more  or  less  permanent,  the  result  of  the  destruction  of  the  nerve- 
elements  in  the  affected  area.  The  permanent  symptoms  depend  on 
the  position  of  the  lesion ;  the  symptoms  that  attend  the  onset  vary 

*  As  an  illustration  of  the  free  arterial  communication  that  often  exists  in  the 
cortex,  it  may  be  mentioned  that  Prof.  Thane  has  informed  me  that  attempts  to 
inject  separately  the  arteries  supplying  the  cortex  fail  more  often  than  they  succeed, 
on  account  of  the  readiness  with  which  the  injection  passes  from  one  arterial  region 
to  another. 


432  BRAIN. 

according  not  only  to  the  seat,  but  also  to  the  nature  of  the  vascular 
occlusion. 

Premonitory  symptoms  are  rare  in  embolism.  When  present  they 
are  not  true  prodromata,  but  consist  in  slighter  attacks  of  the  same 
character,  or  they  are  the  first  symptoms  of  the  onset  when  the  occlu- 
sion is  gradual.  There  is  no  preceding  indication  of  encephalic 
disease,  because,  until  the  plug  obstructs  the  vessel,  the  brain  is  in  a 
normal  state.  In  thrombosis  from  atheroma,  on  the  other  hand, 
premonitory  symptoms  are  frequent.  They  depend  on  the  inter- 
ference with  the  supply  of  blood,  due  to  the  disease  of  the  vessels. 
They  may  exist  for  months  before  the  onset  or  only  for  a  few  hours. 
The  most  common  are  dull  general  headache,  giddiness,  tingling, 
"  numbness,"  slight  weakness  in  one  half  of  the  body,  sometimes 
limited  to  a  single  limb,  and  often,  but  not  always,  corresponding 
in  seat  to  the  subsequent  paralysis  ;  less  commonly  there  is  defective 
articulation,  or  some  mental  change,  failure  of  memory,  or  irrita- 
bility due  to  the  general  malnutrition  of  the  brain,  that  is  produced 
by  wide-spread  arterial  disease.  In  syphilitic  disease  premonitory 
symptoms  are  also  frequent.  In  some  cases  they  resemble  those 
just  described,  but  more  severe  general  cerebral  symptoms  are  both 
conimqn  and  characteristic.  Headache  is  the  most  frequent,  and  is 
often  severe,  usually  general,  and  may  be  worse  at  night.  It  may 
exist  for  weeks  or  only  for  a  day  or  two  before  the  onset.  Another 
occasional  premonitory  symptom  is  giddiness.  Sometimes  there  is 
considerable  mental  dulness  or  a  somnolent  condition,  lasting  for 
weeks.  This  is  true  also  of  other  forms  of  arterial  disease,  but  pre- 
monitory symptoms  are  absent  in  simple  thrombosis.  In  all  cases,  their 
presence  is  far  more  significant  than  their  absence. 

The  onset  of  cerebral  softeniug  is  attended  by  loss  of  consciousness 
in  a  considerable  number  of  cases,  although  this  is  less  frequent  than 
in  hemorrhage.  The  sudden  obstruction  of  a  large  vessel,  however 
produced,  frequently  entails  a  distinct  apoplectic  attack.  The  obstruc- 
tion of  a  small  branch,  causing  only  a  small  spot  of  softening,  often 
causes  no  loss  of  consciousness.  For  lesions  of  equal  size,  the  more 
sudden  the  obstruction,  the  more  pronounced  is  the  apoplectic  seizure. 
This  is  well  seen  in  cases  of  the  same  nature.  In  embolism  a  gradual 
onset,  occupying  many  hours,  is  rare,  but  when  it  occurs  there  is  no 
unconsciousness  ;  but  with  a  sudden  onset  loss  of  consciousness  is  very 
frequent.  In  syphilitic  disease,  on  the  other  hand,  consciousness  is 
more  frequently  preserved  than  lost.  The  contrast  between  these  two 
conditions  is  more  marked  than  between  embolism  and  senile  softening, 
because  the  advanced  life  renders  loss  of  consciousness  more  readily 
produced.  When  there  is  well-marked  apoplexy,  the  loss  of  con- 
sciousness may  be  the  first  symptom,  but,  rather  more  frequently  than 
in  hemorrhage,  focal  symptoms,  especially  hemiplegia,  come  on  before 
the  coma.  This  is  especially  the  case  in  atheromatous  thrombosis. 
The  apoplectic  condition  itself  presents  no  characteristic  feature ;  it 


ACUTE    SOFTENING.  433 

resembles  closely  that  produced  by  haemorrhage.  The  turgid  face 
and  strongly  pulsating  carotids  are,  as  a  rule,  absent,  but  these  are 
not  very  common  in  haemorrhage.  As  a  rule,  the  degree  of  coma  is 
slighter,  and  its  duration  shorter,  tban  in  haemorrhage;  but  when  a 
large  vessel  is  plugged,  the  coma  may  be  as  intense  and  as  prolonged, 
the  resolution  of  the  limbs  as  perfect,  and  the  interference  with 
breathing  as  marked,  as  in  a  severe  cerebral  haemorrhage.  It  may 
last  for  several  days,  and  end  in  death  or  in  recovery.  Coma  lasting 
for  five  or  six  days  may  pass  away  when  it  is  due  to  softening,  but 
usually  ends  in  death  if  due  to  haemorrhage. 

The  mechanism  by  which  apoplexy  is  produced  by  vascular  obstruc- 
tion can  scarcely  be  altogether  the  same  as  in  haemorrhage,  since  the 
element  of  pi'essui-e  is,  if  not  absent,  at  least  trifling  in  degree  and 
late  in  time,  due  only  to  the  cedematous  swelling  which  comes  on 
after  the  onset.  Attempts  have  been  made  to  explain  the  uncon- 
sciousness by  the  disturbance  of  the  circulation.  It  has  been  ascribed, 
for  instance,  to  the  increase  of  blood-pressure  in  the  other  branches 
of  the  same  vessel,  owing  to  the  pressure  being  suddenly  diminished 
in  the  area  of  the  infarction  by  the  arrest  of  the  blood-tension  within 
it  (Heubner,  "Wernicke).  This  mechanism,  however,  does  not  seem 
adequate.  Moreover,  the  fact  that  extensive  softening  is  sometimes 
unattended  with  apoplexy,  even  when  quite  sudden  in  onset,  is  difficult 
to  explain,  but  on  the  whole  it  seems  most  probable  that  the  sudden 
cessation  of  nutrition  in  the  affected  area  is  equivalent  to  a  traumatic 
irritation,  and  that  the  loss  of  consciousness  is  chiefly  due  to  an  inhi- 
bition of  the  highest  centres,  similar  to  that  which,  in  haemorrhage, 
results  from  the  laceration  of  the  fibres. 

Convulsion  frequently  accompanies  the  onset  in  embolism.  It  may 
be  general,  and  irrespective  of  the  artery  plugged ;  sometimes  it  begins 
locally  in  the  part  afterwards  most  paralysed,  and  is  then  generally 
due  to  embolism  of  the  middle  cerebral,  affecting  the  motor  cortex. 
In  atheromatous  softening,  and  in  syphilitic  disease,  initial  convulsions 
are  much  more  rare.  Vomiting  is  not  more  common  in  any  form  of 
softening  than  in  cerebral  haemorrhage.  It  is  most  frequent  in 
obstruction  of  the  basilar.  Delirium  may  take  the  place  of  loss  of 
consciousness  in  either  embolism  or  thrombosis.  In  atheromatous 
softening,  brief  initial  loss  of  consciousness  is  often  succeeded  by 
quiet  delirium,  lasting  for  several  days  or  even  weeks. 

When  there  is  no  loss  of  consciousness,  the  onset  is  usually  marked 
by  sudden  headache,  giddiness,  or  incoherence,  to  which  are  quickly 
added  the  paralytic  or  other  symptoms  due  to  the  destructive 
lesion.  The  loss  of  power  is  often  accompanied  by  tingling  in  the 
affected  side,  but  sometimes  comes  on  without  any  associated  sym- 
ptom. 

Focal  Symptoms. — In  rare  instances  focal  symptoms  are  absent,  the 
lesion  being  so  placed  as  to  cause  none.  In  most  cases,  focal  symptoms 
may  be  recognised  during  the  period  of  unconsciousness,  similar  to 
vol.  ii.  28 


434:  BRAIN. 

those  produced  bv  haemorrhage, — unilateral  atony  of  muscles,  loss  of 
lv-flex  actiou,  inequality  of  face,  and  conjugate  deviation  of  head  and 
eyes.  Hemiplegia  is  the  most  common  form  of  palsy,  because  the 
middle  cerebral  is  the  artery  most  often  plugged,  and  aphasia  usually 
accompanies  it  when  the  left  artery  is  affected.  Bilateral  palsy  may 
be  due  to  bilateral  obstruction  or  to  thrombosis  of  the  basilar,  causing 
softening  of  the  pons.  In  the  latter  case,  the  paralysis  on  each  side 
is  usually  partial. 

The  fall  of  temperature  that  attends  tbe  onset  of  haemorrhage  is  less 
mai-ked  in  softening,  rarely  exceeding  half  a  degree,  and  is  very  often 
absent.  A  rise  usually  occurs  in  ten  or  twelve  hours,  or  may  be 
deferred  for  some  days.*  The  period  of  inflammatory  reaction  is 
more  pronounced  in  softening  than  in  haemorrhage  whatever  be 
the  cause  of  the  sof  teniug ;  but  it  is  most  considerable  in  the  old, 
whose  brains  are  generally  ill-nourished,  and  in  embolism,  especially 
when  the  plug  comes  from  a  septic  source,  such  as  ulcerative  or 
septicemic  endocarditis  Any  previous  elevation  of  temperature  in 
these  cases  increases  considerably  after  the  occurrence  of  embolism. 
In  occlusion  of  the  basilar  artery  there  may  be  hyperpyrexia,  as  in 
ha3inorrhage  into  the  pons,  but  less  rapidly  developed,  and  it  may  be 
preceded  by  a  greater  depression  of  temperature.  In  the  febrile  dis- 
turbance, the  temperature  is  often  one  or  two  degrees  higher  on  the 
paralvsed  side;  sloughing  of  the  skin  is  common  in  septic  embolism ; 
and  inflammation  of  the  joints  is  met  with  less  rarely  than  in  haemor- 
rhage. The  headache  that  accompauies  the  secondary  inflammation  is 
usually  considerable,  and  both  delirium  and  convulsions  are  not  un- 
frequent.  Optic  neuiitis,  practically  unknown  from  haemorrhage,  is  also 
unknown  as  a  result  of  senile  (atheromatous)  softening  and  of  softening 
from  syphilitic  tumour  of  the  arteries.  If  it  co-exists  with  these  it  is 
as  the  result  of  associated  causes,  as  Bright' s  disease  in  the  former,  or  a 
syphilitic  tumour  in  the  latter  case,  which  may  co-exist  with  the  arterial 
disease.  But  optic  neuritis  is  met  with  occasionally  in  embolism,  when 
the  plug  comes  from  an  inflamed  endocardium, f  and  it  is  apparently 
the  consequence  of  the  irritative  character  of  the  secondary  inflamma- 
tion, induced  by  the  infective  material  carried  by  the  plug.  In  ulcer- 
ative endocarditis,  another  ophthalmoscopic  change  may  be  met  with — 
rounded  haemorrhages,  with  white  centres,  scattered  over  the  retina. 
They  are  the  result  of  the  septic  obstruction  of  minute  vessels ;  similar 
haemorrhages  may  be  found  in  the  pia  mater. 

Otherwise  the  local  symptoms  consist  in  motor  and  sensory  paralysis, 
&c,  according  to  the  seat  of  the  softening.     As  in  haemorrhage,  the 

*  Softening  of  the  central  ganglia  may  be  attended  by  a  rise  (Hale  White). 
In  a  case  of  haemorrhagic  softening,  outside  the  optic  thalamus,  in  a  girl  of 
twenty-three,  the  temperature  rose  to  108D,  but  there  was  ulcerative  endocarditis 
(Pasteur). 

t  Such  cases  have  been  recorded  by  Broadbent  and  Stephen  Mackenzie,  and 
another  has  come  under  my  own  observation. 


ACUTE    SOFTENING.  435 

initial  symptoms  are  more  extensive  than  those  that  persist,  and  those 
that  pass  away  during  the  first  two  weeks  must  be  regarded  as  '  in- 
direct '  in  origin.  We  cannot  explain  them  as  pressure  effects,  but 
they  are  no  doubt  the  result,  partly  of  inhibition,  and  partly  of  the 
interference  with  function  from  slight  damage,  wider  than  the  area 
of  actual  destruction. 

The  chief  differences  between  the  local  symptoms  in  softening  and 
haemorrhage  are  the  following.  Aphasia  is  more  common  in  softening 
on  account  of  the  frequency  with  which  the  cortex  suffei's  in  the  region 
of  the  middle  cerebral  artery.  Partial  hemiplegia,  "  monoplegia," 
of  arm,  or  face  and  arm,  rarely  of  the  leg,  is  also  more  common 
for  the  same  reason  ;  because  softening  affects  the  cortex  more  fre- 
quently, and  such  palsies  are  usually  due  to  a  lesion  where  the  motor 
structures  are  separate,  i.  e.  in  the  cortex.  Another  cause  is  that  the 
effect  of  softening  is  more  restricted  than  is  that  of  haemorrhage,  on 
account  of  the  absence  of  grave  damage  to  adjacent  parts.  Recurring 
convulsions  are  also  far  more  frequent  after  softening,  owing  to  the 
more  frequent  affection  of  the  cortex,  aided  by  the  persistence  of  slighter 
adjacent  damage.  In  the  later  chronic  stage,  disorders  of  move- 
ment, choreoid,  athetotic,  &c,  are  also  more  common  after  softening 
than  after  haemorrhage,  although  the  explanation  of  the  fact  is  still 
uncertain.  Mental  failure,  loss  of  memory,  and  emotional  disturbance, 
are  rather  greater  in  degree  during  the  chronic  stage  of  softening, 
but  the  difference  is  less  than  is  commonly  imagined,  and  is  chiefly 
related  to  three  facts  :  (1)  foci  of  softening  are  often  more  nu- 
merous than  those  of  haemorrhage;  (2)  softening  from  atheroma  is 
often  accompanied  by  disease  of  other  vessels,  interfering  widely  with 
the  nutrition  of  the  brain  ;  (3)  this  is  also  the  case  in  syphilitic  dis- 
ease, in  which,  moreover,  there  may  be  a  marked  tendency  to  nerve 
degeneration. 

Another  point  of  difference  is  that  an  entire  absence  of  focal  sym- 
ptoms is  rather  more  common  in  softening,  on  account  of  the  pressure 
exerted  by  haemorrhage.  This  is  often  seen  in  lesions  of  the  central 
ganglia.  It  is  rare  for  a  haemorrhage  limited  to  the  caudate  or 
lenticular  nucleus  not  to  cause  hemiplegia  by  the  pressure  it  exerts 
on  the  internal  capsule,  whereas  it  is  not  uncommon  to  meet  with 
an  extensive  softening  of  one  of  these  nuclei  without  any  focal  sym- 
ptoms, past  or  present.  Again,  the  onset  is  sometimes  in  two  stages, 
especially  in  syphilitic  disease.  Slight  weakness,  in  one  case,  lasted 
for  four  days  before  sudden  hemiplegia.  In  another,  the  leg  was  weak 
one  morning,  and  the  arm  and  face  lost  power  in  the  course  of  the 
next  three  or  four  days. 

Bilateral  obstruction  of  large  vessels  occurs  chiefly  from  arterial 
disease  ;  it  is  rarely  simultaneous,  but  sometimes  occurs  in  quick  suc- 
cession, and  may  then  cause  bilateral  symptoms  very  closely  resembling 
those  produced  by  ventricular  haemorrhage.  The  initial  disturbance 
may  or  may  not  have  passed  away  when  coma  recurs  or  suddenly 


436  miAlN. 

deepens,  and  quickly  becomes  intense  with  general  relaxation  or  rigid- 
ity of  muscles.  The  patient  may  die  in  the  course  of  a  few  hours. 
When  the  vessel  occluded  is  less  important,  bilateral  symptoms  result 
resembling  those  produced  by  softening  of  the  pons.  In  rare  cases  of 
thrombosis  or  embolism  tbe  corresponding  areas  in  tbe  two  hemispheres 
have  been  affected,  cortical  centres  or  the  path  from  them  causing 
symmetrical  paralysis  of  partial  extent.  Thus  an  affection  of  the 
lower  part  of  each  motor  cortex  or  central  structures  has  caused  not 
only  total  loss  of  speech,  but  paralysis  of  tbe  lips,  tongue,  and 
throat,  closely  resembling  that  produced  by  a  lesion  of  the  medulla 
oblongata — the  "  pseudo-bulbar  paralysis,"  mentioned  at  p.  320. 

Complications. —  In  some  forms  of  softening  the  symptoms  produced 
by  the  lesion  may  be  accompanied  by  others  that  are  produced  by 
associated  morbid  processes,  besides  those  already  mentioned  as 
directly  concerned  in  tbe  causation  of  tbe  arterial  obstruction,  rheu- 
matism, gout,  &c.  Tbus  syphilitic  arterial  disease  is  sometimes 
associated  with  syphilitic  meningitis,  or  with  a  syphilitic  tumour. 
In  ulcerative  endocarditis  the  circulation  of  septic  material  in  the 
blood  often  causes  general  fever,  with  rigors,  beadacbe,  and  delirium, 
enlargement  and  tenderness  of  the  spleen,  or  hsematuria  from  renal 
embolism.  Delirium  may  occur  without  softening,  in  consequence  of 
the  blood-state,  or  of  capillary  obstructions  in  the  brain  or  meninges  ; 
and  it  is  not,  therefore,  surprising  to  find  that  it  often  accompanies  tbe 
symptoms  of  an  actual  softening.  In  all  cases  of  embolism  the  indica- 
tions of  a  similar  process  elsewhere  are  frequent.  An  interesting 
complication  is  embolism  of  the  central  artery  of  the  retina.  It 
usually  occurs  at  some  other  time  than  the  cerebral  embolism,  but  I 
have  recorded  one  case  in  which  the  two  accidents  were  simultaneous.* 

Obstruction  of  Particular  Arteries. — The  distribution  of  the 
several  arteries,  which  determines  the  seat  of  softening  and  the  sym- 
ptoms produced,  has  been  already  described  (see  p.  60). 

Internal  Carotid. — Ligature  of  the  common  carotid  may  cause  no 
symptoms,  or  transient  hemiplegia,  or  severe  hemiplegia,  ending  in 
deajh  at  the  end  of  a  week  or  ten  days.  In  the  former  case  the  com- 
munications of  the  circle  of  Willis  suffice  to  carry  on  the  circulation 
in  the  hemisphere.  After  a  time  tbe  communicating  arteries  are  found 
considerably  dilated.  Persistent  hemiplegia  is  usually  the  consequence 
of  these  vessels  being  unusually  small,  so  that  enough  blood  is  not 
conveyed  to  prevent  necrotic  softening,  which  may  be  found,  post 
mortem,  in  the  greater  part  of  the  hemisphere  except  in  the  region 
supplied  by  the  posterior  cerebral.  When  the  communicating  arteries 
are  absent  this  result  necessarily  follows.  In  embolism  of  the  internal 
carotid,  the  symptoms  depend  on  the  place  at  which  tbe  plug  is  arrested. 
If  tbis  is  at  the  curve  in  the  cavernous  sinus  the  circulation  is  usually 

*  '  Medical  Ophthalmoscopy,'  Case  47,  2nd  ed.,  p.  332. 


ACUTE    SOFTENING.  437 

maintained  in  the  part  above  by  the  communicating  arteries,  so  that 
softening  does  not  ■  result,  while  the  connection  between  the  oph- 
thalmic and  the  facial  arteries  helps  to  maintain  the  circulation  in  the 
former.  If  the  plug  is  arrested  at  tiie  division  of  the  internal  carotid, 
the  i-esulting  symptoms  are  the  same  as  in  obstruction  of  the  middle 
cerebral  artery ;  the  anterior  communicating  conveying  a  supply  of 
blood  to  the  anterior  cerebral.  Thrombosis  in  the  internal  carotid 
consequent  on  atheroma  may  cause  the  same  effects  as  embolism, 
but  they  are  often  more  serious,  because  there  is  a  greater  tendency 
for  the  thrombus  to  spread,  from  the  extensive  disease  of  the  wall 
of  the  vessel.  Such  a  clot  may  spread  into  the  anterior  and  middle 
cerebrals,  and  along  the  former  it  may  pass  beyond  the  communicating 
artery,  producing  softening  of  the  anterior  two  thirds  of  the  hemi- 
sphere, only  the  occipital  lobe  and  the  lower  and  inner  portions  of  the 
temporal  lobe  escaping.  It  may  spread  also  into  the  ophthalmic 
artery,  producing  (as  I  have  seen)  a  necrosis  of  the  eyeball,  so  that 
the  sclerotic  after  death  was  rotten  and  discoloured.  The  symptoms 
of  this  extensive  thrombosis  are  necessarily  severe — hemiplegia  with 
deepening  coma  and  death  at  the  end  of  (usually)  four  or  five  days. 
The  ophthalmoscopic  appearances  due  to  the  thrombosis  of  the 
ophthalmic  artery  are  not  known,  but  they  probably  resemble  that 
produced  by  embolism  of  the  central  artery,  perhaps  with  rapid 
opacity  of  the  media.  It  is  very  important,  in  every  case  of  apoplexy, 
that  the  eyes  should  be  daily  examined,  because  the  obstruction  of 
the  ophthalmic  artery  develops  gradually  during  coma,  and  subjective 
indications  of  the  accident  may  be  absent. 

The  anterior  cerebral  is  rarely  obstructed  except  by  plugging  of  the 
extremity  of  the  internal  carotid,  because,  on  account  of  its  direction 
at  right  angles  to  the  carotid,  an  embolus  seldom  enters  it.  Obstruc- 
tion of  the  first  part  of  the  vessel  may  cause  a  small  spot  of  softening 
in  the  head  of  the  caudate  nucleus,  but  not  elsewhere  in  the  region 
supplied,  unless  the  anterior  communicating  artery  is  absent,  or  the 
thrombus  extends  beyond  its  junction.  Moreover,  a  collateral  circu- 
lation from  the  branches  of  the  middle  cerebral  may  aid  in  main- 
taining the  nutrition  of  the  cortex.  Hence  softening  in  the  cortical 
region  supplied  by  this  vessel  is  rare,  except  in  association  with 
obstruction  of  the  middle  cerebral.  Softening  of  the  olfactory  bulb 
and  adjacent  part  of  the  orbital  lobule  has,  however,  been  known  to 
result  from  an  embolism  of  the  first  branch  of  the  artery.  Very 
rarely  softening  is  limited  to  the  paracentral  region,  or  to  the  pre- 
cuneus. Except  the  loss  of  smell  that  results  from  disease  of  the 
olfactory  nerve,  the  symptoms  of  softening  in  the  region  of  the  ante- 
rior cerebral  are  not  distinctive.  Theoretically  a  monoplegia  affecting 
the  leg  only  should  result  from  softening  of  the  marginal  convolution 
and  the  paracentral  lobule,  but  I  do  not  know  of  an  observed  case. 

Middle  Cerebral. — Since  this  artery  supplies  the  motor  cortex  and 
the  motor  path  through  the  ganglia,  its  obstruction,  partial  or  com- 


438  ERAIN. 

plete,  usually  gives  rise  to  paralysis.  One  or  more  of  its  four  cortical 
branches  (see  Fig.  47,  p.  63)  may  be  occluded,  or  all  may  be 
obstructed  by  a  plug  at  the  point  of  division  of  the  artery  at  the 
island  of  Reil.  Occlusion  of  the  branches  may  cause  softening  in  th^ 
area  supplied  by  them,  shown  in  Fig.  48.  That  of  the  first  produces 
softening  of  the  third  frontal,  and,  if  on  the  left  side,  aphasia ;  of  the 
second  or  third,  softening  of  the  ascending  frontal  or  ascending- 
parietal  convolution  and  hemiplegia,  partial  when  the  softening  is 
incomplete;  and  of  the  fourth,  softening  about  the  posterior  limb  of 
the  fissure  of  Sylvius,  and  if  on  the  left  side,  sensory  aphasia,  defective 
perception  of  words,  with  corresponding  impairment  of  speech,  are 
produced.  When  all  the  coi-tical  branches  are  obstructed,  the 
softening  extends  over  all  the  area  supplied,  although  usually  in 
varying  degree  in  different  parts,  in  consequence  of  partial  anasto- 
moses, and  the  upper  region  of  the  hemisphere  may  escape  (see  Fig. 
15,  p.  23).  The  usual  effect  is  severe  hemiplegia,  with  impairment 
of  sensibility  for  a  time,  and  sometimes  even  affection  of  the  special 
senses,  and  ptosis  on  the  opposite  side.  Partial  obstruction  of  the 
deep  central  branches,  from  the  first  part  of  the  artery,  either  by 
embolism,  disease  of  the  wall  at  their  origin,  or  thrombosis,  causes 
softening  in  the  lenticular  nucleus,  caudate  nucleus,  and  anterior  part 
of  the  optic  thalamus,  very  variable  in  extent;  when  considerable  the 
internal  capsule  always  suffers,  and  hemiplegia  results.  Complete 
obstruction  of  the  middle  cerebral  near  its  origin  always  causes 
softening  in  the  central  ganglia  and  hemiplegia,  with  or  without 
softening  of  the  cortex  supplied  by  it. 

Posterior  Cerebral. — The  rarity  of  softening  from  obstruction  of  the 
posterior  cerebral,  due  to  the  freedom  of  its  anastomoses,  renders  our 
knowledge  of  the  symptoms  produced  much  less  definite  than  in  the 
case  of  the  middle  cerebral.  They  are  for  the  most  part  sensory; 
there  may  be  hernianaesthesia  from  softening  of  the  tegmentum  of  the 
crus,  or  the  internal  capsule,  or  hemianopia  from  softening  of  the 
occipital  lobe.  Such  softening,  especially  of  the  cuneus,  is  the  most 
common  cause  of  cortical  hemianopia,  but  the  same  symptom  is  very 
ccnn.cn  m  obstruction  of  this  artery  when  the  cortex  is  intact,  from 
interruption  to  the  optic  path.  Complete  but  transient  loss  of  sight 
has  also  attended  embolism  of  one  posterior  cerebral:  it  is  probably 
inhibitory  in  origin.  The  symptoms  of  limited  softenings  of  the  inner 
and  lower  part  of  the  temporal  lobe  are  not  known. 

Basilar  Artery. -^The  symptoms  present  considerable  variations 
according  to  the  seat  of  obstruction,  whether  in  the  middle,  lower,  or 
upper  portions,  or  whether  there  is  merely  occlusion  of  the  arteries  that 
come  off  from  it,  in  consequence  of  disease  of  the  wall,  or  of  incom- 
plete embolism.  In  the  obstruction  of  the  transverse  arteries,  the 
softening  produced  may  be  bilateral  or  unilateral,  often  small  in  extent, 
near  the  middle  line  or  in  the  outer  part  of  the  pons,  according  as 
median  or  radicular  branches  are  obstructed  (see  p.  65).     Hemiplegia 


ACUTE   SOFTENING.  439 

usually  results,  -which  may  be  "  alternate,"  of  limbs  and  cranial  nerves, 
or  may  resemble  that  produced  by  a  lesion  of  the  corpus  striatum, 
according  to  the  seat  of  the  disease  (see  p.  315).  In  some  cases  the 
occlusion  of  different  branches  takes  place  successively,  and  the  patient 
may  have  several  sudden  seizures,  with  irregular  paralysis  of  limbs 
and  cranial  nerves.  In  occlusion  of  the  whole  basilar,  the  limbs  of 
both  sides  are  usually  affected,  suddenly  or  in  the  course  of  a  few 
days.  .  The  limbs  on  one  side,  for  instance,  may  become  weak  and 
then  improve  ;  a  day  or  two  afterwards  the  other  side  becomes  weak, 
and  then  there  is  again  loss  of  power  in  the  first  side.  The  affection 
of  the  facial  or  fifth  nerves  may  present  the  same  variations,  and  often 
does  not  correspond  in  degree  to  that  of  the  limbs.  There  is  usually 
considerable  impairment  of  articulation  and  of  swallowing.  Loss  of 
the  conjugate  movement  of  the  eyes  to  one  side  is  occasionally 
obseiwed,  with  or  without  palsy  of  the  facial  nerve  on  the  side  of  the 
affected  external  rectus  (see  p.  188).  This,  however,  less  frequently 
results  from  softening  than  from  tumour.  When  the  obstruction 
involves  the  upper  part  of  the  vessel,  as  is  usually  the  case  in  embolism, 
there  are  ocular  symptoms  other  than  the  conjugate  deviation,  ptosis, 
contracted  or  dilated  pupils,  with  loss  of  reflex  action  to  light,  some- 
times transient.  There  is  occasionally  paralysis  of  the  whole  or  part 
of  one  third  nerve,  or  of  both,  sometimes  also  of  the  fourth. 
Less  common  is  hemianopia,  from  extension  of  clot  along  one 
posterior  cerebral  beyond  the  origin  of  the  posterior  communi- 
cating artery.  Obstruction  of  the  lower  extremity  of  the  basilar 
is  not  common,  except  as  the  result  of  the  extension  of  a  clot  from 
one  of  the  vertebral  arteries.  The  onset  of  obstruction  of  the 
basilar  is  usually  attended  with  a  distinct,  but  transient  apoplectic 
seizure  ;  it  often  recurs,  and  gradually  deepens.  The  patient  may 
lie  for  some  days  in  a  state  of  incomplete  coma,  can  be  roused  to 
open  his  eyes,  but  does  not  speak.  Convulsions  occasionally  attend 
the  onset,  but  are  on  the  whole  not  frequent ;  they  may  be  general  or 
partial ;  one  limb  or  one  side  of  the  face  may  escape.  Rigidity  or 
clonic  spasm  in  the  legs  or  arms  is  much  less  common  than  in  haemor- 
rhage into  the  pons.  Undue  frequency  and  irregularity  of  the  heart's 
action,  and  impaired  respiration  (laboured  or  sighing,  or  of  Cheyne- 
Stokes  rhythm,  or  with  irregular  variations)  are  very  common  before 
death,  and  may  occur  from  the  commencement  when  the  obstruction 
involves  the  lower  extremity  of  the  basilar,  from  which  the  arterioles 
arise  that  supply  the  pneumogastric  centre.  If  there  is  an  apoplec- 
tiform onset  there  may  be  an  initial  fall  of  temperature,  much  greater 
than  is  observed  in  the  occlusion  of  other  vessels,  and  resembling  that 
met  with  in  cerebral  haemorrhage.  In  one  case  the  rectal  temperature 
fell  to  95°.*  Towards  the  end  there  is  often  the  rise  of  temperature 
so  common  in  haemorrhage  into  the  pons.  In  one  recorded  case  the 
rise  reached  109°  before  death  and  109  5°  after  death.  The  duration 
*  Bastian,  Clin.  Soc,  March  13th,  18S5. 


440  BRAIN. 

of  life  is  usually  from  three  to  seven  days  ;  occasionally  death  occurs 
within  twenty-four  hours — iu  five  and  a  half  hours  in  the  case  men- 
tioned above,  in  which  the  temperature  fell  to  95°.  Rarely  life  is  pro- 
longed for  a  fortnight.  Recovery  probably  occurs  in  some  cases  of 
syphilitic  disease  with  incomplete  obstruction,  but  not  in  atheromatous 
thrombosis,  and  perhaps  not  in  embolism. 

Vertebral  Artery  — The  frequent  anomalies  in  the  arrangement  of 
the  arteries  of  the  medulla  render  the  symptoms  of  thrombosis  of  the 
vertebral  artery  very  variable.  It  usually  supplies  the  "bulbar" 
nuclei,  hypoglossal,  accessory,  glosso-pharyngeal,  in  part  directly,  and 
in  part  by  the  anterior  spinal;  and,  through  the  latter,  it  supplies  the 
anterior  pyramids  and  also  the  lower  part  of  the  medulla.  The 
typical  effect  of  its  occlusion  is  one-sided,  bulbar  paralysis — lips, 
tongue,  palate,  and  larynx — with  paralysis  of  the  limbs  on  the  same 
side.*  The  hemiplegia,  usually  transient,  is  often  accompanied  by 
tingling,  and  sometimes  by  anaesthesia.  It  is  transient  because  the 
anterior  spinal  receives  blood  from  the  other  vertebral  artery,  and  the 
supply  to  the  lower  part  of  the  medulla  is  renewed.  The  paralysis  of 
the  bulbar  nerves,  the  nuclei  of  which  are  supplied  in  part  from  the 
anterior  spinal,  is  usually  imperfect,  but  the  impairment  of  swallovv- 
ino-  and  of  articulation  is  always  great.  The  median  arterioles  may 
come  altogether  from  one  anterior  spinal  (when  there  are  two), 
and  if  this  is  occluded,  the  bulbar  paralysis  is  bilateral,  and  may 
resemble  perfectly  that  from  chronic  degenerative  disease.  If,  as  is 
often  the  case,  the  clot  extends  up  into  the  commencement  of  the 
basilar,  the  arrest  of  the  blood-supply  to  the  respiratory  centre  causes 
rapid  death.  There  may  be  softening  of  the  posterior  part  of  the 
cerebellum,  the  occurrence  and  extent  of  which  is  influenced  by  the 
extent  of  the  arterial  anastomoses. 

Cerebellar  Arteries. —  These  vessels  are  rarely  the  seat  of  isolated 
obstruction,  and  although  softening  may  result  from  occlusion  of  the 
arteries  from  which  the  cerebellar  vessels  spring,  the  softening  is 
always  less  extensive  than  the  area  of  distribution  of  the  affected, 
vessel,  on  account  of  the  free  connections,t  and  any  symptoms  that 
are  produced  are  lost  in  the  more  serious  disturbance  that  results 
from  the  damage  to  the  pons  and  medulla.  Softening  is  most  common 
in  the  region  supplied  by  the  posterior  cerebellar,  the  obstruction  of 
which  is  usually  secondary  to  occlusion  of  the  vertebral.  Inco- 
ordination of  movement  has  been  observed  in  one  or  two  cases  of  this 
kind.  Occasionally  an  isolated  area  of  softening  is  found  in  the 
middle  of  one  hemisphere,  without  any  symptoms  that  could  be 
ascribed  to  it. 

*  The  limbs  were  affected  on  the  same  side  as  the  thrombosis  in  most  recorded 
cases. 

t  The  whole  cerebellum  can  be  injected  from  any  one  of  its  arteries,  even  if  the 
basilar  is  tied  (Duret). 


ACUTE    SOFTENING.  441 

Diagnosis. — The  diagnosis  of  obstructive  softening  rests  on  the 
symptoms  of  a  sudden  cerebral  lesion,  occurring  in  the  conditions  that 
are  known  to  be  causes  of  vascular  occlusion.  The  characters  of  the 
attack  have  less  diagnostic  significance  than  the  causal  indications. 
The  chief  difficulty  is  the  distinction  of  atheromatous  obstruction  from 
hemorrhage.  Under  forty,  hemorrhage  would  only  be  suspected  if 
the  apoplectic  attack  were  one  of  considerable  severity,  and  the  coma 
prolonged;  a  cause  of  aneurism,  heart  disease,  syphilis,  or  injury  can 
then  usually  be  traced.  In  most  cases  during  the  first  half  of  life 
the  apoplectiform  symptoms  are  moderate,  slight,  or  absent,  and  one 
of  the  two  common  causes  of  vascular  obstruction  can  be  traced — 
heart  disease  or  syphilis.  Usually  one  is  present  and  the  other  absent, 
and  the  diagnosis  can  then  be  made  with  confidence.  If  both  are 
present,  e.  g.  if  the  patient  is  suffering  from  heart  disease  and  has 
had  syphilis,  the  diagnosis  is  much  more  difficult,  and  rests,  first,  on 
the  evidence  of  activity  of  one  or  the  other  of  these  causes,  and 
secondly,  on  the  presence  of  any  other  symptoms  that  may  be  due  to 
syphilitic  disease  of  the  brain.  If  there  is  considerable  valvular 
mischief,  if  there  has  been  recent  endocarditis,  and  especially  if 
evidence  of  embolism  elsewhere  can  be  discovered  (as  an  enlarged  and 
tender  spleen,  or  sudden  hematuria,  or  embolism  of  the  central 
artery  of  the  retina),  the  probability  of  cerebral  embolism  is  very 
great.  On  the  other  baud,  persistent  headache  for  some  days  or 
weeks  before  the  onset,  transient  attacks  of  tingling,  numbness,  or 
weakness  in  the  limbs  afterwards  paralysed,  or  a  dull  somnolent  state 
before  the  attack,  suggest  syphilitic  disease  of  the  arteries.  Evidence 
of  recent  activity  of  the  syphilis  adds  weight  to  the  other  symptoms, 
but  is  not  often  forthcoming,  since  the  period  at  which  arterial  disease 
occurs  is  later  than  that  at  which  the  obtrusive  manifestations  of  con- 
stitutional syphilis  are  common.  Apparent  quiescence  of  the  consti- 
tutional disease  is  thus  no  contra-indication,  nor  is  past  antisyphilitic 
treatment,  however  thorough.  This  is  a  frequent  source  of  error. 
Hence,  before  the  degenerative  period  of  life,  in  the  absence  of  other 
causes,  syphilitic  disease  is  probable,  unless  the  ordinary  mode  of 
infection  can  be  absolutely  excluded.  As  an  instance  of  the  difficulty 
the  diagnosis  sometimes  preseuts,  I  may  mention  the  case  of  a  man 
who  had  an  attack  of  hemiplegia  at  forty-five.  He  had  a  loud  aortic 
regurgitant  murmur,  and  it  seemed  probable  that  the  hemiplegia  was 
due  to  embolism,  with  which  the  onset  was  consistent.  But  he  had 
had  severe  headache  for  some  weeks  before  the  attack.  Shortly 
afterwards  a  node  appeared  on  his  skull,  and  it  was  ascertained  that 
in  youth  he  had  had  syphilis.  This  fact  gave  significance  to  the  head- 
ache, and  made  it  far  more  probable  that  the  vascular  obstruction 
was  due  to  syphilitic  disease  than  to  embolism. 

A  year  or  more  after  the  onset,  the  absence  of  heart  disease  does 
not  exclude  embolism,  or  even  render  it  less  improbable,  if  the  hemi- 
plegia occurred  during  or  soon  after  an  illness  known  to  cause  endo- 


442  Bii.MX. 

carditis,  especially  rheumatism  or  chorea ;  but  without  such  disease, 
or  soou  after  the  onset,  embolism  is  unlikely  if  no  source  can  be  found. 
A  girl  had  an  attack  of  chorea,  attended  by  endocarditis  and  mitral 
regurgitation.  While  still  ill  with  the  chorea  she  had  an  attack  of 
hemiplegia,  no  doubt  due  to  embolism.  Some  years  later,  the  hemi- 
plegia persisting,  her  heart  presented  no  abnormal  sign  in  sound  or 
impulse.* 

During  the  degenerative  period  of  life,  after  forty-five,  the  diagnosis 
of  softening  presents  much  greater  difficulties.  The  help  afforded  by 
causal  indications  is  more  limited.  The  conditions  associated  with 
haemorrhage  and  softening  are  to  a  large  extent  the  same.  Atheroma, 
the  chief  cause  of  softening,  is  met  with  in  four  fifths  of  the  cases  of 
haemorrhage.  The  state  of  the  heart  is  of  more  significance  than 
that  of  the  vessels.  A  strongly  acting,  hypertrophied  heart  suggests 
haemorrhage;  a  feeble,  irregular  heart,  softening:  the  former  tends 
to  burst  a  weak  vessel,  the  latter  to  permit  clotting  in  one  that  is 
diseased.  The  causes  which  predispose  to  thrombosis  by  influencing 
the  blood  and  circulation  are  also  of  diagnostic  importance.  Thus 
gout,  cancer,  phthisis,  prostration,  or  mental  depression  are  all  in 
favour  of  this  lesion.  Other  diagnostic  indications  are  drawn  from 
the  characters  of  the  onset,  but  these  have  been  already  described  in 
the  chapter  on  haemorrhage.  It  must  be  remembered  that  the  dia- 
gnosis is  always  a  matter  of  probability,  sometimes  high  and  some- 
times low,  but  it  is  seldom  that  the  indications  are  so  equally 
balanced  that  a  probable  diagnosis  cannot  be  made. 

Still  more  complicated,  however,  are  the  cases  in  which  more  than  ono 
cause  of  a  vascular  lesion  of  the  brain  can  be  traced,  but  the  additional 
complexity  relates  to  the  cause  of  softening  rather  than  to  the  dis- 
tinction from  haemorrhage.  The  latter  is  indeed  facilitated,  since 
the  presence  of  more  than  one  condition  capable  of  causing  softening 
increases  the  probability,  cseteris  paribus,  that  the  lesion  is  not  haemor- 
rhage. But  the  question  which  of  several  causes  of  vascular  obstruc- 
tion has  been  effective  in  a  given  case  can  only  be  answered  by  a 
careful  consideration  of  the  apparent  activity  of  the  several  causal 
influences,  and  by  the  symptoms  at  the  onset  as  already  described. 
Atheroma  and  syphilitic  disease  may  both  be  probable,  and  they  have 
more  svmptoms  in  common  than  either  has  with  embolism,  since  in 
each  there  may  be  interference  with  the  circulation,  and  often  there- 
fore slight  symptoms  before  the  onset.  Moreover,  the  co-existence 
of  heart  disease  with  the  causes  of  thrombosis  introduces  another 
element  of  uncertainty,  since  the  same  condition  of  the  circulation 
favours  the  formation  of  clot  in  the  vessels  of  the  brain  and  on  the 
valves  of  the  heart.  This  is  true  both  of  svphilitic  disease  of  the 
arteries  and  of  atheroma,  and  illustrates  the  law  that  in  all  eases  of 
merely  probable  diagnosis,  the  rules  that  lead  to  a  correct  opinion  in 

*  Yet  several  years  later  she  presented  signs  of  mitral  constriction,  a  most  sig- 
nificant !act,  although  not  strictly  relevant  to  the  present  subject. 


ACUTE    SOFTENING.  443 

most  cases,  and  must  therefore  be  followed,  now  and  then  fail  us.  A 
woman,  aged  sixty,  was  brought  unconscious  to  the  hospital  with 
symptoms  that  pointed  to  obstruction  in  the  basilar  artery.  Her 
vessels  were  highly  degenerated,  and  she  had  a  loud  murmur  of  mitral 
constriction.  Of  the  two  lesions  that  seemed  possible,  atheromatous 
thrombosis  and  embolism,  the  rarity  of  the  latter  in  the  basilar  artery 
made  the  former  rather  more  likely.  She  died,  and  thrombosis  of  the 
basilar  was  found  as  anticipated,  but  it  was  due,  not  to  atheroma, 
but  to  intense  and  characteristic  syphilitic  disease  of  the  vessel,  which 
there  was  nothing  during  life  to  suggest.  Another  example  of  a  like 
difficulty  has  just  been  mentioned. 

Prognosis. — The  prospect  of  recovery  from  the  initial  symptoms 
depends  on  their  severity  and  duration,  on  the  previous  occurrence  of 
similar  attacks,  on  the  artery  affected,  and  on  the  nature  of  the  cause. 
Intensity  of  apoplexy  is  a  graver  indication  than  its  duration.  In  this 
respect  softening  differs  from  haemorrhage.  It  is  not  uncommon  for 
a  patient  to  recover  after  what  may  be  called  "  comatose  stupor"  has 
lasted  for  five  or  six  days  ;  but  deep  coma,  with  impairment  of  respira- 
tion, is  as  rarely  recovered  from  in  softening  as  in  haemorrhage.  The 
stage  of  inflammatory  reaction  is  attended  with  considerable  danger 
in  severe  cases,  and  the  occurrence  of  rapid  sloughing  or  of  convulsions 
is  usually  of  fatal  augury. 

It  is  rare  for  a  patient  to  die  in  a  first  attack  of  cerebral  softening 
unless  a  very  large  vessel  is  occlurled.  But  if  the  brain  has  been 
damaged  by  a  preceding  attack,  recovery  occurs  less  readily,  and  the 
immediate  danger  to  life  increases  with  the  number  of  preceding 
attacks,  especially  in  the  old,  or  when  there  is  extensive  &yphilitic 
disease,  or  wide-spread  atheroma. 

Thrombosis  of  the  internal  carotid  or  of  the  basilar  entails  imminent 
danger  to  life  ;  indeed,  the  la.tter,  from  whatever  cause  it  arises,  is 
rarely  survived.  Next  in  gravity  is  obstruction  of  the  vertebral,  and 
next  that  of  the  middle  cerebral.  Obstruction  of  the  trunk  of  both, 
middle  cerebrals  is  almost  always  fatal.  Subject  to  these  indications, 
the  danger  to  life  is  far  less  in  embolism  and  in  syphilitic  disease  than 
in  senile  softening.  In  most  fatal  cases  of  cerebral  embolism  death 
has  been  due  rather  to  the  state  of  the  heart  or  to  some  general  disease, 
as  rheumatism.  Syphilitic  disease  rarely  causes  death  unless  the 
basilar  artery  or  many  vessels  are  affected,  or  the  nature  of  the 
malady  is  not  recognised  and  met  by  appropriate  treatment, 

The  prognosis  as  to  recovery  from  the  persisting  symptoms  depends 
on  the  seat  of  the  disease,  and  the  reasons  for  regarding  the  symptoms 
as  "  direct"  or  "  indirect"  in  nature.  These  indications  are  the  same 
as  in  cerebral  haemorrhage,  and  are  described  in  the  account  of  this 
(p.  396),  and  also  in  the  description  of  the  individual  symptoms.  The 
prospect  of  recovery  depends  also  to  some  extent  on  age.  Recovery  of 
slightly  damaged  parts,  and  compensation  by  other  parts,  take  place 


444  BRAIN. 

more  readily  in  the  young  than  in  the  old.  But  the  prognosis  as 
regards  recovery  is  but  little  influenced  by  the  nature  of  the  disease. 
It  is  no  better  in  syphilitic  disease  than  in  embolism.  We  may,  by 
treatment,  remove  the  disease  of  the  wall  of  the  occluded  vessel,  we 
may  prevent  an  increase  in  the  symptoms,  but  we  cannot  remove  the 
clot  that  has  finally  closed  it,  and  has  extended  on  into  the  distal 
branches  of  the  vessel.  We  cannot,  therefore,  restore  the  circulation 
through  the  vessel.  Neither  can  we  iufluence,  by  antisyphilitic  treat- 
ment, the  process  of  softening,  which,  in  syphilitic  disease,  just 
as  in  embolism,  is  a  process  of  simple  necrosis.  Therefore  the 
syphilitic  oiigin  of  the  disease  does  not  influence  the  prognosis  of 
developed  palsy.  Most  cases  improve,  and  many  recover,  but  they 
improve  and  recover  in  the  same  way  as  in  every  other  form  of  acute 
cerebral  lesion — because  the  symptoms  are  of  indirect  and  not  of 
direct  origin,  and  sometimes  because  a  collateral  circulation  is 
possible.  If  the  softening  involves  the  motor  path  or  centres,  and  no 
compensation  is  possible,  enduring  paralysis  is  the  result.  It  is 
necessary  to  insist  strongly  upon  this  fact.  Because  a  palsy  is  due 
to  syphilis,  it  is  often  assumed,  as  a  matter  of  course,  that  it  will  be 
removed  by  antisyphilitic  treatment.  The  assumption  is  correct  as 
regards  many  pressure-effects  of  syphilitic  growths,  and  many  syphilitic 
inflammations,  but  it  is  not  true  of  necrotic  softening  from  vascular 
disease.  I  have  seen  many  patients  who  had  been  assured  that, 
because  their  hemiplegia  was  of  syphilitic  origin,  they  would  certainly 
be  cured :  aud  when,  after  a  year  or  two,  the  paralysis  i-emained,  they 
were  naturally  indignant  at  the  erroneous  opinion  they  had  received. 

It  must  be  remembered  that  convulsions  at  an  interval  after  the 
onset  are  prone  to  recur,  and  the  tendency  to  the  return  is  greater 
the  longer  the  interval.  They  may  continue  even  when  the  para- 
lysis has  passed  away,  and  may  constitute  a  disease  resembling- 
epilepsy  in  its  course.  Such  recurring  convulsions  are  far  more 
frequent  after  softening  than  after  haemorrhage,  partly  because  the 
cortex  is  more  often  involved. 

The  probability  of  a  recurrence  of  paralysis  varies  according  to  the 
nature  of  the  disease.  In  embolism  it  is  not  great.  Although  a 
second  attack  is  possible,  and  instances  are  occasionally  met  with,  it 
is  a  rare  accident,  and  in  any  given  case  a  recurrence  is  unlikely. 
In  syphilitic  disease  the  probability  of  a  recurrence  depends  on  proper 
aud  repeated  treatment  (see  "  Syphilitic  Tumour"),  aud  also  on  the 
previous  duration  of  the  disease.  The  arterial  walls  may  be  so  pro- 
foundly altered,  that  treatment  can  only  induce  a  cicatricial  state  so 
abnormal  that  coagulation  is  favoured.  But  the  nature  of  the  case  is 
now  usually  recognised  and  treated  early,  and  hence  a  recurrence  of 
softening  is  extremely  rare.  In  atheromatous  softening,  on  the  other 
hand,  the  tendency  to  recurrence  is  very  great.  Many  arteries  are 
always  affected ;  the  disease  of  their  walls  is,  for  the  most  part, 
beyond  control,  and  sooner  or  later  other  vessels  become  obstructed. 


ACUTE    SOFTENING.  445 

Recurrence  is  more  likely  to  be  speedy — e.  g.  within  two  or  three  years — 
if  the  first  attack  occurred  independently  of  influences  favouring 
thrombosis,  than  if  it  was  "  excited."  If,  for  instance,  the  attack 
came  on  after  depressing  grief,  during  a  condition  of  general  illness,  or 
in  consequence  of  prostrating  fatigue,  and  these  influences  are  avoided, 
a  recurrence  is  more  likely  to  be  long  deferred.  This  is  also  true  of 
states  of  the  blood  which  are  under  control.  On  the  other  hand,  a 
speedy  recurrence  is  more  probable  if  there  are  conditions  favouring 
thrombosis  that  cannot  be  removed,  especially  cardiac  weakness  and 
dilatation.  Exceptions  to  these  rules  naturally  occur,  because  we 
cannot  tell  the  extent  and  degree  of  the  vascular  disease,  and  this 
may  sometimes  invalidate  conclusions  that  are  reached  by  a  process 
which  usually  leads  to  a  correct  opinion. 

Treatment. — The  treatment  of  the  initial  apoplexy  is  in  part  the 
same  as  in  cerebral  hsemorrhage;  in  part  it  is  different.  The  same 
precautions  are  necessary  as  to  the  avoidance  of  movement,  and  of 
any  hindrance  to  the  return  of  blood  from  the  head.  Sinapisms  to 
the  back  of  the  neck  seem  to  hasten  the  recovery  of  consciousness, 
and,  by  causing  reflex  contraction  of  the  arteries,  they  probably 
quicken  the  cerebral  circulation  and  lessen  the  tendency  to  stasis. 
But  whereas  in  hsemorrhage  the  object  of  treatment  is  to  lower  the 
blood-pressure  and  promote  coagulation,  in  softening  the  aim  is  to 
lessen  the  tendency  to  clotting,  and  to  increase  the  flow  of  blood  at 
least  up  to  normal  conditions.  The  action  of  the  heart  should  be 
kept  uniform  and  strengthened  if  necessary  by  small  doses  of  digitalis 
or  strophanthus.  By  doing  this  we  may  lessen  the  tendency  to  the 
spread  of  the  thrombus  (whether  this  is  primary  or  secondary). 
The  patient  should  lie  with  the  head  and  shoulders  slightly  raised. 
The  bowels  should  be  opened,  but  more  gently  than  in  haemorrhage, 
because  violent  purgation,  weakening  the  heart,  may  increase  the 
tendency  to  an  extension  of  the  clot.  If  the  patient  is  gouty  and  the 
heart  regular,  a  somewhat  stronger  aperient  may  be  given,  which 
should  contain  some  mercury.  Under  the  same  circumstances  a 
diuretic  is  useful — half-drachm  doses  of  nitrous  ether  by  the  mouth 
or  by  the  rectum.  Venesection  is  not  to  be  thought  of  in  any  case 
that  may  possibly  be  of  this  nature.  Whether  stimulants  are  given 
or  not  must  depend  on  the  state  of  the  pulse  and  heart.  If  indicated, 
ether,  ammonia,  or  alcohol  may  be  given,  the  latter  more  freely  than 
in  haemorrhage.  If  there  is  doubt  whether  alcohol  should  be  given  or 
not  in  haemorrhage,  it  is  better  to  withhold  it  j  in  softening  it  is  better 
to  give  it. 

After  the  patient  has  regained  consciousness,  mental  and  physical 
tranquillity  is  of  the  first  importance.  All  excitement  and  movement 
should  be  carefully  avoided,  since  whatever  disturbs  the  heart's 
action  is  liable  to  be  followed  by  reactionary  failure  that  will  favour 
extension  of  the  thrombus.     Food  should  be  light,  easily  digested, 


446  BRAIN. 

and  nutritious.  Alcohol  is  better  avoided  after  the  first  two  or  three 
days  (uuless  the  state  of  the  pulse  demands  it),  on  account  of  the  risk 
of  increasing  the  intensity  of  the  inflammatory  reaction.  During  this 
stage  the  management  of  the  case  requires  great  care,  and  should 
be  conducted  on  the  same  principles  as  a  local  inflammation  else- 
where. The  diuretic  given  at  the  onset  may  be  continued.  The 
bowels  must  be  kept  carefully  open.  The  patient's  head  may  be  raised 
a  little  higher,  but  the  shoulders  should  always  be  raised  as  well  as  the 
head.  If  there  is  headache  and  fever,  ice  may  be  applied  to  the 
head,  and  moderate  doses  (10  or  12  gr.)  of  antipyrin  may  be  given. 
Leeching  has  been  advocated,  but  it  is  safer  to  abstain  from  any  form 
of  depletion,  uuless  the  patient  is  manifestly  plethoric.  If  convulsions 
occur  during  this  stage,  they  are  often  arrested  by  the  measures  recom- 
mended for  the  headache,  and  moderate  doses  of  bromide  may  be 
given.  The  same  treatment  is  suitable  for  delirium.  Extreme  clean- 
liness is  essential ;  it  is  at  this  stage  that  bedsores  are  most  apt  to 
form.  The  limbs  and  back  should  be  daily  examined,  and  on  the  least 
indication  of  trophic  disturbance  the  patient  should  be  placed  on 
a  water-bed,  or  the  pressure  be  kept  from  any  reddened  spot  by 
pillows  or  cotton  wool.  The  latter,  charged  with  some  disinfecting 
agent,  is  especially  useful  when  there  is  any  escape  of  urine.  After 
the  inflammatory  stage  is  over,  tonics  are  usually  needed,  especially 
iron  and  nux  vomica  or  strychnine  ;  but  the  measures  likely  to  lessen  the 
tendency  to  further  thrombosis  must  be  continued,  and  the  state  of 
the  pulse,  heart,  urine,  &c,  should  be  frequently  observed. 

The  variations  in  this  treatment  which  the  special  form  of  obstruc- 
tion renders  necessary  are  not  great.  In  embolism  the  general  princi- 
ples of  treatment  are  also  in  the  main  the  same  as  in  thrombosis, 
because  the  latter  process  is  always  associated  with  embolism,  clot 
forming  not  only  on  the  distal  side  but  also  on  the  proximal  side  of 
the  obstruction  up  to  the  origin  of  the  first  lai'ge  branch,  and  it  is  im- 
portant to  avoid  whatever  may  facilitate  the  extension  downwards  of 
this  secondary  clot.  Moreover,  it  is  important  in  embolism  as  in 
thrombosis  to  strengthen  and  steady  the  action  of  the  heart,  in  order 
to  lessen  the  risk  of  further  embolism.  This  is  more  likely  to  occur  if 
the  heart  acts  irregularly,  because  vegetations  tend  to  increase  during 
the  feeble  action,  and  to  be  detached  when  it  becomes  excited.  But,  in 
syphilitic  disease,  although  treatment  is  powerless  to  undo  mischief 
that  has  already  occurred,  it  may  prevent  its  increase  or  fresh  lesions. 
Many  arteries  are  usually  affected ;  the  same  artery  may  Le  diseased  at 
separate  places,  and  it  is  of  the  utmost  importance  to  remove  this 
disease.  Iodide  of  potassium  should  therefore  be  given  in  doses 
of  seven  or  ten  grains  every  six  or  eight  hours,  or  fifteen  grain  doses 
may  be  injected  into  the  rectum.  It  may  be  well  also  to  rub 
in  some  mercury,  especially  if  the  symptoms  indicate  extensive 
disease.  The  importance  of  prompt  treatment  cannot  be  too  strongly 
urged,   because   the   closure   of   another   artery   may  be  prevented, 


ACUTE   SOFTENING.  447 

or  very  early  symptoms,  due  to  commencing  thrombosis,  may  certainly 
be  arrested.  But  it  is  not  well  to  give  iodide  in  larger  doses,*  or  to 
employ  it  in  other  forms  of  thrombosis,  because  it  has  a  distinct  ten- 
dency to  promote  coagulation,  as  its  value  in  aneurisms  testifies. 

When  treatment  fails  to  avert  further  thrombosis,  it  is  because  the 
arterial  walls  are  so  profoundly  changed  that  it  is  not  possible  for 
them  to  regain  a  normal  state.  Nor  is  it  well  to  continue  the  treat- 
ment for  more  than  six  or  eight  weeks.  In  that  time  it  will  have 
achieved  its  objects  :  persistent  symptoms  are  due  to  the  disease  of  the 
nerve-elements,  and  may  or  may  not  slowly  pass  away.  But  the 
treatment  should  be  renewed  for  three  weeks  every  six  months,  for 
at  least  three  or  four  years,  to  arrest  the  development  of  commencing 
disease,  probably  by  preventing  insusceptible  germs  from  becoming 
susceptible  and  injurious  organisms. f 

The  physical  rest  that  is  needed  must  vary  with  the  severity  of  the 
disease,  and  may  be  two  weeks  in  slight  cases,  and  four  or  six  weeks 
in  those  that  are  more  severe.  When  the  stage  of  inflammatory 
disturbance  is  over,  and  the  process  of  repair  of  the  less  damaged 
structures  has  commenced,  nervine  tonics  may  be  given,  such  as 
quinine,  strychnia,  hypophosphite  of  soda,  and  other  tonics  that  may 
be  indicated,  such  as  iron.  For  the  reasons  to  be  mentioned  presently, 
it  is  impossible  to  obtain  satisfactory  evidence  that  nervrhe  tonics  do 
good,  but  it  is  probable  that  they  have  some  influence  in  the  right 
direction. 

For  the  treatment  of  the  residual  symptoms  that  depend  on  the 
destruction  of  tissue,  little,  unfortunately,  can  be  done.  It  is  con- 
venient here  to  describe  the  general  treatment  of  hemiplegia,  since 
the  measures  suitable  to  that  which  is  produced  by  softening  are  the 
same  as  in  other  lesions.  Many  of  these  effects  lessen  after  a  time, 
with  and  without  treatment,  in  consequence  of  the  compensation 
effected  by  other  parts  of  the  brain.  In  hemiplegia,  for  instance, 
improvement  always  occurs  in  the  leg,  even  when  the  motor  path  to 
the  affected  side  is  completely  interrupted,  in  consequence  of  the  other 
hemisphere  gaining  that  power  over  the  limb  for  which  anatomical 
arrangements  always  exist.  The  indirect  symptoms  pass  away 
spontaneously. 

In  the  early  stage  of  hemiplegia,  gentle  rubbing  of  the  limbs  is  all 
the  local  treatment  admissible.  It  has  a  tendency  to  lessen  the 
rigidity,  and  may  be  continued  and  made  more  vigorous  when  the 
early  rigidity  has  passed  away  and  the  late  rigidity  has  set  in. 
Upward  rubbing  of  the  muscles  has  most  influence  in  lessening  the 
spasm.  The  influence  of  electricity  on  the  paralysis  is  very  small,  as 
may,    indeed,  be  anticipated  from  the  nature  of  the   palsy.     Late 

*  Unless  unwise  persistence  lias  habituated  the  patient  to  it,  so  that  it  no  longer 
checks  the  syphilitic  lesions  when  given  in  ordinary  doses,  to  which  the  organisms 
of  the  disease  seem  to  get  accustomed.     (See  next  note.) 

t  See  the  writer's  lectures  on  «  Syphilis  and  the  Nervous  System,'  London,  1893. 


418  BRAIN. 

rio-idity  in  the  flexors  is  lessened,  for  the  moment,  by  faradisation  of 
the  extensors,  and  repeated  applications  sometimes  seem  slightly  to 
diminish  the  contraction.  If  there  is  some  power  of  voluntary  move- 
ment, the  stimulation  of  the  muscles  by  any  form  of  electricity  is 
followed  by  a  slight  temporary  improvement  in  power,  but  the  im- 
provement is  not  permanent,  and.  it  is  doubtful  -whether  any  lasting 
benefit  i-esults  from  a  course  of  such  treatment.  In  any  case  it  is  not 
desirable  to  apply  electricity  to  the  limbs  during  the  first  six  weeks 
after  the  onset.  The  stimulation  of  the  sensory  nerves  of  the  limbs 
has  an  influence  on  the  brain,  as  the  arrest  of  a  commencing  epileptic 
fit  by  such  means  clearly  shows,  and  the  early  application  of  elec- 
tricitv  has  been  followed  immediately  by  a  fresh  attack  of  paralysis. 
Any  influence  on  the  cerebral  disease,  of  the  voltaic  current  applied  to 
the  heart,  is  not  within  the  range  of  therapeutic  possibility.  The  ten- 
dencv  to  improvement  by  cerebral  compensation,  and  by  the  sponta- 
neous disappearance  of  indirect  symptoms,  is  very  marked,  and  makes  it 
difficult  to  estimate  the  actual  influence  of  treatment  that  is  employed, 
especially  of  methods  that  extend  over  a  long  period,  and  thus  have 
time  on  their  side ;  moreover  it  renders  these  cases  a  tempting  field 
for  the  assumptions  of  the  quasi- therapeutist.  It  is  most  important, 
when  there  is  evidence  of  destruction  of  the  motor  path,  that  the 
friends'  of  the  patient,  if  not  the  patient  himself,  should  be  made 
aware  of  the  hopelessness  of  a  search  after  a  "  cure,"  on  the  one  hand, 
and,  on  the  other,  of  the  slow  improvement  that  time  will  bring. 

In  addition  to  the  measures  just  mentioned  which  tend  to  lessen 
late  contractures,  mechanical  means  are  sometimes  necessary  for  cases 
in  which  it  becomes  extreme  in  degree.  The  hand  may  be  placed  on 
a  splint  for  a  few  hours  each  day ;  the  spasm  may  be  readily  over- 
come, so  as  to  apply  the  splint,  by  gentle  continued  extension,  aided 
in  severe  cases  by  the  immersion  of  the  limb  in  warm  water.  A  small 
cylinder  may  be  placed  in  the  hand  within  the  flexed  fingers,  or  an 
india-rubber  ball  to  which  a  tube  is  attached  may  be  introduced,  and 
inflated  after  it  is  in  the  hand.  When  the  paralysis  of  the  leg  is  con- 
siderable, there  is  often  shortening  of  the  calf  muscles,  due  to  the 
weight  of  the  foot,  which  brings  it  into  the  position  of  extension  as  the 
patient  lies.  This  is  a  serious  inconvenience,  because  it  may  prevent 
the  patient  standing  and  walking  when  he  acquires  sufficient  muscular 
power.  It  can  be  more  readily  prevented  than  cured.  The  foot 
t^hould  be  carefully  kept  at  right  angles  to  the  leg  during  the  early 
stage,  by  a  footboard,  or  by  a  sand-bag,  about  nine  inches  in  diameter, 
beneath  the  sole.  At  a  later  period  it  may  be  necessary  to  keep  the 
foot  up  by  attaching  a  cord,  with  a  spring  inserted  in  it,  from  the 
front  of  the  boot  to  the  knee,  or  by  the  use  of  a  suitable  splint.  The 
active  character  of  the  contracture  renders  tenotomy  undesirable. 

The  post-hemiplegic  athetoid  spasm  is  very  difficult  to  influence  by 
treatment.  Electricity  fails,  as  a  rule,  to  lessen  it.  I  have,  indeed, 
met  with  one  case  in  which  the  spasm  presented  a  very  marked  and 


ACUTE    SOFTENING.  449 

permanent  diminution  during  a  course  of  treatment  with  the  voltaic 
current,  but  no  such  effect  was  produced  in  a  number  of  similar 
cases  in  which  I  employed  the  same  treatment,  and  I  am  therefore 
disposed  to  regard  the  improvement  as  a  coincidence  rather  than  as  a 
consequence.  The  inco- ordination  is  somewhat  lessened  by  the  per- 
severing practice  of  hand  gymnastics — rhythmical  movements  of  the 
fingers  and  thumb.  A  set  of  "  dumb  piano  "  keys  is  convenient  for 
this  purpose.  These  are  made  for  exercising  the  fingers  of  pianists, 
and  are  so  constructed  that  the  resistance  of  the  keys  can  be  varied 
by  a  spring.  A  type-writer  is  useful  for  slighter  cases,  and  trains 
the  brain  as  well  as  the  hand.  Systematic  rubbing  has  also  a  trifling 
influence  on  this  as  on  other  forms  of  inco-ordinate  spasm. 

Softening  of  the  brain  is  the  most  common  cause  of  aphasia,  and 
the  question  often  arises  whether  any  special  treatment  should  be 
adopted  for  the  loss  of  spaech.  So  far  as  concerns  general  therapeutic 
measures,  the  treatment  for  the  condition  of  the  brain  already  men- 
tioned is  all  that  can  be  done ;  the  only  special  treatment  for  the  loss 
of  speech  is  educational.  The  question  only  arises  in  a  severe  case  of 
speech  defect ;  slight  defects  pass  away  without  more  training  than 
ordinary  life  supplies.  But  if  there  is  destruction  of  the  speech  region, 
motor  and  sensory,  on  the  left  side  of  the  brain,  speech  is  recovered  by 
a  process  of  training  of  the  right  hemisphere  so  as  to  bring  the  right- 
sided  speech-processes  into  a  relation  to  the  will  similar  to  that  of  the 
processes  in  the  left  hemisphere.  The  readiness  with  which  this  can 
be  effected  varies  in  different  individuals.  In  some  it  occurs  speedily, 
in  others  it  never  occurs,  and  all  treatment  fails  to  evoke  any 
power  of  voluntary  speech.  In  the  former,  systematic  training  hastens 
the  compensation.  Possibly  it  is  facilitated  by  the  use  of  the  left  baud 
for  working  and  other  objects.  The  precise  method  to  be  adopted 
must  depend  on  the  character  of  the  defect,  consisting  in  the  exer- 
cise of  the  speech-process  that  is  deficient.  If  there  is  word-deafness, 
simple  directions  must  be  uttered  to  the  patient,  and  gradually  varied 
and  made  more  complex ;  if  the  patient  has  a  difficulty  in  reviving 
word- images,  he  must  be  exercised  in  naming  objects  ;  if  there  is  motor 
aphasia  without  word-deafness,  he  should  try  to  repeat  words  after 
another  person.  So  with  inability  to  read  and  to  write.  In  motor 
aphasia,  attempts  to  write  are  useless  until  the  patient  has  made  some 
progress  with  articulate  expression.  In  every  case  the  exercises  must 
begin  with  the  simplest  word-processes  of  each  kind,  and  these  should 
be  mastered  before  more  difficult  processes  are  attempted.  The 
practice  should  not  be  continued  long  enough  to  fatigue  the  brain, 
but  should  be  repeated  several  times  a  day.  Patience  and  persever- 
ance are  needed,  but  will  meet  with  their  reward. 


vol.  ii.  29 


450  BRAIN. 


Thrombosis  in  the  Cerebral  Sinuses  and  Veins. 

Coagulation  of  blood  may  occur  in  the  cerebral  sinuses  and  veins, 
and  may  cause  mechanical  congestion,  oedema,  capillary  haemorrhages, 
and  sometimes  softening,  in  the  parts  from  which  the  blood  should  be 
conveyed  by  the  occluded  vessel.  The  occurrence  is  usually  of  very 
serious  significance,  on  account  not  only  of  its  effects,  but  also  of  the 
gravity  of  the  conditions  with  which  it  is  associated.  In  order  to 
understand  the  pathology  of  the  condition,  it  is  necessary  to  bear  in 
mind  the  chief  facts  regarding  the  venous  circulation  of  the  brain, 
already  described  at  p.  60. 

Causes. — Sinus-thrombosis  may  occur  (1)  from  the  state  of  the 
blood  and  circulation  generally ;  (2)  in  consequence  of  disease  adja- 
cent to  the  sinuses.  Having  regard  to  the  local  process  itself,  the 
former  may  be  called  primary,  the  latter  secondary  thrombosis.  The 
secondary  thrombosis  is  more  than  twice  as  common  as  the  primary. 

1.  Primary  thrombosis  usually  occurs  in  association  with  general 
malnutrition  and  prostration,  and  hence  is  often  termed  "  marantic 
thrombosis."*  It  occurs  at  all  ages,  but  most  frequently  in  children, 
and  next  in  frequency  in  the  very  old.  In  children,  it  is  met  with  up 
to  fourteen  years  of  age,  but  the  chief  liability  is  during  the  first  six 
months  of  life,  and  the  chief  cause  is  severe  and  exhausting  diarrhoea. 
It  may,  however,  follow  almost  any  prostrating  malady,  lung  disease, 
long-continued  suppuration,  or  acute  specific  diseases.  In  adults,  it 
occurs  occasionally  during  the  last  stage  of  phthisis,  sometimes  from 
acute  diseases,  in  the  puerperal  state,  as  a  result  of  gout,  or  in  the 
course  of  cancer. 

These  causes  no  doubt  act  partly  by  weakening  the  heart  and  so 
retarding  the  circulation,  and  partly  by  rendering  the  blood  more 
prone  to  coagulate.  Diarrhoea  may  act  also  by  reducing  the  volume 
of  the  blood.  The  rigid  walls  of  a  sinus  cannot  contract  in  adapta- 
tion to  the  lessened  volume  of  the  blood,  and  hence  the  circulation  in  it 
must  be  unduly  retarded.  The  trabeculse  that  cross  its  cavity  doubt- 
less also  facilitate  the  formation  of  a  clot,  and  so  also  does  the  irre- 
gular shape  of  the  cavity.  The  seat  of  primary  thrombosis  is  almost 
invariably  the  superior  longitudinal  sinus,  very  rarely  the  lateral,  but 
occasionally,  in  old  persons,  the  cavernous  sinus.  It  is  probable  that 
the  current  of  blood,  in  the  superior  longitudinal  sinus  is  normally 
more  feeble  than  in  any  other  vessel  of  the  body.  The  veins  that  it 
receives,  open  into  it  in  a  forward  direction,  so  that  the  motion  of  the 
entering  blood  is  opposed  to  that  of  the  blood  in  the  sinus.  More- 
over, these  veins  ascend  to  the  sinus,  and  nowhere  else  in  the  body  do 
ascending  veins  receive  the  blood  of  ascending  arteries.     Destitute, 

*  The  term  marasmus  is  currently  used  in  a  more  restricted  sense  than  is  implied 
in  this  vise  of  the  adjective,  although  the  latter  is  justified  by  the  original  meaning 
of  the  word. 


SINUS-THROMBOSIS.  451 

therefore,  of  the  influence  of  the  hydrostatic  pressure  so  potent  else- 
where, the  blood  within  them  is  only  influenced  by  the  force  of  the 
heart,  exerted  through  the  capillaries.  It  is,  therefore,  not  surprising 
that  thrombosis  should  readily  occur  in  this  vessel,  when  the  circula- 
tion is  still  further  weakened  by  disease.  This  result  is  favoured  by 
the  irregularity,  not  only  of  the  shape,  but  of  the  inner  surface  of  the 
sinus,  which  is  such  that  a  layer  of  a  clot  is  sometimes  found  upon  it, 
although  a  channel  remains  for  the  passage  of  the  blood. 

Does  primary  thrombosis  ever  occur  in  the  veins  and  not  in  a 
sinus  ?  There  is  some  pathological  evidence  that  it  does.  Young 
children  are  sometimes  seized  with  hemiplegia,  commencing  with 
unilateral  convulsions  that  are  prone  to  recur.  Sometimes  the  attack 
comes  on  without  exciting  cause,  sometimes  under  the  same  condi- 
tions as  sinus-thrombosis.  The  lesion  which  causes  the  symptoms  is 
often  cortical,  and  its  ultimate  aspect  is  consistent  with  the  theory  that 
it  was  due  to  thrombosis  in  one  of  the  veins  of  the  convexity.  Very- 
similar  symptoms  in  the  course  of  tubercular  meningitis  have  been 
proved  to  be  due  to  thrombosis  in  a  vein,  and  the  same  process  has 
been  met  with  in  the  subjects  of  phthisis  without  inflammation  or 
visible  tubercle. 

2.  Secondary  thrombosis  is  the  result  of  disease  adjacent  to  a  sinus. 
The  most  common  cause  is  caries  of  the  bone,  and  especially  disease 
of  the  internal  ear.  Other  causes  are  injury  to  the  bone  (especially 
when  attended  with  inflammation  of  the  diploe),  meningitis,  espe- 
cially tubercular,  compression  of  a  sinus  by  a  tumour  or  foreign 
body,  and  suppurative  diseases  outside  the  skull,  erysipelas,  carbuncle 
of  face  or  neck,  malignant  ulceration,  and  even,  it  is  said,  suppurating 
eczema  of  the  scalp  (Tonnele).  This  form  occurs  with  nearly  the 
same  frequency  throughout  life,  except  that  it  is  rare  in  the  very 
young  and  in  the  very  old. 

The  mechanism  by  which  local  disease  acts  is  probably  threefold. 
First,  the  inflammation  may  extend  to  the  wall  of  the  sinus,  and 
the  inflamed  wall  may  cause  coagulation  of  the  blood  within  it. 
Secondly,  a  clot  may  extend  along  a  vein  that  passes  from  the 
seat  of  the  disease  to  the  sinus.  Almost  every  sinus  receives 
veins  from  the  exterior  of  the  skull  (see  p.  67),  many  of  them  also 
from  the  diploe,  while  the  superior  petrosal  and  lateral  sinus  receive 
blood  from  the  internal  ear.  The  third  mechanism  is  the  simple 
compression  of  a  sinus,  but  this  is  very  rare.  The  first  and  second 
are  common,  and  it  is  often  difficult  to  say  which  has  been  effective 
in  a  given  case.  There  is  sometimes  distinct  evidence  of  inflamma- 
tion of  the  wall  of  the  sinus,  and  meningitis  frequently  co-exists. 
But  in  other  cases  the  wall  of  the  sinus  is  healthy,  and  the  clot  has 
apparently  extended  into  it  by  prolongation.  Even  when  there  is 
inflammation  of  the  wall,  this  may  be,  in  some  cases,  spcondary  to 
the  formation  of  the  clot.  Hence  it  is  not  desirable  to  call  the  whole 
of  this  group  "phlebitic  thrombosis."     The  sinus  affected  is  always 


452  BRAIN. 

that  nearest  to  the  local  disease,  and.  as  ear  disease  is  the  most 
common  cause,  the  most  common  seat  of  thrombosis  is  the  superior 
petrosal  or  lateral  sinus.  The  superior  longitudinal  sinus  is  very 
rarely  the  seat  of  a  secondary  thrombus.  In  tubercular  meningitis 
and  phthisis  the  clot  may  be  limited  to  a  vein. 

Pathological  Anatomy. — The  affected  sinus  is  usually  filled  with 
a  clot  adherent  to  the  walls,  the  more  firmly  the  older  it  is.  A  recent 
clot  is  dark  red  and  soft,  but  after  a  few  days  becomes  paler,  granu- 
lar, and  friable.  It  is  usually  laminated.  Sometimes  the  clot  does 
not  entirely  fill  the  sinus.  When  due  to  adjacent  caries,  it  is  usually 
softened  and  puriform  in  aspect,  and  often  contains  pathogenic 
organisms.  The  clot  may  be  limited  to  one  part  of  the  sinus,  or  may 
extend  through  its  whole  length,  and  even  beyond  it,  into  the  tribu- 
tary veins,  or  into  another  sinus,  and  even  (in  the  case  of  the  lateral 
sinus)  into  the  commencement  of  the  internal  jugular  vein.  The  wall 
of  the  sinus  is  rarely  inflamed  in  marantic  thrombosis,  but  often 
when  the  condition  is  due  to  the  extension  of  adjacent  inflammation 
of  septic  character.  Meningitis  is  common  under  the  same  circum- 
stances. The  veins  from  which  the  sinus  receives  its  blood  are 
always  greatly  distended,  and  the  coagulation  may  have  spread  into 
one  or  more.  The  mechanical  obstruction  to  the  return  of  the  blood 
causes  intense  congestion  and  oedema  in  the  part  from  which  the 
tributary  vessels  come.  Capillaries  often  give  way,  especially  in  the 
grey  substance,  so  that  this  is  crammed  with  minute  points  of  haemor- 
rhage. This  is  most  marked  when  and  where  the  clot  has  extended 
into  the  tributary  veins.  If  the  clot  is  limited  to  a  sinus,  some  blood 
can  pass  from  the  veins  by  other  channels;  but  if  a  vein  is  plugged, 
the  circulation  in  the  part  is  arrested.  The  result  of  the  oedema  and 
haemorrhage  is  to  cause  softening,  often  limited  to  minute  foci,  but 
sometimes  diffuse,  so  that  a  mulberry-coloured  pulp  results.  Very 
rarely  there  is  meningeal  haemorrhage.  If  the  patient  recovers,  the 
destruction  of  tissue  is  rarely  so  great  as  in  arterial  obstruction,  and 
the  affected  part  of  the  cortex  ultimately  presents  atrophy  and 
induration  of  the  convolutions.  When  the  clot  softens,  foci  of 
inflammation  may  often  be  found  in  the  lungs,  sometimes  purulent, 
constituting  secondary  septic  abscesses.  They  are  present  in  about 
half  of  the  cases  of  secondary  (septic)  thrombosis. 

Symptoms. — The  symptoms  vary  much,  and  are  often  masked  by 
those  of  the  condition  that  gives  rise  to  the  thrombosis  or  results 
from  it, — the  cerebral  anaemia  in  primary  thrombosis,  the  adjacent 
disease  or  the  meningitis  it  excites  in  the  secondary  form.  The 
symptoms  directly  due  to  the  thrombosis  are  of  two  kinds, — those 
produced  by  the  interference  with  the  functions  of  that  part  of  the 
brain  in  which  the  circulation  is  obstructed,  and  those  due  to  the 
disturbed  circulation  outside  the  skull  in  the  parts  from  which  veins 
pass  through  the  bone  to  the  internal  sinus.     The  former  symptoms 


SINUS-THROMBOSIS.  453 

Lave  little  in  themselves  that  is  characteristic  ;  and  the  latter,  although 
characteristic,  are  comparatively  rare. 

Symptoms  of  Thrombosis  of  Special  Sinuses  :  Superior  Longitudinal. — 
External  oedema  and  distension  of  veins  may  he  present  on  the  sides 
of  the  head  and  forehead.  There  may  he  epistaxis  from  the  veins  of 
the  nose,  which  communicate  with  the  anterior  extremity  of  the  sinus. 
In  young  children,  the  fontanelle  may  become  prominent,  in  striking 
contrast  to  its  previous  depression  if  there  had  been  collapse  from  diar- 
rhoea. Cerebral  symptoms  are  chiefly  general — apathy,  somnolence, 
and  coma ;  vomiting  and  convulsions,  usually  general,  but  sometimes 
local ;  rigidity  of  the  neck,  and  sometimes  of  the  muscles  of  the  back. 
In  adults,  convulsions  are  less  common  than  delirium,  quiet  or  active. 
There  is  usually  headache.  In  both  children  and  adults  there  may 
be  strabismus,  tremor  of  tongue  or  limbs,  rigidity  of  all  the  limbs,  or 
of  the  arms  only  or  the  legs.  Unilateral  symptoms  are  usually  due 
to  the  extension  of  the  thrombus  into  veins  over  one  hemisphere,  and 
then  there  may  be  unilateral  convulsions,  often  beginning  locally,  and 
loss  of  power  on  one  side,  sometimes  limited  in  extent.  Thus,  in  a 
man  in  the  last  stage  of  phthisis,  the  superior  longitudinal  sinus  con- 
tained an  old,  granular,  partly  discoloured  clot,  which  did  not  quite 
fill  it,  aud  a  more  recent  clot  had  extended  into  the  veins  over  the 
right  frontal  lobe,  which  was  intensely  congested  with  capillary 
haemorrhages.  The  symptoms  were  mental  dulness  for  a  day  or  two, 
and  then  repeated  convulsions,  each  beginning  in  the  left  arm,  and 
involving  the  whole  of  the  left  side,  then  ceasing  on  the  left  side  and 
involving  the  right.  They  recurred  every  ten  minutes  until  death  two 
hours  later.  Such  symptoms,  if  initial,  suggest  that  the  thrombus 
began  in  the  vein. 

Cavernous  Sums. — There  is  usually  some  oedema  about  the  eyelids 
and  temples,  and  enlargement  of  the  veins  about  the  orbit,  in  conse- 
quence of  the  communication  of  the  ophthalmic  and  facial  veins. 
There  may  be  distension  of  the  retinal  veins,  usually  transient,  aud 
slight  oedema  of  the  optic  papilla.  The  eyeball  may  be  prominent 
from  the  distension  of  the  orbital  vessels.  Headache  is  common,  but 
unilateral  limb  symptoms  are  rare.  Sometimes  there  is  paralysis  of 
the  nerves  to  the  orbit  which  run  in  the  wall  of  the  sinus,  including 
the  first  division  of  the  fifth.  Bilateral  symptoms  have  resulted  from 
thrombosis  of  both  sinuses.  Neuro-paralytic  ophthalmia  has  been 
observed  (Lebert). 

Petrosal  Sinuses. — It  is  doubtful  whether  distinctive  symptoms 
attend  thrombosis  of  either  of  the  petrosal  sinuses. 

Lateral  Sinus. — There  may  be  distension  of  veins  and  oedema  over 
the  mastoid  process,  and  the  cause  of  the  thrombosis,  ear  disease,  is 
usually  obtrusive.  The  cerebral  symptoms  are  not  distinctive,  since 
they  resemble  those  of  local  meningitis. 

Symptoms  due  to  the  Nature  of  the  Thrombosis.  —  In  primary 
marantic  thrombosis  the  symptoms  vary  in  their  accentuation.     In 


45  A  BRAIN. 

adults,  the  symptoms  of  a  cerebral  lesion  of  some  kind  are  usually 
distinct ;  the  significance  of  the  somnolence  and  coma,  of  the  delirium 
and  headache,  or  of  the  motor  symptoms,  is  unmistakable.  But  in 
young  children,  the  simple  exhaustion  from  the  diarrhoea  is  ofteu 
attended  by  somnolence  and  inertia  hardly  less  severe  than  that  which 
attends  the  occlusion  of  the  sinus.  Epistaxis,  oedema  of  the  scalp,  or 
retraction  of  the  head,  under  such  circumstances,  should  always 
attract  attention.  The  temperature  is  normal,  or  raised  only  one  or 
two  degrees. 

Secondary. — The  phlebitic  form  is  usually  due  to  ear  disease,  and 
the  sinuses  most  often  occluded  are  those  near  the  ear:  the  blood  is 
able  to  escape  by  other  channels  ;  the  damage  to  the  brain  is  there- 
fore slighter,  and  the  direct  symptoms  are  less  obtrusive  than  in 
thrombosis  of  the  superior  longitudinal  sinus.  Indeed,  the  cerebral 
symptoms  that  occur  are  due  rather  to  the  meningitis  which  usually 
coincides  than  to  the  closure  of  the  sinus.  The  clot  that  forms  is 
usually  septic,  and  breaks  down  quichly  into  purulent  infective 
material;  hence  the  symptoms  of  septicaemia  are  often  more  pronounced 
than  are  those  of  intra- cranial  disease.  In  some  cases  the  local  sym- 
ptoms have  been  so  slight  that  the  occurrence  of  a  morbid  process  was 
not  suspected  until  the  signs  of  secondary  pulmonary  abscesses  were 
found. '  More  frequently  the  septieamric  symptoms  are  of  considerable 
severity, — ligors,  remitting  or  intermitting  pyrexia,  and  a  typhoid 
aspect.  Gradually,  cerebral  symptoms  become  more  prominent ; 
there  is  headache,  sometimes  local.  The  patient  becomes  dull, 
somnolent,  and  comatose ;  or,  on  the  other  hand,  there  may  be 
delirium,  quiet  or  violent.  Motor  symptoms  may  consist  in  varied 
paralyses,  disordered  sensation,  convulsions,  or  rigidity,  due  chiefly 
to  the  meningitis.  Their  significance  depends  on  their  association 
with  septic  symptoms,  or  with  the  subcutaneous  oedema  already  de- 
scribed. When  the  secondary  thrombosis  affects  other  sinuses,  the 
special  local  symptoms  already  described  may  be  more  pronounced. 

The  onset  of  the  symptoms  is  sometimes  sudden,  but  more  often 
insidious.  Their  duration  varies  from  a  few  days  to  a  fortnight. 
Coma  usually  precedes  death.  Occasionally  severe  convulsions  may 
exhaust  the  patient  in  a  few  hours.  Recovery  is  extremely  rare 
when  the  external  symptoms  leave  no  doubt  of  the  accuracy  of  the 
diagnosis,*  but  it  sometimes  occurs  in  marantic  cases.  It  is  probable 
that  the  clot  may  be  absorbed  and  circulation  re-established ;  but  if 
the  thrombus  has  extended  into  a  vein,  permanent  damage  to  the 
cortex  may  result. 

Diagnosis. — In  marantic  thrombosis  in  the  adult  the  occurrence  of 

*  An  instance  of  recovery  with  some  permanent  damage  to  the  left  hemisphere  is 
recorded  hy  Voormnn  ('  Deut.  med.  Wochenschrift,'  1882,  No.  36)  in  a  child  four 
months  old,  in  whom  the  symptoms  were  tremor  of  tongue  and  right  limbs,  rigidity 
of  neck,  opisthotonos,  with  distension  of  the  left  temporal  vein,  and  oedema  of  the 
s«calp. 


SINUS-THROMBOSIS.  455 

cerebral  symptoms  may  lead  to  a  suspicion  of  the  condition  if  the 
patient  has  no  heart  disease  and  has  not  reached  the  degenerative 
period  of  life,  but  the  diagnosis  is  only  certain  when  there  is  external 
oedema  or  distension  of  veins.  In  an  old  person,  without  these  sym- 
ptoms, the  cerebral  disturbance  is  more  likely  to  be  due  to  thrombosis 
in  an  artery  than  in  a  vein.  In  young  children,  somnolence,  coma,  and 
even  general  convulsions  may  be  due  merely  to  cerebral  anaemia  (in 
the  state  termed  "  hydrocephaloid  "),  but  if  these  symptoms  continue 
after  the  diarrhoea  has  ceased  and  the  collapse  is  slighter,  thrombosis 
is  probable ;  the  occurrence  of  local  brain  symptoms  increases  very 
much  the  degree  of  probability,  and  the  addition  of  the  external  sym- 
ptoms renders  the  diagnosis  certain.  In  phlebitic  thrombosis  the 
diagnostic  difficulties  are  much  greater.  The  cerebral  symptoms  are 
due  to  and  suggest  meningitis  rather  than  thrombosis,  and  the  indi- 
cations of  the  latter  are  chiefly  those  of  septicaemia  (due  to  the  soften- 
ing of  the  clot)  and  especially  the  external  oedema. 

Prognosis. — This  is  extremely  grave  in  all  cases.  Phlebitic 
thrombosis  with  septicaemia  is  probably  always  fatal.  Marantic 
thrombosis  is  occasionally  survived  in  children,  but  scarcely  ever  in 
adults,  in  whom  it  usually  supervenes  on  a  disease  that  is  itself  in- 
compatible with  the  long  continuance  of  life.  If  a  patient  recovers, 
the  general  symptoms  pass  away,  but  local  symptoms  may  persist,  and 
there  may  be  some  impairment  of  intellect.  Possibly  some  cases  of 
so-called  atrophy  of  the  brain,  that  supervene  on  an  acute  illness  in 
childhood,  have  this  origin. 

Treatment. — In  cases  of  primary  thrombosis  the  most  important 
elements  in  treatment  are  to  arrest  the  cause  of  the  prostration,  and 
to  maintain  and  increase  the  strength  of  the  circulation  by  stimulants 
and  tonics  such  as  bark.  The  posture  should  be  that  which  will  aid 
the  flow  of  blood  in  the  special  sinus  affected — if  it  is  the  superior 
longitudinal,  for  instance,  flexion  of  the  neck  should  be  carefully 
avoided.     No  depleting  measures  are  permissible. 

In  secondary  thrombosis,  treatment  usually  fails  to  exert  any  influ- 
ence on  the  disease.  Free  exit  for  all  discharges  from  any  wound  must 
be  secured.  For  the  septicaemic  form,  quinine  and  salicylate  of  soda 
have  been  recommended.  I  think  that  full  doses  of  tincture  of  the 
perchloride  of  iron  more  frequently  produce  a  distinct  effect  upon  this 
condition  than  any  other  drug,  but  it  may  be  doubted  whether  recovery 
ever  results  from  the  use  of  internal  remedies  only.  Surgical  measures 
have,  moreover,  been  successfully  employed,  even  in  cases  due  to  ear 
disease.  Ballance  has  opened  the  sinus  after  (double)  ligature  of  the 
jugular  vein,  and  has  cleared  out  the  thrombus  with  a  satisfactory 
result,  and  without  extension  to  the  opposite  sinus.*     Sulzer  has  done 

*  Ballance  states  that  the  left  sinus  opens  into  the  straight  sinus,  and  the  right 
into  the  longitudinal  sinus  (Ballance,  '  Lancet,'  1890,  vol.  i). 


45b'  J3EAIN. 

the  same,  including  the  removal  of  necrosed  dura  mater  over  the  sinus, 
outside  which  was  a  collection  of  pus.* 

Acute  Cekebral  Palsy  of  Childhood 
(Infantile  Hemiplegia). 

Hemiplegia  of  sudden  onset  is  not  uncommon  in  children,  especially 
in  young  children. f  There  is  considerable  difference  of  opinion  as  to 
the  exact  pathological  condition  on  which  it  usually  depends,  and  it 
is  probable  that  the  cause  is  not  always  the  same.  Hence  it  is  con- 
venient to  give  a  brief  account  of  the  condition  as  a  clinical  variety  of 
disease.  It  is  probably  not  a  distinct  pathological  variety.  Many  of 
the  cases  are  examples  of  one  or  other  of  the  forms  of  disease  already 
described.  In  almost  all  cases  there  is  paralysis — hemiplegia.  Some- 
times, perhaps,  a  lesion  occurs  and  causes  no  local  symptom,  but  such 
cases  can  scarcely  be  recognised.  Very  rarely  there  is  general  loss  of 
power,  but  it  is  probable  that  in  such  cases  both  hemispheres  are 
diseased  :  there  is  double  hemiplegia. 

It  is  to  be  understood  that  only  the  cases  in  which  the  onset  is 
acute  or  sudden  are  now  considered.  Hemiplegia  of  chronic  onset  is 
generally  due  to  a  cerebral  tumour.  Another  class  of  cases  which 
must  be  excluded  are  those  in  which  the  paralysis  dates  from  birth, 
and  is  due  to  injury  received  during  the  process  of  birth.  These 
cases  have  been  considered  in  the  section  on  meningeal  haemor- 
rhage. 

The  following  account  of  the  acquired  palsy  is  based  on  an  extensive 
and  consecutive  series  of  cases  that  have  come  under  my  observation. 

Acute  cerebral  palsy  with  a  distinct  onset  during  infancy  or  childhood 
is  rather  more  common  in  females  than  in  males,  the  proportion  being 
about  five  to  four.  In  three  fifths  of  the  cases  the  onset  was  during 
the  first  two  years  of  life,  three  quarters  during  the  first  three  years, 
and  seven  eighths  during  the  first  five  years.  It  seems  to  be  equally 
common  in  the  first  and  second  year  of  life.  Males  preponderate 
during  the  first  year,  and  females  after  the  first  year. 

In  the  majority  of  the  cases  the  disease  is  not  distinctly  secondary 
to  any  morbid  influence ;  it  was  apparently  primary  in  five  of  the 
eight  cases.  In  some  of  these  the  onset  was  duriug  hot  weather,  and 
in  a  few  there  had  been  distinct  exposure  to  the  sun,  but  the  relation 
to  season  was  not  investigated  in  a  sufficiently  large  number  to  justify 
any  conclusion.     We  must  remember  that,  by  mere  coincidence,  nearly 

*  'Wien.  klin.  Wochensch.,5  1890. 

f  The  condition  has  been  carefully  studied  by  S  tram  pell,  and.  valuable  analyses 
of  cases  have  been  published,  since  the  first  edition  of  this  work  appeared  by  Osier 
('The  Cerebral  Palsies  of  Children/  1889)  and  Sachs  (see  reference  on  p.  413,  aud  in 
"Die  Hirnlahmungen  der  Kinder,"  '  Volkmann's  Samml.  Kl.  Vortrage/  1892). 
Most  of  the  facts  ascertained  by  them  are,  however,  embraced  in  the  briefer  account 
which  follows. 


INFANTILE   HEMIPLEGIA.  457 

a  third  of  the  cases  may  be  expected  to  occur  during  the  time  of  the 
year  when  hot  weather  is  occasionally  met  with.  The  onset  some- 
times occurs  within  a  few  days  of  a  severe  fall,  especially  during  the 
first  two  years  of  life.  It  may  also  be  secondary  to  pneumonia  and  to 
severe  diarrhoea,  chiefly  in  early  infancy. 

Of  other  diseases  to  which  the  condition  was  distinctly  secondary, 
two  acute  specific  diseases  take  the  first  place — scarlet  fever  and 
measles.  In  almost  all,  the  onset  was  during  the  decline  of  the 
acute  specific  disease,  or  within  a  fortnight  of  its  termination.  In 
some  of  the  cases  after  scarlet  fever,  dropsy  was  present  at  the  time 
of  the  onset;  in  others  there  was  no  dropsy.  The  cases  after 
scarlet  fever  occur  chiefly  between  two  and  five  years  of  age ;  those 
after  measles  between  one  and  four.  The  malady  may  also  come  on 
during  severe  and  prolonged  whooping-cough  or  bronchitis,  and  in 
later  childhood  during  the  course  of  "  gasiric  fever."  It  very  rarely 
comes  on  during  rheumatic  fever,  but  I  have  known  it  to  follow 
mumps. 

The  onset  was  attended  by  severe  convulsions  in  more  than  half  the 
cases ;  in  some  the  convulsions  recurred  at  short  intervals  durino- 
several  hours,  and  at  the  end  of  that  time  the  child  was  found  paralysed. 
In  other  cases,  several  distinct  attacks  of  convulsion  were  separated  by 
hours  or  days,  and  the  hemiplegia  was  only  found  after  two  or  three 
had  occurred,  or  when  the  series  was  over.  The  initial  convulsions 
are  generally  one-sided,  affecting  the  limbs  afterwards  paralysed,  and 
the  later  fits  have  almost  always  this  distribution  ;  sometimes  the 
initial  fits  are  general.  In  some  cases  the  hemiplegia  comes  on  with- 
out any  convulsion.  In  most  instances,  whether  there  are  convulsions 
or  not,  the  onset  is  attended  by  severe  cerebral  symptoms,  and  the 
child  often  lies  unconscious  for  several  days.  Sometimes  there  is 
fever  and  vomiting.  In  older  children  there  may  be  some  pain  in  the 
head,  but  this  symptom,  on  the  whole,  is  not  prominent.  In  the  cases 
that  are  secondary  to  some  acute  disease,  attended  with  general  pros- 
tration, or  in  which  such  prostration  follows  general  convulsions,  the 
hemiplegia  may  not  be  discovered  for  some  days  or  weeks  after  the 
onset.  If  the  paralysis  is  on  the  right  side,  it  may  be  accompanied 
by  distinct  aphasia  in  those  children  who  have  already  acquired  the 
power  of  speech.  The  aphasia  passes  away  completely  in  the  course 
of  a  few  weeks ;  rarely  it  lasts  for  a  month  or  two. 

The  further  course  of  the  symptoms,  and  the  persistent  condition, 
vary  in  different  cases.  In  most  of  them  a  considerable  degree  of 
hemiplegia  remains,  but  it  is  probable  that  in  some  instances  a  cere- 
bral lesion  of  the  same  character  is  so  placed  as  to  cause  no  persistent 
symptoms,  and  there  may  then  be  no  indication  of  its  existence.  I 
remember,  many  years  ago,  finding  a  large  cavity,  the  size  of  a  hen's 
egg,  in  the  posterior  part  of  the  left  parietal  lobe,  in  a  man  in  whom, 
no  cerebral  lesion  was  even  suspected.  With  the  exception  of  the 
half -vision  centre,  in  the  posterior  extremity  of  the  hemisphere,  it  is 


458  BKA1N. 

probable  that  a  lesion  in  early  life  causes  lasting  symptoms  only  when 
it  involves  the  motor  path  or  motor  cortex. 

The  residual  hemiplegia  affects  the  right  or  left  side  with  about 
equal  frequency.  In  some  cases  the  amount  of  the  persistent  palsy 
is  slight.  If  at  first  incomplete,  it  soon  passes  away  from  some  part 
of  the  side,  the  arm  or  the  leg.  More  often  it  is  at  first  complete, 
and  continues  so  for  a  few  months,  and  then  power  slowly  returns  in 
some  parts,  especially  the  face  and  arm,  in  consequence  of  the  com- 
pensation by  the  other  hemisphere.  Yery  rarely  the  paralysis  has 
been  bilateral  from  the  first,  and  both  sides  have  remained  paralysed. 
This  is  doubtless  the  result  of  a  bilateral  lesion,  as  one  recorded  case 
proves;*  ■compensation  is  then  impossible,  and  the  palsy  remains 
absolute  in  the  legs  as  well  as  in  the  arms. 

The  ultimate  condition  of  these  cases  necessarily  depends  on  the 
severity  of  the  symptoms.  In  a  large  number  the  arm  remains 
considerably  paralysed.  Some  power  is  recovered  in  the  shoulder  and 
elbow,  and  a  little  in  the  hand,  and  as  movement  returns  contracture 
comes  on.  In  the  vast  majority  the  limb  becomes  the  seat  of  mobile 
spasm  (athetosis,  post-hemiplegic  chorea),  of  which  these  cases  pre- 
sent the  most  typical  examples. t  There  is  varying  flexor  and  extensor 
spasm  at  the  several  joints,  the  variations  being  greatest  in  the  hand, 
in  which  there  are  of  ten  spontaneous  movements,  quick  or  slow,  while 
voluntary  movement  is  disordered  and  ataxic.  The  condition  is  that 
described  at  p.  85.  The  subluxation  of  the  middle  joint  of  the 
fingers,  in  consequence  of  the  spasm  in  the  interosseal  muscles,  is 
generally  conspicuous.  The  active  changing  spasm  is  proportioned  to 
the  amount  of  voluntary  power ;  when  this  is  slight  there  is  much 
fixed  spasm,  by  which  the  wrist-joint  is  olten  strongly  flexed.  The 
spasm  in  the  upper  part  of  the  arm  may  be  considerable,  and  may 
keep  the  limb  rigid,  generally  in  extension.  A  strong  effort  with  the 
affected  hand  causes  a  corresponding  movement  in  the  other  hand, 
and  vice  versa.  In  some  cases  recovery  is  so  great  that  only  a  slight 
amount  of  inco-ordiuation  remains,  and  occasionally  even  this  is 
absent.  The  paralysed  arm  is  shorter  than  the  other  in  most  of  the 
severe  cases,  and  all  the  bones,  even  the  scapula,  present  a  diminution 
in  size.  The  muscles  may  also  be  small,  but  are  occasionally  hyper- 
trophied  from  the  effect  of  their  continuous  over-action.  The  leg 
always  regains  considerable  power,  and  the  patient  can  walk  without 
difficulty,  although  the  growth  of  the  limb  may  be  so  hindered  as  to 
cause  a  limp.  The  knee-jerk  is  excessive,  and  a  clonus  can  sometimes 
be  obtained.  Spasm  is  generally  slight,  but  often  causes  some  talipes 
equinus,  or  equino-varus,  always  to  be  overcome  by  gentle  pressure  : 
the  toes  are  sometimes  over-extended  in  the  act  of  walking.      In  the 

*  Heubner  (see  p.  4  61  note). 

f  On  nccounfc  of  the  frequency  of  this  symptom  the  cases  have  been  termed 
'-  cerebral  spastic  paralysis,"  but  the  designation  is  too  wide  in  its  meaning  to  be 
very  appropriate. 


INFANTILE    HEMIPLEGIA.  459 

face  the  residual  weakness  is  trifling,  but  often  there  is  distinct  over- 
action  of  the  muscles  on  the  affected  side.  This  is  seen  best  iu  the 
act  of  smiling,  in  which  a  slight  movement  occurs  earlier,  and  is  at  first 
more  marked,  than  on  the  other  side,  although  a  strong  movement 
may  be  distinctly  slighter. 

As  a  rule,  sensation  is  perfectly  normal  on  the  paralysed  side.  It 
is  probably  impaired  iu  some  cases  during  the  early  stage,  but  recovery 
is  constant,  so  constant  that  it  can  only  be  by  the  compensation  effected 
by  the  other  hemisphere.  In  the  only  case  I  Lave  seen  in  which  there 
was  any  loss  of  sensation  some  years  after  the  onset,  the  loss  was 
clearly  fuuctioual,  hysterical  hemiansesthesia ;  a  week  later  it  had  dis- 
appeared, and  existed  on  the  opposite  side.  Mental  defect  is  very 
common,  and  presents  every  conceivable  degree,  from  a  slight  amount 
of  hysteria  to  pronounced  iodicy.  One  of  the  most  severe  cases  of 
hysteria  that  I  have  seen  was  in  a  girl,  the  subject  of  old  infantile 
hemiplegia.  Another  frequent  symptom  is  convulsion,  recurring,  and 
resembling  idiopathic  epilepsy  in  its  course,  although  not  in  its  origin. 
Such  recurring  fits  are  met  with  in  at  least  two  thirds  of  the  cases. 
Sometimes  they  continue  from  the  onset;  sometimes  an  interval  of 
years  may  elapse  before  the  fits  begin,  and  occasionally  the  hemiplegia 
occurs  in  infancy,  and  the  convulsive  attacks  are  only  added  when  the 
age  of  puberty  is  reached.  These  cases  will  be  agaiu  considered  in  the 
chapter  on  "  Epilepsy."  The  convulsions  are  almost  always  one-sided, 
affecting  only  the  paralysed  limbs,  and  often  begin  locally  after  the 
fashion  of  "  cortical  epilepsy."  It  is,  however,  a  significant  fact,  in- 
dicating how  profound  is  the  influence  of  the  repeated  discharges  on 
the  brain,  that  the  fits  may  ultimately  be  preceded  by  an  aura  identi- 
cal with  some  one  of  the  most  common  warnings  of  idiopathic  epilepsy, 
and  that  minor  attacks  may  be  developed  which  consist  only  of  loss 
of  consciousness. 

Pathology. — Very  few  observations  have  been  made  on  the  condi- 
tion of  the  brain  in  these  cases,  and  those  are  chiefly  on  cases  long 
after  the  onset.  The  conditions  found  have  varied,  and  are  susceptible 
of  different  explanations.  In  some,  a  cavity  has  been  found  in  the 
central  region  of  the  hemisphere,  involving  the  central  ganglia,  and 
sometimes  extending  as  far  as  the  cortex  of  the  motor  region.  If 
there  is  an  opening  on  the  surface  of  the  brain  the  condition  has  been 
distinguished  by  a  special  name,  "  porencephalia."*  The  actual  cavity 
may  be  very  large,  or  may  be  small,  and  may  appear  as  if  cicatricial 
contraction  had  drawn  the  walls  together.  On  the  other  hand,  there 
is  sometimes  no  cavity  or  evidence  of  extensive  destruction  of  tissue, 
but  some  convolutions  are  small  and  indurated.     In  most  cases  the 

*  It  is  curious  that  in  some  cases  of  such  cavity  there  has  been  a  defect  in  the 
bone  corresponding  to  the  hole  in  the  brain.  The  origin  of  such  defect  in  skull 
and  brain  is  not  known,  but  it  is  improbable  that  the  condition  belongs  to  the  class 
now  under  consideration. 


460  BIJAIN. 

whole  of  the  hemisphere  in  which  the  lesion  is  found  is  smaller  than 
the  other;  the  diminution  in  size  may  involve  all  parts  of  the  cortex, 
and  its  substance  is  firmer  than  normal,  and  contains  more  connective 
tissue.*  The  condition  has  been  termed  "  diffuse  lobar  sclcrosis,"f 
or  "chronic  encephalitis."!  Occasionally  such  a  diminution  in  size 
of  the  whole  hemisphere  is  the  only  visible  disease  ;  the  atrophy  is, 
however,  generally  more  marked  in  one  part  than  in  another.  In  the 
former  case  it  is  possible  that  there  has  been  a  primary  lesion  in  one 
part  of  the  cortex,  and  the  wasting  elsewhere  has  been  secondary, 
although  the  two  can  scarcely.be  distinguished  after  the  lapse  of 
years.  We  are  only  considering  now  the  cases  in  which  there  was  a 
sudden  onset,  and  it  is  scarcely  conceivable  that  any  disease,  affect- 
ing primarily  in  such  a  manner  all  parts  of  a  hemisphere,  can  have 
come  on  suddenly,  or  that  actually  sudden  palsy  should  be  the  mani- 
festation of  a  chronic  process.  It  seems  more  probable  that,  in  such 
cases,  the  diffuse  change  is  really  a  secondary  atrophy. 

Two  kinds  of  lesion  have  been  assumed,  in  current  theory,  as  the 
cause  of  these  acute  symptoms.  According  to  the  one,  the  primary 
lesion  is,  in  most  cases,  vascular  occlusion;  according  to  the  other, 
which  has  been  put  forward  by  Strumpell.§  and  widely  accepted  in 
Germany,  it  is  inflammation  of  the  grey  matter  of  the  cortex,  "  polio- 
encephalitis," analogous  to  the  inflammation  of  the  grey  substance  of 
the  spinal  cord,  "polio-myelitis."  Attractive  as  the  latter  theory  is 
at  first  sight,  it  rests  upon  no  evidence,  and,  as  Sachs  has  pointed  out, 
the  scanty  pathological  facts  we  possess  are  opposed  to  its  validity,  as 
are  also  the  facts  of  etiology.  A  primary  inflammation  of  a  part  of 
the  cortex  of  the  brain  is  a  purely  theoretical  disease  ;  if  it  occurs  not 
rarely  in  childhood  (as  must  be  assumed  on  this  theory),  pathological 
evidence  of  it  would  certainly  have  been  forthcoming,  even  more 
abundant  than  that  of  the  analogous  spinal  malady,  as  every  kind  of 
organic  brain  disease  is  more  often  fatal  than  is  disease  of  the  cord. 
It  must  be  remembered  that  the  general  liability  of  the  brain  to 
primary  inflammation  is  very-  much  less  than  is  that  of  the  spinal 
cord,  and  we  are  therefore  not  justified  in  relying  on  analogy  as  a 
basis  for  theory.  The  circumstances  of  the  onset  present  a  marked 
contrast  to  those  of  the  spinal  malady,  since  the  latter  is  scarcely  ever 
secondary  to  a  general  disease,  while  the  cerebral  lesion,  whatever  its 
nature,  frequently  is.|| 

The  alternative  theory,  vascular  obstruction,  has  much  to  support 
it.     It  is  the  common  cause  of  such  central  cavities  as  have  been 

*  Many  examples  of  this  are  on  record.  A  good  instance  has  been  described  by 
Kast,  'Arcli.  f.  Psych.,'  Bd.  xviii,  Heft  2. 

f  Marie  and  Jendrassik,  '  Arch,  de  Pliysiologie,'  1885,  No.  1. 

X  Bourneville,  '  Recherches  sur  l'Epilepsie.' 

§  'Deut.  me<l.  Wochenschr.,'  1881,  No.  44. 

||  This  paragraph  has  been  left  unchanged  from  the  first  edition,  because  the 
evidence  is  practically  unaltered. 


INFANTILE    HEMIPLEGIA.  4G1 

found  in  some  cases.  It  is  a  known  consequence  of  such  genei*al 
diseases  as  frequently  precede  the  cerebral  lesion.  It  has  been 
actually  found  in  some  cases  of  the  kind.*  A  cavity  in  the  central 
ganglia  can  hardly  be  due  to  any  other  cause  than  arterial  obstruc- 
tion. But  whether  this  is  the  result  of  embolism  or  thrombosis  is  an 
open  question.  The  former  has  generally  been  assumed. f  But  in 
the  vast  majority  of  cases  of  proved  embolism  there  has  been  an 
obvious  source  for  the  occluding  plug,  in  most  cases  endocarditis. 
In  some  of  the  conditions  in  which  infantile  hemiplegia  comes  on, 
endocarditis  is  most  improbable;  whereas  we  know  that,  at  least  in 
the  sinuses  of  the  brain,  primary  thrombosis  occurs  in  children,  and 
sometimes  occurs  under  the  circumstances  in  which  infantile  hemi- 
plegia comes  on.J  Hence,  while  some  cases  may  be  due  to  embolism, 
it  seems  on  the  whole  more  probable  that  when  tbe  primary  lesion  is 
obstruction  of  an  artery,  this  is  the  result  of  thrombosis  in  situ.  In 
the  cases  in  which  there  is  no  evidence  of  softening  en  masse,  in  which 
there  is  no  cavity,  but  only  shrinking  and  induration  of  part  of  the 
cortex,  I  have  suggested  that  the  lesion  is  probably  thrombosis  in  a 
surface  vein,§  and  that  the  reason  why  this  lesion  is  so  seldom  found 
post  mortem  is  because  in  fatal  cases  tbe  clot  usually  spreads  into  a 
sinus  before  death,  and  the  case  is  then  regarded  as  one  of  sinus- 
thrombosis.  We  know  that  the  closure  of  a  vein  does  not  commonlv 
cause  softening  of  the  whole  of  the  cerebral  tissue  from  which  the 
blood  should  pass  to  the  vein,  but  merely  intense  congestion,  minute 
extravasations,  and  punctiform  softening,  a  condition  that  may  well 
leave  the  state  of  atrophy  and  induration  met  with  in  some  cases.  It 
is  certain  that  thrombosis  may  be  limited  to  veins.  An  instructive 
case  has  been  published  by  Money,  in  which  such  thrombosis  was 
found  after  scarlet  fever,  and  the  extravasations  into  the  related 
brain- substance   showed  that  the  coagulation  had  occurred   during 

*  As,  for  instance,  that  recorded  by  Heubner,  '  Med.  Wien.  Blatt./  1883,  No.  13. 
Bilateral  palsy  and  rigidity  with  trismus  developed  during  prostration  after  bron- 
chitis in  a  child  one  year  and  four  months  old.  Cavities  were  found  in  both  hemi- 
spheres and  the  pons,  with  clots  in  the  middle  cerebral  arteries,  but  these  clots  were 
"canalised,"  and  the  arteries  beyond  were  .pervious.  Embolism,  from  ventricular 
endocarditis,  was  the  assumed  lesion,  the  lining  membrane  of  the  left  ventricle 
being  thickened.     But  thrombosis  in  situ  could  not  be  excluded. 

f  See  Abercrombie,  '  Brit.  Med.  Journal,'  1887,  vol.  i,  p.  1323. 

%  Heubner  assumes  that  in  his  case  embolism  had  occurred.  There  was  thick- 
ening of  the  lining  membrane  of  the  left  ventricle,  and  he  supposed  that  there  had 
been  a  ventricular,  not  valvular,  endocarditis,  from  which  the  plug  had  come.  This 
theory,  to  those  familiar  with  diseases  of  children,  will  seem  far  less  probable  than 
that  of  thrombosis  in  situ,  especially  when  the  multiplicity  of  the  cerebral  lesion  is 
compared  with  the  fact  that  elsewhere  in  the  body  only  one  uncertain  trace  of 
embolism  was  found.  Moreover  the  canalisation  of  a  clot  formed  in  situ  is  far 
more  probable  than  is  that  of  an  embolic  obstruction. 

§  This  has  also  been  accepted  as  the  most  probable  explanation  by  Sachs  (Clin. 
Lect.  in  Volkmann's  Series,  1892). 


462  BRAIN. 

life.*  We  must  remember  that  thrombosis  iu  a  sinus  does  not 
always  involve  its  whole  cavity:  the  clot  may  be  limited  to  the  wall 
or  to  one  side,  and  the  vessel  may  remain  pervious.  In  this  connec- 
tion it  is  instructive  to  note  that  in  one  of  my  cases  the  history 
strongly  suggested  thrombosis  in  the  superior  longitudinal  sinus.  A 
child  of  four  months  old  was  prostrated  by  severe  diarrhoea,  and  the 
fontanelle  depressed  ;  convulsions  set  in,  and  the  fontanelle  became 
extremely  prominent ;  the  child  lay  motionless  for  four  days,  and 
then,  when  improvement  commenced,  hemiplegia  was  found. 

Recurring  unilateral  convulsions  have  not  quite  the  same  weight 
as  indications  of  a  cortical  lesion  in  these  cases  as  they  have  in  lesions 
of  the  brain  in  adults.  They  have  been  met  with  in  several  cases  in 
which  the  lesion  was  in  the  central  ganglia,  even  supervening  years 
after  the  onset. 

We  cannot  yet  give  any  trustworthy  explanation  of  the  mechanism 
of  the  spasm  in  the  limbs  which  so  constantly  accompanies  the  hemi- 
plegia. It  seems  to  follow  lesions  of  various  kinds,  degrees,  and  seat, 
in  the  cortex  as  well  as  the  central  ganglia.  The  far  greater  frequency 
(almost  constancy)  of  the  symptom  after  a  lesion  in  early  life  makes 
it  probable  that  it  is  in  some  way  due  to  the  disordered  action  of 
centres  that  remain,  and  not  to  the  direct  effect  of  the  disease  itself. 

The  diagnosis  of  these  cases  has  to  be  made  chiefly  from  those  in 
which  birth-palsy  is  one-sided,  and  this  depends  on  the  history  of  a 
distiuct  onset  after  birth,  which  is  scarcely  ever  wanting.  In  cases 
in  which  similar  symptoms  are  due  to  a  stationary  lesion  of  chronic 
character,  such  as  a  tumour,  the  early  history  is  distinctive. 

The  treatment  of  the  cases  in  the  early  stage  must  depend  on  the 
probable  nature  of  the  lesion.  Whatever  be  its  exact  character  the 
treatment  for  thrombosis  in  veins  and  sinuses,  described  at  p.  455, 
will  be  most  suitable.  The  after-treatment  of  the  mobile  spasm  has 
been  considered  in  the  chapter  on  softening  of  the  brain. 

*  Money,  'Treatment  of  Disease  in  Children,'  p.  4t5.  There  had  been  symptoms 
similar  to  these  iu  the  cases  now  under  consideration,  but  the  clot  did  not  seem  of 
sufficiently  old  date  to  make  the  case  a  proof  of  the  relation  of  the  symptoms  to  the 
thrombosis. 


INFLAMMATION.  463 

INFLAMMATION   OF   THE    BRAIN 

(Encephalitis,  Cerebbitis.) 


Acute  Inflammation. 


The  cerebral  tissue,  like  most  other  tissues,  may  be  the  seat  of  inflam- 
mation, but  in  no  organ  has  the  part  played  by  inflammation  in 
producing  morbid  changes  and  symptoms  been  more  variously  esti- 
mated at  different  times.  This  is  due  to  two  causes:  (1)  Inflamma- 
tion causes  softening ;  hence  it  was  once  thought  that  all  forms  of 
softening  are  inflammatory.  It  is  now  known  that  most  are  not,  but 
are  simply  necrotic,  due  to  an  arrest  of  the  supply  of  blood.  Neverthe- 
less some  forms  of  local  disease,  which  are  probably  due  to  vascular 
occlusion,  are  still  regarded  by  some  authorities  as  inflammatory.  (2) 
Inflammation  of  the  surface  of  the  brain  accompanies  that  of  the 
membranes,  and  it  is  through  the  former  that  many  symptoms  of 
meningitis  are  produced.  Hence,  although  the  inflammation  of  the 
membranes  is  the  primary  condition,  and  the  fact  is  now  recognised 
in  terminology,  these  cases  were  formerly  called"  inflammation  of  the 
bi'ain,"  and  are  often  still  thus  designated  in  popular  language. 
These  two  classes  must  be  therefore  put  on  one  side.  The  residual 
cases,  in  which  acute  inflammation  is  known  to  exist,  are  not  nume- 
rous. A  source  of  uncertainty  regarding  the  part  played  by  inflam- 
mation in  the  production  of  local  lesions  arises  from  the  fact  that 
the  ultimate  aspect  of  the  damaged  region,  years  after  the  onset,  has 
alone  beeu  observed,  and  its  aspect  is  not  then  distinctive.  Much 
weight,  however,  may  be  given  to  the  mode  of  onset ;  when  this  is 
actually  sudden,  a  vascular  lesion  is  indicated,  and  not  a  simple 
inflammation.  This  point  needs  attention,  even  in  the  acute  stage 
embolic  softening  has  been  mistaken  for  inflammation. 

Etiology. — Acute  inflammation  of  the  brain  usually  results  from 
one  of  three  causes — a  traumatic  injury,  contiguous  inflammation,  or 
some  septic  influence.  Injury  commonly  sets  up  inflammation  in 
the  meninges  as  well  as  in  the  brain,  but  now  and  then  the  former 
escape,  and  the  latter  is  affected  beneath  the  surface,  apparently 
because  the  white  substance  is  more  easily  injured  than  the  grey.  All 
forms  of  injury  may  be  effective,  blows  and  falls  on  the  head,  frac- 
tures of  the  skull,  and  punctured  wounds.  It  may  occur  from 
mere  concussion,  but  is  doubtless  set  up  by  the  mechanism  of  inter- 
stitial laceration.  Usually  the  cerebritis  is  immediately  beneath  the 
seat  of  the  in j  ury  ;  much  less  commonly  it  occurs  at  the  opposite  side 


464  BRAIN. 

of  the  brain  from  contre-coup.  The  latter  especially  damnges  the 
centre  of  the  convolution,  so  that  there  results  ultimately  an  irre- 
gular shallow  depression  in  its  surface.  This  appearance  is  often 
seen  near  the  apex  of  the  temporal  lobe  in  consequence  of  a  blow  on 
the  vertex.  The  inflammation  may  subside,  leaving  only  the  changes 
above  described,  or  it  may  go  on  to  suppuration,  and  the  abscess  may 
run  an  independent  course.  A  punctured  wound  is  very  apt  to  cause 
an  abscess.  A  very  acute  form  of  cerebritis,  sometimes  involving 
the  whole  hemisphere,  may  follow  rapidly  on  an  operation  on  the 
brain  when  aseptic  precautions  have  been  imperfect.  In  other  cases 
of  trephining,  local  inflammation  of  more  chronic  course  seems  to 
attend  the  formation  of  "  hernia  cerebri."  Another  frequent  cause 
of  cerebritis  is  bone  disease,  usually  actual  caries,  but  sometimes  osteitis 
which  has  not  gone  on  to  caries.  The  affection  of  the  bone  may  be 
traumatic,  syphilitic,  or  the  result  of  contiguous  inflammation.  The 
last  is  almost  confined  to  the  bones  adjacent  to  or  enclosing  the 
organs  of  the  special  senses,  the  nose,  orbit,  and  especially  the  ear. 
The  inflammation  of  the  brain  thus  excited,  usually  accompanies 
meningitis,  but  sometimes  occurs  alone.  It  usually  goes  onto  suppu- 
ration. New  growths  in  the  brain  usually  cause  softening  in  the 
adjacent  cerebral  tissue,  partly  necrotic,  the  result  of  pressure,  > 
partly  inflammatory,  but  the  inflammation  is  slight  in  degree,  is 
attended  with  oedema,  and  scarcely  ever  presents  any  tendency  to 
suppuration.  In  acute  diseases,  especially  erysipelas,  diphtheria,  and 
typhoid  fever,  minute  foci  of  encephalitis,  characterised  especially  by 
ieucocytal  aggregations,  and  sometimes  by  micrococcal  infilt ration, 
are  often  found  on  microscopical  examination.  Lesions  of  consider- 
able size,  in  acute  specific  diseases,  are  generally  due  to  embolism 
or  thrombosis.  In  simple  vascular  .obstruction,  the  softening  which 
results  is  chiefly  necrotic ;  on  its  margin,  inflammation  occurs,  and 
is  often  considerable  when  the  obstructing  plug  comes  from  a  septic 
source,  as  in  acute  endocarditis.  Even  then,  suppuration  is  extremely 
rare.  In  pyaemia,  however,  the  inflammation  thus  excited  always 
goes  on  to  the  formation  of  pus. 

Idiopathic  cerebritis  is  almost  unknown.  It  has  been  supposed  by 
Striimpell  to  be  the  cause  of  sudden  cerebral  palsy  in  children,  and 
the  engaging  character  of  this  theory  of  "  polio-encephalitis  "  has  led  to 
the  use  of  this  name  for  the  affection.  But  no  observations  have 
given  distinct  confirmation  of  the  view;  all  are  otherwise  explicable, 
and  many  certainly  point  to  a  lesion  primarily  vascular  and  not  inflam- 
matory. Actual  inflammation,  however,  seems  sometimes  to  affect 
the  nuclei  of  the  ocular  muscle  nerves,  and  also  those  of  the  bulbar 
nerves. 

Acute  functional  disturbance  of  the  brain  is  usually  attended  by 
minute  changes,  and  especially  by  the  vascular  alterations  that  always 
accompany  such  derangement ;  these  are  revealed  by  the  microscope, 
and  may  be  of  such  degree  as  to  be  distinctly  inflammatory.     For 


INFLAMMATION.  465 

instance,  in  hydrophobia  the  medulla  oblongata,  the  functions  of 
which  are  so  conspicuously  deranged,  presents  such  microscopical 
alterations — aggregations  of  leucocytes  outside  the  vessels  and  even 
in  the  substance  of  the  nerve-tissue.  These  changes  are  not  primary, 
but  are  secondary  to  the  intense  functional  disturbance,  although 
they  have  many  of  the  anatomical  characters  of  inflammation. 

Pathology. — The  alteration  in  the  tissue  of  the  brain  which  results 
from  acute  inflammation  has  been  long  and  accurately  known  under 
the  name  of  "  red  softening,"  since  it  is  usually,  from  the  first,  much 
redder  than  the  softening  which  results  from  necrosis  or  mere  imbi- 
bition of  effused  fluid  and  is  "yellow"  or  "white."  The  red  tint 
of  the  affected  area  depends  partly  on  the  distension  of  small  vessels, 
but  chiefly  on  minute  points  of  extravasation,  and,  according  to  the 
number  of  the  latter,  the  colour  varies  from  pale  to  deep  red.  The 
consistence  is  lessened,  from  the  disintegration  of  the  tissue-elements 
by  effused  liquid  and  the  separation  of  the  particles.  For  the  same 
reason,  the  affected  area  is  swollen,  and,  on  section,  stands  up  above 
the  level  of  the  adjacent  brain-substance.  It  is  never  sharply  limited, 
and  the  consistence  of  the  adjacent  tissue  is  usually  lessened.  The 
microscope  shows  distension  of  the  vessels,  especially  the  capillaries, 
foci  of  haemorrhage,  and  accumulations  of  lymphoid  (leucocytal) 
elements  in  the  tissue  and  around  vessels.  These  are  always  to  be 
found,  but  vary  in  number;  when  numerous,  the  softened  tissue 
may  have  the  aspect  of  actual  pus.  The  proper  elements  of  the 
tissue — nerve-fibres,  ganglion-cells,  and  neuroglia- cells  are  in  various 
stages  of  degeneration,  and  from  all  these  granule-cells  develop.  The 
cell-elements  undergo  first  the  stage  of  cloudy  swelling,  the  nerve- 
fibres  become  granular,  the  axis-cylinder  presents  fusiform,  highly 
granular  enlargements,  which,  becoming  detached,  also  form  granule- 
cells.  At  the  margin  of  the  inflamed  area,  the  ganglion-cells  also 
pass  into  the  stage  of  cloudy  swelling,  but,  instead  of  breaking  up, 
may  atrophy  or  become  pigmented,  or  undergo  a  sort  of  vitreous 
degeneration.  These  changes  in  the  nerve -elements  are  the  same  as 
are  met  with  in  simple  necrotic  softening,  and  hence  their  occurrence 
does  not  show  that  the  process  was  one  of  primary  inflammation. 

It  is  only  in  the  rare  cases  in  which  the  inflammation  is  vei*y  slight 
in  degree,  and  there  is  no  actual  destruction  of  nerve-elements,  that 
recovery  of  the  affected  part  is  possible.  Small  foci  of  considerable 
inflammation  may  ultimately  cease  to  be  visible  to  the  unassisted  eye — 
a  different  thing  from  actual  recovery.  In  most  cases  visible  damage 
persists.  The  complete  disintegration  of  the  tissue-elements,  and 
absorption  of  the  remains  of  vessels,  leave  a  fatty  emulsion  in  the 
resulting  cavity,  and  to  it  the  remains  of  blood-pigment  (often  hsema- 
toidin  crystals)  give  a  yellow  or  reddish  tint,  always  deeper  in  the 
grey  than  in  the  white  substance.  Such  a  cavity  may  at  last  be  indis- 
tinguishable from  one  left  by  a  simple  necrotic  process.  Ultimately, 
vol.  ii.  30 


466  BRAIN. 

the  fatty  granules  may  be  slowly  removed,  and  a  little  clear  fluid  may 
alone  remain.  Occasionally  a  reticulated  stroma  persists  (or  is  formed) 
in  the  softened  area ;  the  loculated  cavities  thus  constituted  may 
contract,  so  that  ultimately  a  sort  of  fibrous  cicatrix  remains,  with  a 
little  adjacent  atrophy,  the  result  of  the  initial  oedema  around  the 
focus  of  inflammation.  Now  and  then  this  cicatrix  contains  a  central 
nucleus  of  fatty  debris  and  hsematoidin  crystals.  An  increase  of  con- 
nective-tissue elements  may,  perhaps,  sometimes  cause  the  development 
of  sclerotic  induration  in  the  affected  area,  but  this  is  far  less  common 
than  it  is  in  cases  of  chronic  inflammation,  venous  thrombosis,  and 
compression  by  meningeal  hemorrhage,  and  it  is  doubtful  whether  such 
a  state  ever  justifies  the  diagnosis  of  an  initial  acute  inflammation. 
When  the  process  is  intense,  the  lymphoid  (pus)  cells  are  so  numerous 
that  the  softening  becomes  actually  purulent,  and  a  cavity  thus  results 
containing  pus.  This  result  of  inflammation  is  further  described  in 
the  chapter  on  "  Cerebral  Abscess."  A  distinctly  purulent  appear- 
ance has  been  acquired  in  so  short  a  time  as  six  or  seven  days.  If  a 
very  acute  and  malignant  form  of  inflammation  affects  an  extensive 
area,  rapid  and  infiltrating  suppuration  occurs,  with  acute  sloughing 
of  the  cerebral  tissue. 

The  traces  of  inflammation  in  typhus  and  typhoid  fevers  are 
seldom  to  be  recognised  by  the  unassisted  eye.  They  consist  of 
aggregations  of  lymphoid  cells  around  the  vessels  or  in  the  tissue,  and 
may  sometimes  constitute  a  mass  of  relatively  large  dimensions,  com- 
parable in  size  to  a  tubercular  granulation  (Fig.  124).  They  are  not 
always  met  with,  and  are  more  pronounced  in  typhus  than  in  typhoid. 

They  have  been  especially  studied 
by  Popoff,  who  states  that  the  lym- 
phoid corpuscles  sometimes  enter 
the  protoplasm  of  the  nerve-cells, 
and  may  cause  multiplication  of 
the  nucleus  and  other  changes.* 

The  disseminated  inflammation 
that  occurs  in  some  cases  of  erysi- 
pelas and  diphtheria,  and  some- 
times in  septicaemia,  is  of  especial 

interest  on  account  of  the  organ- 

Fl&.  124. — Section  from   the  cortex  of     .  j.i>„*. n    „„r,^«;„+«^    ™;+i,    ;+ 

•  the  frontal  lobe  in  exanthematic  ty-  isms  that  are  associated  With  it. 
phus :  a,  accumulation  of  lymphoid  Sometimes  minute  points  of  sof ten- 
elements  ;  b,  a  cavity  from  which  such  :„„.  may  ^e  visi"ble  ;  more  often  the 
cells   have  fallen.      (Popoff,    ' Virch.       ,&         J  ,     '    .  ,       .,, 

Arch./ Bd.  lxxxvii,  pi.  i.)  changes  are  only  discovered  with 

the  microscope.  In  certain  spots 
micrococci  may  be  seen  around  the  vessels,  scattered  through  the 
brain  tissues,  and  even  densely  aggregated  in  definite  "  colonies."  The 
condition  has  been  termed  "  mycosis  of  the  brain."f 

*  Popoff,  '  Virchow's  Archiv,'  Bd.  lxxxvii. 

t  See  Schule, '  Virchow's  Archiv,'  lxvii;  Letzerich,  ib.,  Bd.  lxxv ;  and  Blaschko,  ib., 
Bd.  lxxxii.     It  must  not  be  confused  with  "actinomycosis,"  6ee  p.  467. 


INFLAMMATION.  467 

Symptoms. — Our  knowledge  of  the  exact  symptoms  of  simple 
cerebritis  is  meagre,  on  account  of  the  rarity  with  which  it  exists  alone. 
Headache  is  certainly  frequent ;  vomiting  occasional ;  but  optic 
neuritis  is  a  rare  result  of  the  acnte  process.  General  convulsions  and 
delirium  may  also  be  met  with.  These  symptoms  are  irrespective  of 
the  seat  of  the  inflammation.  When  the  special  motor  or  sensory 
region  is  involved,  corresponding  symptoms  may  be  present,  the  most 
frequent  being  weakness  in  the  limbs  on  the  opposite  side,  and  con- 
vulsions, local,  or  beginning  locally.  Such  symptoms  are  not  uncommon 
a  few  days  after  a  cerebral  injury,  and  are  often  attended  by  some 
elevation  of  temperature.  They  may  pass  away  completely  or  may 
persist  in  slighter  form.  They  differ  from  the  actual  injury  to  the 
brain  by  coming  on,  not  immediately,  but  two  or  three  days  after  the 
injury.  The  symptoms  of  an  abscess,  on  the  other  hand,  only  develop 
after  some  weeks.  A  young  child  fell  off  a  chair  with  a  pair  of 
scissors  in  her  hand,  and  fell  on  the  point  of  the  scissors,  one  blade  of 
which  entered  the  skull  just  in  front  of  the  middle  of  the  right 
temporal  fossa.  It  passed  in  for  about  an  inch  and  a  half  in  such  a 
direction  that  the  point  must  have  been  very  near  the  internal  capsule 
There  were  no  immediate  symptoms,  but  three  days  after  the  injury 
hemiplegia  came  on ;  probably  the  inflammation  in  the  neighbourhood 
of  the  wound  reached  the  internal  capsule.  Sometimes  traumatic 
inflammation  seems  to  set  up  a  degenerative  process,  which  runs  an 
independent  course,  and  is  manifested  by  chronic  mental  failure. 

It  is  seldom  that  definite  symptoms  can  be  ascribed  to  the  dis- 
seminated inflammation  that  occurs  in  acute  specific  diseases. 
Delirium  and  somnolence  and  subsequent  mental  weakness  may  be 
in  part  due  to  these  changes,  but  we  cannot  at  present  distinguish  the 
effects  of  the  definite  lesions  and  of  the  influence  of  the  blood-state. 

Diagnosis. — In  many  cases  the  symptoms  are  identical  with  those 
of  meningitis  over  the  corresponding  region  of  the  brain.  In  the  form 
that  results  from  specific  blood-states  the  condition  may  be  suspected 
if  cerebral  symptoms  become  more  pronounced  after  the  pyrexia,  but 
our  knowledge  of  the  effect  of  the  lesions  is  still  too  meagre  to  permit 
any  definite  diagnostic  rules  to  be  laid  down. 

The  Prognosis  of  acute  simple  inflammation  of  the  brain,  as  dis- 
tinguished from  that  of  the  membranes,  can  only  be  made  from  the 
severity  of  the  symptoms.  Its  Treatment  is,  on  the  whole,  similar 
to  that  of  inflammation  of  the  membranes. 

Actinomycosis  of  the  Brain. — A  few  cases  are  on  record  in  which  the 
peculiar  fungus  which  gives  rise  to  this  disease  in  animals,  and  some- 
limes  elsewhere  in  man,  has  caused  foci  of  inflammation  in  the  sub- 
stance of  the  brain.  Within  these  the  spherules  of  the  fungus  are 
mingled  with  pus-cells.  Usually  secondary,  it  has  been  perhaps  in 
one  case  primary.  The  symptoms  have  resembled  those  of  secondary 
abscess,  but  the  nature  of  the  disease  has  been  suspected  only  when 


468  BRAIN. 

its  existence  was  recognised,  elsewhere  in  the  body,  and  it  is  too  rare 
to  be  of  practical  importance.* 

Chronic  Inflammation. 

Of  chronic  cerebritis  we  have  also  very  little  exact  knowledge.  It 
is  true  the  term  "chronic  encephalitis"  or  "nieningo-encephalitis" 
is  frequently  employed,  especially  by  French  writers,  but  for  the  most 
part  as  a  convenient  designation  for  obscure  cases,  the  exact  nature 
of  which  is  unknown.  In  this  loose  way  the  term  is  applied  to  all 
conditions  in  which  traces  of  inflammation  can  be  found,  and  the  fact 
of  inflammation  is  allowed  to  override  the  question  whether  the 
process  was  primary  or  secondary. 

One  class  of  these  cases  is  that  in  which  the  chief  alteration  is  an 
increase  in  the  connective  tissue  in  some  part  of  the  brain,  but  these 
cases  are  described  in  the  chapter  on  "  Sclerosis  of  the  Brain." 

The  inflammation  which  surrounds  new  growths  in  the  brain  is 
often  chronic,  as  well  as  acute ;  and  acute  cerebritis,  however  caused, 
may  pass  into  a  chronic  stage.  Indications  of  extensive  primary  chronic 
cerebritis,  diffuse  in  distribution,  are  sometimes  found  in  cases  of  dis- 
eases usually  regarded  as  degenerative,  as  general  paralysis  of  the 
insane.  Leucocytal  aggregations  around  the  vessels  and  in  the  cortex 
are  occasionally  met  with  in  this  disease,  but  its  extremely  chronic 
course,  and  the  absence  of  the  headache  which  usually  attends  en- 
cephalitis, discountenance  the  view  that  it  is  primarily  inflammatory 
in  its  nature.  The  term  "  chronic  cerebritis  "  seems,  however,  strictly 
applicable  to  certain  rare  cases  in  which  a  patient  suffers  from  head- 
ache and  other  cerebral  symptoms  (which  may  even  include  optic 
neuritis), — symptoms  that  run  a  chronic  course  and  may  end  in  death. 
After  death  the  only  changes  are  the  microscopical  indications  of 
slight  general  inflammation.  For  instance,  a  woman  aged  thirty-four 
had  attacks  of  epileptoid  nature,  some  vertiginous,  others  with  tran- 
sient loss  of  sight.  Some  months  later  she  suffered  from  severe 
headache,  with  paroxysmal  exacerbations,  accompanied  by  vomiting, 
intense  optic  neuritis,  slight  pyrexia  and  terminal  coma,  the  duration 
of  the  severe  symptoms  having  been  about  six  months.  No  naked-eye 
alterations  were  found  in  the  brain,  but  slight  diffuse  inflammatory 
changes  were  found  throughout  its  substance  on  microscopical  exami- 
nation.f  A  somewhat  analogous  condition  throughout  the  cortex  of 
one  hemisphere  has  been  observed  to  follow  injury  in  childhood,  which 
led  to  mental  defect  and  epilepsy,  with  left-sided  weakness  and  cho- 
reoid  movements,  in  a  case  observed  by  Fletcher  Beach. J 

*  Cases  will  be  found  recorded  by  Keller,  'Brit.  Med.  Journ.,'  1890;  Orlow, 
'  Deufc.  med.  Wocbensch.,'  1890,  and  Bollinger,  '  Munch,  med.  Wochensch.,'  1887  ; 
the  last,  coincident  with  an  ovarian  formation,  being  believed  to  be  primary  and 
due  to  unboiled  milk. 

+  Hughlings  Jackson,  '  Ophth.  Hosp.  Rep.,'  vol.  viii,  p.  445. 

J  '  Journal  of  Med.  Science,'  1887- 


INFLAMMATION. 


469 


Fig.  125. — Chronic  disseminated  scle- 
rotic inflammation  of  pons,  &c.  (see 
text).   (After  Charcot  and  Gombault.) 


A  very  rare  variety  of  cerebritis  is  a  disseminated  form  of  chronic 
inflammation,  sclerotic  and  caseating,  due  probably  to  syphilis.  A 
similar  affection  of  the  spinal  cord 
is  less  rare.  In  the  case  described 
by  Charcot  and  Gombault,  of  which 
the  spinal  lesions  are  shown  in  Fig. 
102,  vol.  i,  p.  337,  similar  foci  of  dis- 
ease existed  in  the  pons,  crura,  and 
optic  nerves,  and  are  shown  in  the 
adjoining  figure  (Fig.  125).  The 
affected  spots  were  grey  in  tint, 
with  yellowish  centres  due  to 
caseation,  such  as  are  represented 
in  the  smaller  figure,  which  is  a  sec- 
tion of  the  diseased  area  in  the  pons 
marked  A.  Both  sixth  nerves  and 
the  right  third  nerve  are  partially 
degenerated.  Thus  in  the  tendency 
to  caseation  the  morbid  process  has 
the  characters  seen  in  syphilitic 
growths,  but  the  histological  cha- 
racters of  the  diseased  areas  were 
those  of  a  sclerotic  inflammation 
rather  than  of  a  growth.  In  these 
points  the  process  has  considerable  analogy  to  that  of  the  more 
common  chronic  syphilitic  meningitis.  The  patient  had  had  syphilis 
nearly  twenty  years  before  the  onset  of  the  symptoms.  Extreme 
mental  dulness  existed,  and  obscured  to  a  considerable  extent  the 
symptoms  due  to  the  intra-cranial  lesions.*  Such  disseminated  in- 
flammation is  related,  on  the  other  hand,  to  insular  sclerosis  (q.  v.). 

It  is  probable  that  certain  rare  forms  of  chronic  softening  of  the 
brain  (described  here  as  such)  are  inflammatory  in  nature,  but  very 
little  is  known  of  their  early  stages,  and  no  distinctly  inflammatory 
process  can  be  traced  in  them  at  the  later  period  in  which  they 
usually  come  under  observation.  There  is  another  remarkable  group 
of  cases,  in  which  the  symptoms  suggest  chronic  focal  inflammation, 
although  the  nature  of  the  lesion  has  not,  I  believe,  been  ascertained, 
nor  have  the  cases  been  hitherto  described.  The  examples  I  have 
seen  have  been  in  men  over  forty-five  years  of  age,  of  gouty  diathesis. 
The  symptoms  have  been  those  of  a  chronic  focal  lesion  at  the  surface 
of  the  brain,  and  have  consisted  in  convulsions  beginning  locally, 
hemiplegic  weakness,  aphasic  disturbance,  delirium,  and  sometimes 
slight  pyrexia.  They  closely  resembled  in  character  and  course  those 
of  a  cerebral  tumour,  but  headache  has  never  been  prominent,  and 
optic  neuritis  has  always  been  absent.  The  course  of  the  affection  was 
marked  by  successive  periods  of  increase,  partial  subsidence,  and  a 
*  Charcot  and  Gombault,  'Arch,  de  Physiologie/  1873,  vol.  v,  p.  143. 


470  BKA1N. 

stationary  state.  The  condition  may,  however,  end  in  death  after  a 
course  of  one  or  two  years.  A  chronic  relapsing  gouty  cerebritia 
affords  the  best  explanation  of  it. 

The  treatment  of  chronic  inflammation,  if  its  existence  is  suspected, 
must  be  in  the  main  directed  against  its  cause.  Improvement  of  the 
general  health  is  of  great  importance,  together  with  tranquillity, 
attention  to  posture,  the  state  of  the  bowels,  &c.  Mercury  seems 
also  to  influence  the  process,  and,  especially  in  the  cases  of  presum- 
ably gouty  cerebritis,  it  should  be  given  by  the  mouth  or  inunction  in 
proportion  to  the  intensity  of  the  lesion,  the  arrest  of  which  some- 
times distinctly  follows  its  use.  It  may  also  be  given  in  syphilitic 
cases,  followed  by  iodide  and  combined  with  tonics. 


ABSCESS   OF   THE   BRAIN. 


Collections  of  pus  may  form  on  the  surface  of  the  brain  or  within 
its  substance.  In  the  former  case,  the  membranes,  thickened  by 
inflammation,  constitute  one  wall  of  the  abscess.  In  the  latter  case, 
which  is  the  more  common,  the  pus  is  separated  from  the  surface  by 
a  layer  of  brain-tissue,  normal  or  only  slightly  damaged,  although  a 
communication  sometimes  exists  through  this  layer  between  the 
interior  of  the  abscess  and  the  surface.  The  white  substance  of  the 
brain  appears  to  be  more  prone  to  suppuration  than  the  grey.  An 
abscess  may  occur  in  any  part,  but  is  most  frequent  in  the  cerebral  or 
cerebellar  hemispheres,  and  is  rare  in  the  central  ganglia,  the  pons, 
medulla,  or  the  middle  lobe  of  the  cerebellum.  Usually  there  is  only 
a  single  abscess,  sometimes  there  are  two  or  more,  and  occasionally 
there  are  many.  There  is  an  increasing  tendency  in  modern  patho- 
looy  to  ascribe  all  forms  to  an  organised  virus,  although  the  theory  is 
as  yet  unproved  as  regards  many  varieties,  especially  the  deeper 
traumatic  forms. 

General  Etiology. — Abscess  of  the  brain  is  usually  due  to  injury 
or  to  suppurative  inflammation,  near  or  distant,  from  which  septic 
material  is  conveyed  to  the  brain.  The  most  common  cause  is  disease 
of  the  bones  of  the  skull,  and  of  such  disease  that  of  the  bony  invest- 
ment of  the  organ  of  hearing  is  the  most  frequent.  Injury  usually 
causes  an  abscess,  sometimes  directly,  but  indirectly  as  a  result  of 
bone  disease  thus  produced.  We  may  conveniently  divide  the  imme- 
diate causes  of  cerebral  abscess  into  two  classes,  the  near  and  the 
distant.  The  near  causes  are  the  most  frequent,  and  to  them  no  less 
than  70  per  cent,  of  the  cases  are  due.*    Ear  disease  causes  42*5  per 

*  One  hundred  and  seventy-three  of  241  cases  collected  from  various  sources,  in- 
cluding the  76  cases  tabulated  by  Gull  and  Sutton  ('  Reynolds'  System  of  Medicine,' 
vol.  ii,  2nd  ed.,  art.  "Abscess  of  the  Brain").  Ear  disease,  102  cases;  injury, 
57  cases. 


ABSCESS.  471 

cent.,  and  injury  24  per  cent.,  while  disease  of  the  nose,  the  orbit, 
non-trauniatic  caiies  of  other  bones,  and  tumour  of  the  brain  give 
rise  to  the  small  remainder.  The  distant  influences  cause  15  per  cent. 
of  the  whole ;  and  the  most  frequent  is  suppuration  elsewhere  than 
near  the  bones  of  the  skull,  and  without  general  pyaemia.  Oidium 
albicans  has  twice  produced  cerebral  abscess,  but  is  merely  a  patholo- 
gical curiosity.     In  the  remaining  15  per  cent,  no  cause  was  detected. 

Age  and  Sex. — Cerebral  abscess  is  far  more  common  in  males  than 
in  females,  the  ratio  being  as  3  to  1.*  The  various  causes  do  not, 
however,  influence  the  two  sexes  in  the  same  proportion.  From  ear 
disease  the  ratio  of  males  to  females  is  2  to  1,  from  injury  5  to  1, 
from  suppuration  elsewhere  4  to  1.  The  greater  liability  of  males  to 
traumatic  abscess  is  readily  explained  by  their  more  frequent  exposure 
to  injury ;  their  greater  liability  to  abscess  from  other  causes  is  less 
easy  to  understand. 

~No  time  of  life,  from  birth  to  old  age,  is  exempt,  but  the  affection  is 
very  rare  during  the  first  year  of  life.  The  following  is  the  relative 
distribution  of  223  cases : 


1 — 9,  24  cases 
10—19,  48    „ 
20—29,  72    „ 


30—39,  29  cases  I  60—69,  7  cases 

40—49,  26    „  70  and  over,  1  case 

50—59,  16    „  1 


Thus  one  third  occur  in  the  third  decade  of  life,  and  one  fifth  in  the 
second.  The  twenty  years  between  ten  and  thirty  yield  more  than  half 
the  cases.  Those  due  to  ear  disease  are  distributed  through  life 
nearly  as  the  total  number.  Traumatic  abscess  is  relatively  more 
frequent  in  early  life,  two  fifths  occurring  under  twenty,  and  nearly  one 
fifth  under  ten.  Pyaemia  never,  and  distant  suppuration  rarely,  causes 
cerebral  abscess  under  twenty. 

Geneeal  Pathology. — Suppuration  in  the  brain,  as  elsewhere, 
must  be  considered  as  a  result  of  inflammation,  and  the  first  stage  of 
the  process  is  apparently  "  red  softening."  In  this  some  pus-corpus- 
cles are  found  in  the  diseased  tissue,  and  if  they  are  numerous  the 
softened  tissue  assumes  a  purulent  aspect.  It  has  been  thought  that 
pus  may  be  formed  without  an  initial  stage  of  simple  inflammatory 
softening  (Huguenin),  but  the  point  is  doubtful.  The  pus  of  a  cere- 
bral abscess  has  a  greenish  tint,  and  usually  an  acid  reaction.  It  is 
foetid  in  one  fifth  of  the  cases  (Mayer)  ;  on  what  the  fcetor  depends 
is  uncertain,  but  it  is  probably  the  result  of  some  special  septic  con- 
dition. Under  the  microscope,  the  pus-cells  in  old  abscesses  are 
indistinct,  having  undergone  granular  disintegration.  The  wall  of 
the  cavity  is  irregular  at  first  (in  some  cases  for  a  long  time),  and 
there  is  a  tendency  to  an  increase  of  the  abscess  by  the  necrosis  of 
portions  of  the  limiting  tissue.  The  "  capsule,"  which  forms  after  a 
time,  is  at  first  thin  and  delicate,  and  gradually  increases  in  firmness 

*  174  males  to  58  females. 


472  BRAIN. 

and  in  thickness.  It  Las  a  smooth  inner  surface,  and  its  substance  is 
composed  of  connective-tissue  elements,  looser  externally  than  in  the 
middle.  Beyond  it  the  brain-tissue  is  often  softened  by  slight  oedema, 
and  in  the  immediate  vicinity  of  the  capsule  there  is  some  fatty  de- 
generation of  the  cerebral  elements.  Doubtless  most  of  the  pus-cells 
are  escaped  leucocytes,  but  some  may  be  formed  from  the  cells  of  the 
neuroglia.  After  the  capsule  is  formed,  pus-cells  still  increase  in  the 
cavity  of  the  abscess,  and,  if  there  is  a  channel  by  which  the  contents 
may  escape,  the  formation  of  pus  may  be  continuous  and  abundant. 

Taking  together  all  cases  of  cerebral  abscess,  it  is  about  equally 
common  for  a  capsule  to  be  present  or  absent.  The  time  at  which 
one  is  formed  is  important,  because,  if  known,  its  presence  affords 
some  indication  of  the  age  of  the  abscess.  The  question  can  only  be 
decided  by  traumatic  cases,  in  which  the  commencement  can  be  accu- 
rately determined.  In  such  cases  the  first  indication  of  a  delicate 
membrane  has  been  seen  at  the  end  of  the  second  week,*  but  it  is 
rarely  distinct  before  the  end  of  the  third  week,f  and  it  only  assumes 
its  character  as  a  well-defined  membrane  with  a  smooth  surface  at 
the  end  of  two  months.  But  an  abscess  may  remain  for  a  much 
longer  time  without  a  capsule.  The  absence  of  this  is  therefore  of 
less  significance  than  its  presence.  The  abscess  may  be  entirely 
closed,  but  not  unfrequently  an  opening,  sometimes  a  fistulous 
channel,  connects  it  with  the  surface  of  the  brain,  especially  when 
there  is  bone  disease,  and  it  may  thus  communicate  with  the  exterior 
of  the  skull.     It  may  also  open  into  the  ventricles. 

The  shape  of  the  encapsuled  abscess  is  more. or  less  rounded,  but  a 
recent  abscess  with  adjacent  sloughing  may  be  irregular  and  ill- 
defined.  Barely  it  consists  only  of  a  fistulous  channel  extending 
from  the  surface  of  the  brain  to  the  ventricles.  The  size  varies  in 
most  cases  between  that  of  a  walnut  and  a  hen's  egg,  but  it  may  be 
so  large  as  to  occupy  apparently  two  thirds  of  the  cerebral  hemi- 
sphere, or,  on  the  other  hand,  it  may  be  no  larger  than  a  pea. 
Multiple  pysemic  abscesses  are  usually  small.  In  about  four  fifths  of 
the  cases  the  abscess  is  single — almost  always  when  of  traumatic 
origin,  and  usually  when  due  to  ear  disease.  On  the  other  hand, 
■when  due  to  distant  suppuration,  the  abscess  is  single  in  less  than 
half  the  cases,  and  in  general  pyaemia  the  abscesses  are  multiple  in 
two  thirds  of  the  cases,  and  they  are  generally  numerous  and  small. 
When  multiple,  it  is  about  as  frequent  for  there  to  be  two,  a  few,  or 
many.  In  half  the  cases  of  multiple  abscesses,  these  are  situated  in 
the  same  hemisphere  of  the  cerebrum.  Suppuration  occurs  in  both 
hemispheres  only  when  due  to  distant  septic  causes.  In  one  quarter 
of  the  cases  the  abscesses  are  situated  in  the  same  side  of  both  cere- 
brum and  cerebellum.  Less  frequently  there  are  multiple  abscesses 
in  the  cerebellum,  and  the  cerebrum  is  free. 

*  Lallemand,  quoted  by  Lebert. 

t  Lei  ert,  '  Virchow's  Arcliiv,'  Bd.  x,  1856,  p.  95. 


ABSCESS.  473 

Suppuration  occurs  in  the  cerebrum  four  times  as  frequently  as  in 
the  cerebellum,  and  is  very  rare  in  the  pons  or  medulla  oblongata.* 
Cerebral  abscess  may  result  from  any  cause,  but  cerebellar  abscess  is 
produced  almost  exclusively  by  ear  disease  or  distant  influences.  In 
the  cerebrum,  suppuration  is  a  little  more  frequent  on  the  right  side 
than  on  the  left,  but  the  two  hemispheres  suffer  almost  equally  from 
distant  causes  and  from  ear  disease.  The  general  excess  of  abscess  in 
the  right  hemisphere  depends  entirely  on  the  influence  of  other  local 
causes  than  ear  disease  ;  these  show  a  remarkable  proclivity  to  affect 
the  right  rather  than  the  left  hemisphere. f  Cerebellar  abscess, 
generally  due  to  ear  disease  or  distant  causes,  corresponds  in  this 
respect  to  the  cerebral  abscesses  of  the  same  origin,  and  the  two 
cerebellar  hemispheres  are  affected  with  equal  frequency.  Suppura- 
tion is  very  rare  in  the  middle  lobe  of  the  cerebellum.  Any  part  of 
the  cerebral  or  cerebellar  hemispheres  may  be  affected,  but  the  posi- 
tion of  an  abscess  due  to  local  dis.ease  is  determined  by  the  situation 
of  its  cause. 

An  abscess,  if  of  any  size,  exerts  pressure  on  adjacent  parts,  although 
not  to  the  same  degree  as  a  tumour.  The  convolutions  over  it  are 
flattened,  and  the  adjacent  brain  is  anaemic  and  often  softened. 
Moreover,  an  abscess  in  the  middle  lobe  of  the  cerebellum  may  cause 
internal  hydrocephalus,  just  as  does  a  tumour  in  the  same  situation. 

Anatomical  Course. — An  abscess  which  has  become  encapsuled 
may  remain  for  a  long  time  stationary.  The  capsule  becomes  thick 
and  tough,  may  even  become  calcified,  and  very  rarely  the  contents 
undergo  a  similar  change.J  More  often,  before  a  capsule  is  formed, 
or  while  this  is  still  thin,  the  abscess  enlarges,  usually  more  in  one 
direction  than  in  another,  and  the  patient  may  die  from  the  extensive 
interference  with  the  cerebral  functions.  It  may  ultimately  burst 
into  one  of  the  lateral  ventricles,  less  commonly  on  the  surface  of  the 
brain.  The  former  occurs  in  one  sixth  of  all  cases ;  most  frequently 
(one  in  three  and  a  half)  in  abscess  from  distant  suppuration  (not 
distinctly  pysemic)  ;  less  commonly  in  abscess  from  ear  disease  (one 
in  five)  ;  still  less  frequently  in  traumatic  cases  (one  in  nine).  The 
effect  of  rupture,  external  or  internal,  is  to  excite  purulent  inflamma- 
tion, of  the  meninges  in  the  one  case,  of  the  lining  membrane  of  the 
ventricles  in  the  other,  and  these  cavities  become  filled  with  pus. 
Purulent  inflammation  of  the  ventricles  may  also  be  excited  without 
actual  rupture.  Occasionally  the  ventricles  contain  an  excess  of 
turbid  fluid  but  no  pus.     An  abscess  due  to  bone  disease  may  com- 

*  Cerebrum  186  times  (not  cases)  ;  cerebellum  41 ;  pons  3 ;  medulla  oblongata 
once. 

f  Thus  injury  caused  abscess  in  the  right  hemisphere  22,  in  the  left  15  times ; 
disease  of  the  nose,  right  7,  left  1 ;  disease  of  the  orbit,  right  3,  left  0  ;  caries  of 
other  bones  than  the  temporal,  right  4,  left  1.  The  greater  influence  of  these  causes 
on  the  right  hemisphere  seems  to  be  too  uniform  to  be  accidental. 

X  Fenman, '  Edin.  Med.  Journ./  October,  1879. 


474  BRAIN. 

municate  with  the  latter  by  a  perforation  through  the  thickened  and 
adherent  membranes,  and  pus  may  thus  be  discharged  from  the 
interior  of  the  brain  through  the  ear,  nose,  &c.  A  very  rare  accident 
is  hemorrhage  into  the  sac  of  an  abscess ;  in  one  case  extensive 
meningeal  hsemorrhage  from  a  vein  occurred  over  an  abscess  just 
beneath  the  surface.  Small  abscesses  are  occasionally  found  in  the 
vicinity  of  a  larger  one,  and  contiguous  abscesses  may  coalesce. 

Special  Etiology  and  Pathology. — A.  Local  Causes. — (1)  Injury. 
— While  the  observed  proportion  of  abscesses  referred  to  injury  is 
about  one  quarter,  it  is  probable  that  the  actual  proportion  is  larger, 
and  that  many  of  the  cases  in  which  no  cause  can  be  traced  are  due 
to  some  unnoticed  or  forgotten  traumatic  influence — a  blow  or  fall  on 
the  skull,  causing  fracture  of  bone  in  some  cases,  or  necrosis,  although 
a  careful  examination  has  sometimes  revealed  no  injury  to  the  bone. 
The  abscess  is  usually  situated  beneath  the  part  struck,  near  the  sur- 
face when  there  is  fracture,  deeply  in  the  brain  when  the  bone  is  unin- 
jured. When  traumatic  necrosis  of  the  bone  exists  the  abscess  is 
sometimes  deep,  sometimes  superficial,  and  its  cavity  often  communi- 
cates with  the  pus  about  the  bone.  In  fracture,  the  inner  table  is 
often  splintered,  spiculse  project  into  the  brain,  and  the  suppuration 
may  be  near  the  surface,  or  it  may  be  deep-seated  and  connected  by 
a  fistulous  passage  with  the  irritating  splinter.  Another  occasional 
traumatic  cause  is  a  penetrating  wound,  as  a  stab  or  a  fall  on  a  pro- 
jectingnail,  &c.  Traumatic  abscesses  in  the  opposite  partof  the  brain 
are  rare  ;  the  bone  has  been  fractured  or  is  intact  at  the  part  struck. 
A  fall  on  the  occiput  has  caused  an  abscess  in  the  frontal  lobe,  and  a 
fall  on  the  forehead,  fracturing  the  bone,  has  caused  an  abscess  in  the 
corresponding  frontal  lobe,  and  another  in  the  cerebellum. 

(2)  Disease  of  the  ear  is  the  most  frequent  cause  of  abscess.  The 
ear  disease  is  usually  chronic,  and  has  existed  for  several  years — five, 
ten,  fifteen,  and  even  twenty  or  twenty-five  years — before  it  caused  the 
abscess ;  very  rarely  the  mischief  has  existed  only  for  a  few  weeks  or 
months.  There  is  usually  caries  of  the  bone,  following  an  inflamma- 
tion of  the  middle  ear  or  mastoid  cells,  set  up  by  cold,  injury,  or  more 
frequently  by  extension  from  the  throat,  sometimes  by  a  polypus  in 
the  external  meatus.  A  purulent  discharge  from  the  ear  (the  tympa- 
nitic membrane  being  perforated)  has  usually  existed  for  a  long  time. 
In  many  cases  the  abscess  has  followed  the  arrest  of  this  discharge; 
less  commonly  it  has  followed  an  increase  in  the  ear  mischief,  due 
to  fresh  cold  or  to  a  blow  on  the  ear. 

Occasionally  there  is  suppurative  inflammation  of  the  middle  ear 
or  mastoid  cells,  and  no  bone  disease.  The  tympanic  cavity  and 
mastoid  cells  are  separated  from  the  interior  of  the  skull  only  by  a 
thin  layer  of  bone,  which  is  readily  destroyed,  and,  moreover,  this 
is  perforated  by  small  veins  which  pass  from  the  tympanum  to 
the   superior  petrosal,  and  from   the    mastoid  cells    to    the    lateral 


ABSCESS. 


475 


sinus.  Abscess  from  ear 
disease  is  twice  as  fre- 
quent in  the  cerebrum  as 
in  the  cerebellum.  In  the 
former  it  is  usually  in  the 
temporo-sphenoidal  lobe, 
occasionally  in  the  fron- 
tal, rarely  in  the  occipital. 
and  still  more  rarely  in 
the  parietal.  Abscess  of 
the  cerebellum  is  almost 
invariably  in  the  hemi- 
sphere. In  rare  cases  the 
abscess  is  seated  in  the 
pons  Varolii.  Multiple 
abscesses  from  ear  disease 
(met  with  only  in  13  per 
cent,  of  the  cases  due  to 
this  cause)  may  be  in  the 
same  cerebral  or  cerebellar 
hemisphere,  or  in  both  ; 
thev  are  always  on  the 
same  side. 

The  membranes  are  usu- 
ally thickened  over  the 
diseased  bone,  but  ai-e 
sometimes  normal.  Co- 
agula  of  old  date,  some- 
times breaking  down,  are 
occasionally  found  in  the 
petrosal  or  lateral  sinus. 
The  abscess  is  rarely  su- 
perficial ;  commonly  it  is 
seated  within  the  brain. 
separated  from  the  sur- 
face by  normal  cerebral 
substance.  In  other  cases 
an  opening  exists  in  this 
tissue  and  in  the  adhe- 
rent membranes,  so  that 
the  sac  of  the  abscess  may 
communicate  with  the 
diseased  bone,  and  thus 
with  the  exterior.  In 
some  of  these  cases  it  is 
probable  that  the  abscess 
commenced  in  the  interior 


Fig.  126. 


Fig.  127. 
Figs.  126  and  127. — Abscess  of  right  temporal  lobe, 
due  to  ear  disease.     The  enlargement  caused  by  the 
abscess  is  shown  in  Fig.  126  ;  in  Fig.  127  the  cavity 
is  opened. 


476  ERAIN. 

of  the  brain,  and  extended  outwards  towards  the  diseased  bone, 
until  a  communication  was  established. 

The  mechanism  by  which  an  abscess  within  the  brain  is  produced  by 
-ear  disease,  not  directly  continuous  with  the  cerebral  suppuration, 
must  be  by  the  passage  of  septic  material  from  the  bone  disease  into 
the  cerebral  substance.  The  arrest  or  retardation  of  the  circulation  in 
the  sinuses  may  permit  this  material  to  reach  the  brain  by  the  veins 
which,  from  ear  and  brain,  pour  their  blood  into  the  sinuses  ;  but  while 
the  current  is  still  flowing  this  can  scarcely  occur.*  It  is  not  impro- 
bable, however,  that  the  perivascular  lymphatic  canals  are  the  paths  by 
which  the  infection  generally  travels;  in  these  inflammation  may 
extend  by  contiguity,  and  does  so  rapidly  when  septic  in  nature.  The 
internal  carotid  artery  sends  twigs  to  the  interior  of  the  tympanic 
cavity,  and  the  perivascular  sheaths  of  these  have  been  thought 
to  be  the  chief  channels  of  infection  (Binswanger),  but  the  rarity  of 
abscess  in  the  frontal  lobes  in  consequence  of  ear  disease  renders  this 
improbable. 

The  roof  of  the  tympanum  forms  part  of  the  middle  fossa  of  the 
base  of  the  skull,  on  which  lies  the  temporo-sphenoidal  lobe,  and  the 
superior  petrosal  sinus  receives  blood  from  both.  The  bone  which 
separates  the  mastoid  cells  from  the  intra-cranial  cavity  forms  part  of 
the  posterior  fossa  beneath  the  tentorium,  and  on  it  the  cerebellar 
hemisphere  lies,  while  the  lateral  sinus  receives  blood  from  both. 
Hence,  as  Toynbee  first  pointed  out,  disease  of  the  tympanum  causes 
chiefly  cerebral  abscess,  that  of  the  mastoid  cells  cerebellar  abscess. 
Exceptions  to  the  rule  are,  however,  occasionally  met  with. 

Chronic  disease  of  the  nose  is  an  occasional  but  rare  cause  of  cerebral 
abscess  (6  cases  of  240).  There  is  usually  bone  disease,  involving  the 
nasal,  sphenoid,  or  ethmoid  bones,  and  often  syphilitic  in  origin.  In 
some  cases  the  disease  is  confined  to  the  nasal  mucous  membrane,  just 
as  the  ear  disease  maybe  limited  to  the  mucous  membrane  of  the  tym- 
panum. The  abscess,  single  in  two  thirds  of  the  cases,  is  almost  invari- 
ably situated  in  the  frontal  lobe;  in  only  one  recorded  case  was  it  in  the 
parietal  lobe.  Meningitis  frequently  co-exists.  When  there  is  bone 
disease  the  sac  of  the  abscess  may  communicate  with  this,  so  that  pus 
is  discharged  from  the  interior  of  the  brain  through  the  nose. 

Still  rarer  as  a  cause  of  cerebral  abscess  is  orbital  disease  (three 
cases).  In  two  there  was  an  abscess  in  the  orbit,  in  one  a  growth. 
The  suppuration  was  always  in  the  frontal  lobe,  and  single. 

Caries  of  other  bones  than  temporal,  and  not  due  to  injury,  very 
rarely  causes  cerebral  abscess.  Five  cases  only  were  of  this  nature. 
In  one  the  caries  was  syphilitic,  in  one  cancerous.  The  abscess  in 
each  case  was  single. 

The  last  local  cause  of  abscess  (extremely  rare)  is  a  tubercular 
growth  in  the  brain,  which  has  been  known  to  break  down  into  a 

*  Adams, '  Glasgow  Med.  Journ.,'  vol.  xv,  1881,  June,  p.  424.  The  problem  of 
the  mechanism  is  well  discussed  in  this  paper. 


ABSCESS.  477 

collection  of  pus.*  Other  tubercular  tumours,  and  other  evidence 
of  tubercle,  are  usually  present,  and  indicate  the  origin  of  the 
abscess. 

The  Distant  Causes  of  cerebral  abscess  are  morbid  processes  iu  some 
other  part  of  the  body  by  whicb  septic  material  is  produced,  and  this, 
passing  into  the  blood-curreut,  doubtless  causes  the  abscess  of  the 
brain  by  septic  embolism.  The  reality  of  this  mechauism  has  been 
demonstrated  in  one  case  ;  a  cerebral  abscess,  secondary  to  suppuration 
in  the  lung,  was  found  to  contain  lung-pigment.f  Since  embolic 
processes  are  rarely  single,  cerebral  abscess  from  distant  causes  is  fre- 
quently multiple.  From  local  causes  the  proportion  of  cases  in  which 
there  are  more  than  one  abscess  is  only  13"5  per  cent. ;  from  distant 
causes  it  is  61  per  cent. 

In  general  pyaemia  the  brain  is  far  less  frequently  the  seat  of  the 
secondary  suppuration  than  are  some  other  organs,  and  it  is  probable 
that  the  brain  is  less  frequently  affected  in  pyaemia  due  to  injury  than 
in  pyaemia  due  to  non-traumatic  causes.  Only  9  of  234  cases  of 
cerebral  abscess  occurred  as  part  of  general  pyaemia,  and  in  only  one 
of  these  was  the  pyaemia  secondary  to  injury  ;  in  one  it  was  post- 
puerperal  ;  in  three  it  was  secondary  to  abscesses  elsewhere,  and  in  two 
to  abscess  of  the  liver  produced  by  dysentery.  In  one  third  of  the 
cases  the  abscess  was  single,  in  another  third  there  were  from  two  to 
five  abscesses,  in  the  remaining  third  numerous  small  foci  of  suppura- 
tion were  scattered  through  the  brain,  as  many  as  sixty-eight  being 
counted  in  one  case.  J 

In  an  important  group  of  cases  (about  10  per  cent,  of  the  whole) 
an  abscess  of  the  brain  is  the  result  of  suppuration  elsewhere, 
generally  in  the  lung,  without  indications  of  general  pyaemia.  This 
form  bas  been  termed  "  pulmonal  cerebral  abscess  ;"§  the  limitation 
of  tbe  secondary  suppuration  to  the  brain  is  remarkable.  Pneumonia, 
imperfectly  resolved  and  breaking  down  ;  suppurating  cavities  in  the 
lungs,  left  by  such  pneumonia,  or  the  result  of  bronchial  dilatation ; 
simple  foetid  bronchitis ;  and  especially  empyema,  are  the  chief 
causal  conditions.  ||  It  never  results  from  true  tubercular  cavities. 
Suppuration  in  the  abdominal  cavity  is  a  less  common  cause,  and 
still  rarer  is  suppuration  connected  with  the  limbs.     The  abscess  is 

*  For  an  instance  see  D'Espine,  '  Rev.  med.  de  la  Suisse  Roinande,'  1886,  p.  371. 

f  Bottcher,  '  Petersb.  rned.  Zeitschrift,'  1869,  and  '  Virchow's  Jahresbericht/ 
1869,  ii,  51. 

X  It  should  be  noted  that  pyaemia  is  not  always  the  cause  of  a  cerebral  abscess 
with  which  it  co-exists.  The  abscess  may  be  of  local  origin,  and  the  pyseinia  may 
be  the  result  either  of  the  abscess  or  of  the  local  cause  of  the  abscess. 

§  Martins, '  Hirnabscesse,'  Berlin,  1892. 

!|  In  diseases  within  the  lung-substance  capable  of  causing  it,  cerebral  abscess 
appears  to   occur   in   about   8   per   cent,   according   to   some   facts   published   by 
R.  Nather  ('  Deutsche  Archiv  f.  klin.  Med.,'  xxxiv,  p.  169).     Of  ninety-eight  cases  ' 
(forty-nine  of  gangrene  of  the  lungs,  thirty- seven  of  fcetid  bronchitis,  and  twelve 
of  bronchial  dilatation)  there  was  cerebral  abscess  in  eight. 


478  BRAIN. 

single  in  about  half  the  cases,  and  is  generally  situated  in  the  cerebral 
hemispheres,  especially  in  the  posterior  lobe.  The  cerebellum  is  not 
often  affected  from  this  cause,  and  never  suffers  alone.  Numerous 
small  foci  of  suppuration  have  been  met  with,  but  far  less  frequently 
than  from  general  pyaemia,  which  is  a  less  common  cause. 

Oidium  Albicans. — Strange  as  it  may  seem,  in  two  recorded  cases  * 
thrush  in  the  mouth  was  a  cause  of  abscess  of  the  brain.  One  patient 
was  an  infant,  the  other  an  adult.  An  abundant  growth  of  oidium 
occupied  the  mouth  and  throat,  and  the  brain  was  studded  with  small 
abscesses,  containing  the  same  fungus.  The  oidium  in  the  pharynx 
has  been  traced  into  the  epithelial  layer  of  the  mucous  membrane,f 
and  into  the  interior  of  the  vessels,  and  it  doubtless  thus  finds  its  way, 
with  the  blood-current,  to  distant  parts. 

There  remains  about  a  sixth  of  the  total  number  of  cases  in  which 
no  cause  for  the  abscess  could  be  discovered.  In  two  or  three  of  these 
congenital  heart  disease  existed,  and  was  regarded  as  a  cause  of  the 
abscess,  but  no  mechanism  by  which  the  result  could  be  produced  has 
been  suggested.  In  many  of  these  unexplained  cases  it  is  highly  pro- 
bable that  the  abscess  was  really  traumatic,  the  result  of  some  for- 
gotten fall  or  blow.  In  a  few  cases  in  which  the  abscess  was  situated 
in  the  temporo-sphenoidal  lobe,  it  may  have  been  the  consequence  of 
disease  of  the  tympanum,  overlooked  because  there  was  no  caries  of 
the  bone.  It  is  still  an  open  question  whether  all  cases  can  be  thus 
explained,  and  whether  there  is  oris  not  an  idiopathic  form  of  abscess 
of  the  brain.  If  so,  it  must  be  ascribed  to  the  localisation  within  the 
brain  of  a  specific  virus,  probably  of  low  intensity,  and  slow,  limited 
influence.  The  rare  actinomycosis  of  the  brain  (p.  467)  is,  practically, 
a  form  of  abscess. 

Symptoms. — A  cerebral  abscess  originates  in  inflammation,  and 
constitutes,  when  developed,  a  foreign  mass  within  the  brain.  Ulti- 
mately, secondary  processes  occur,  adjacent  cedeina  and  inflammation, 
meningitis,  effusion  into  the  ventricles  ;  or  the  abscess  ruptures  exter- 
nally or  internally.  In  some  cases  of  acute  and  severe  disease,  the  initial 
suppurative  inflammation  progresses  with  rapidity  until  it  destroys 
life.     In  other  cases  it  passes  into  a  stationary  condition  for  a  time. 

The  symptoms  correspond  to  the  morbid  process,  being  at  first 
"those  of  inflammation,  trifling  or  grave.  In  acute  abscess  they  are 
severe,  and  continue  to  the  end.  In  the  cases  of  chronic  abscess  they 
are  sometimes  at  first  so  slight  as  to  be  overlooked,  and  may  also  be 
trifling  when  the  process  has  become  comparatively  stationary,  in 
what  is  termed  the  "  latent  period."  Ultimately  acute  symptoms 
supervene  even  in  such  cases,  it  may  be  suddenly,  and  run  a  rapid 
course,  to  end  in  death.     These  constitute  the  "  terminal  stage." 

*  Zenker,  'Bericht  der   Gesellsch.  f.  Nat.  u.  Heilk.,'  Dresden,  1861,  p.  62; 
Kibbert, « Berl.  kl.  Wochenschr.,'  1879,  p.  617. 
f  Wagner,  '  Jabrb.  f .  Kinderheilk.,'  i,  p.  56. 


ABSCESS.  479 

The  symptoms  that  are  produced  are  thus  in  part  those  of  inflam- 
mation ;  in  part  they  are  those  of  an  irritating  foreign  body,  such  as 
a  tumour  may  cause.  Their  character  is  determined  by  the  character 
of  the  morbid  process,  and  by  its  seat ;  but  local  symptoms,  such  as 
afford  an  indication  of  the  position  of  the  disease,  are  absent  far  more 
frequently  than  in  the  case  of  tumour.  This  is  due  to  two  circum- 
stances. First,  abscesses  are  often  situated  in  parts  of  the  brain,  as 
the  temporo-sphenoidal  and  frontal  lobes,  in  which  a  lesion  often  causes 
no  local  symptoms,  whatever  be  its  nature.  Secondly,  the  pressure  of 
a  slowly  developed  abscess  produces  less  grave  effects  than  does  that 
of  a  tumour. 

Every  gradation  is  met  with  between  the  cases  of  acute  abscess 
with  severe  cerebral  symptoms,  running  a  rapid  course,  and  ending 
fatally  in  two  or  three  weeks,  and  those  chronic  forms  in  which  the 
initial  disturbance  is  so  slight  as  to  be  unnoticed;  while  the 
stationary  period  is  marked  by  complete  latency,  so  that  the  existence 
of  the  disease  is  unsuspected  until  the  rupture  of  the  abscess,  or  some 
acute  consequence,  causes  death.  In  cases  of  pyaemia,  moreover,  the 
existence  of  suppuration  in  the  brain  may  be  unsuspected,  because 
its  symptoms  are  masked  by  those  of  the  general  disease. 

Early  symptoms  are  most  frequent  in  cases  of  traumatic  abscess, 
because  the  initial  inflammation  is  most  extensive.  When  present 
they  resemble  those  of  meningitis,  which  often  co-exists  ;  there  is  head- 
ache, frequently  local,  vomiting,  and  febrile  disturbance,  attended  in 
severe  cases  by  rigors.  Convulsions  are  less  common;  when  general 
they  indicate  that  the  mischief  is  extensive  and  severe.  Local  convul- 
sions occur  only  when  the  disease  is  near  or  beneath  the  central 
convolutions.  Paralysis*  and  delirium  are  rarely  early  symptoms. 
In  the  cases  of  acute  abscess  these  effects  pass  on  into  those  presently 
to  be  described,  such  as  attend  the  terminal  stage  of  chronic  abscess, 
and  usually  consist  in  delirium,  convulsions,  and  paralysis  on  the 
side  opposite  to  the  abscess.  The  temperature  is  raised,  and  severe 
rigors  may  occur.  Delirium  gives  place  to  stupor,  which  deepens 
into  final  coma. 

These  cases  of  acute  abscess  are  most  frequently  the  result  of 
injury,  next  of  distant  suppuration  and  pysemic  embolism,  while  they 
are  not  common  as  a  result  of  otitis.  The  duration  of  the  symptoms 
is  in  most  cases  from  ten  to  thirty  days,  but  sometimes  death  occurs 
at  the  end  of  a  week,  and  suppuration  has  been  found  at  the  end  of 
thirty-six  hours  after  an  injury. f  A  communication  between  the 
lateral  ventricle  and  the  surface  has  been  established  in  twelve  days.t 
The  "  latent  period  "  of  chronic  abscess  varies  much  in  duration, 

*  Such  cortical  motor  symptoms  are  met  with  especially  in  abscess  from  lung 
disease,  in  which  an  embolic  process  occurs  in  the  region  of  the  middle  cerebral 
artery. 

f  Martins,  loc.  cit. 

j  Southam,  «  Brit.  Med.  Journ.,'  1892. 


480  BRAIN. 

from  two  or  three  months  to  several  years.  When,  as  is  often  the 
case,  the  initial  symptoms  were  slight,  its  commencement  cannot  be 
fixed,  bnt  it  seems  to  be  occasionally  very  prolonged ;  an  abscess 
which  has  become  enclosed  in  a  thick  capsule  has  apparently  remained 
for  as  much  as  seven  years  in  one  case,  and  in  another  for  twenty, 
without  exciting  symptoms.  But  the  latency  is  often  imperfect; 
slight  symptoms  exist,  their  nature  being  misunderstood.  Headache 
is  the  most  common,  usually  not  severe.  In  cases  of  ear  disease  it 
sometimes  alternates  with  otorrhoea.  Convulsions  may  have  occurred, 
and  have  been  thought  to  be  due  to  idiopathic  epilepsy.  In  a  few 
cases  slight  mental  disturbance,  usually  melancholic,  has  been  the 
only  symptom. 

The  latent  period  may  end  suddenly  or  gradually.  The  terminal 
stage  is  sometimes  preceded  by  a  gradual  increase  in  the  headache  or 
mental  symptoms,  by  restlessness,  irritability  of  temper,  or  depression. 
Rarely,  acute  symptoms  develop  and  subside,  the  latency  continuing 
as  before.  Such  an  attack  is  usually  due  to  intercurrent  meningitis. 
As  a  rule,  when  the  latency  is  once  broken,  the  active  symptoms 
increase  until  death  occurs. 

The  characteristic  symptoms  of  abscess,  therefore,  are  those  of  the 
terminal  stage ;  these  in  acute  cases  are  continuous  with  the  initial 
disturbance,  and  even  in  chronic  abscess  they  sometimes  exist  in  slight 
degree  during  the  latent  stage,  especially  towards  its  close.  Like 
those  of  tumour,  they  may  be  divided  into  general  and  focal,  but  the 
former  are  the  more  important,  and  exist  alone  more  frequently  than 
in  the  case  of  tumour. 

Headache  is  as  frequent  as  it  is  in  tumour,  and  presents  similar 
characters.  It  is  more  often  moderate  in  degree,  but  now  and  then 
is  extremely  severe,  and  has  even  been  known  to  kill  the  patient  by 
its  violence.  It  is  often  increased  by  posture,  and  by  muscular  effort 
that  causes  mechanical  congestion.  Its  position  corresponds  with  the 
seat  of  the  disease,  and  more  frequently  than  in  the  case  of  tumour  j 
but  it  is  sometimes  referred  to  a  different  part  of  the  head,  and  the 
statements  made  in  a  subsequent  page  regarding  the  pain  of  tumour 
are  applicable  also  to  that  of  abscess.  In  traumatic  abscess  the  pain 
is  generally  referred  to  the  situation  of  the  lesion,  but  in  abscess  from 
ear  disease  pain  in  the  ear  often  blends  with  general  pain  in  the  head. 
Occasionally  the  pain  varies  in  seat  from  day  to  day.  Once 
established,  it  usually  persists.  , 

Vomiting  is  often  associated  with  the  headache,  and  is  especially 
frequent  in  cerebellar  abscess.  The  same  is  true  of  giddiness.  Al- 
though less  frequent  in  cerebral  than  in  cerebellar  abscess,  both  these 
symptoms  are  occasionally  very  marked  in  the  former. 

Optic  neuritis  is  less  common  in  abscess  than  in  tumour,  but  is 
certainly  more  frequent  than  published  facts  suggest.  It  may  occur 
in  both  acute  and  chronic  abscess,  and  probably  the  ophthalmoscope 
would  show  that,  during  the  latent  stage,  it  frequently  precedes  the 


ABSCESS.  481 

onset  of  the  more  acute  symptoms,  but  it  is  rather  more  common  in 
traumatic  abscess  than  in  other  forms.  The  aspect  of  the  neuritis  is 
similar  to  that  which  results  from  cerebral  tumour. 

General  convulsions,  resembling  epileptic  fits,  are  frequent  at  either 
the  beginning  or  end  of  the  terminal  period.  Convulsions  which  are 
local  in  their  distribution  or  commencement,  and  of  cortical  significance, 
are  less  common,  and  are  usually  associated  with  defective  power. 
Eigidity  of  the  neck,  with  retraction  of  the  head  and  slight  opis- 
thotonos, occurs  chiefly  when  rupture  has  excited  purulent  inflamma- 
tion about  the  pons  and  medulla. 

Paralysis,  usually  hemiplegic  in  distribution,  occurs  in  about  half 
the  cases.  It  is  often  slight  and  very  rarely  absolute.  Sometimes  it 
succeeds  a  unilateral  convulsion.  It  is  considerable  only  when  the 
disease  involves  the  motor  fibres  or  cortex,  and  then  may  affect  only 
the  face,  or  the  arm  and  face. 

Sensation  is  affected  much  less  frequently  than  motion.  When 
there  is  hemiplegia  there  is  occasionally  diminished  sensibility,  but 
this  has  been  a  conspicuous  symptom  only  in  a  few  cases  in  which  the 
internal  capsule  may  have  been  compressed  by  an  abscess  in  the  optic 
thalamus,  or  posterior  part  of  the  cerebral  hemisphere,  or  in  cases  of 
abscess  of  the  cerebellum  compressing  the  pons.  The  cranial  nerves 
sometimes  suffer,  but  more  often  from  associated  bone  disease  or 
meningitis  than  from  the  abscess  itself.  The  olfactory  nerves  suffer 
only  in  disease  of  the  nose.  The  optic  nerves  are  often  damaged  by 
optic  nemitis,  and  this  may  cause  loss  of  sight,  but  vision  is  rarely 
affected  by  the  direct  influence  of  the  abscess.  The  pupils  may  be 
unequal,  and  sometimes  irregular,  but  as  a  rule  they  are  normal  until 
the  terminal  coma  sets  in.  The  ocular  muscles  are  sometimes  involved  ; 
there  is  rarely  paralysis  of  a  single  nerve,  but  there  may  be  ptosis, 
generally  ou  the  same  side  as  the!  abscess.  The  movement  of  the  eye- 
balls is  sometimes  impaired  in  an  irregular  manner,  when  a  cerebellar 
abscess  presses  on  the  pons,  and  there  may  then  be  pain  in  the  region  of 
the  fifth  nerve.  Palsy  of  the  facial  nerve  and  deafness  are  common  in 
abscess  from  ear  disease,  but  are  the  result  of  the  caries  of  the  bone. 
Speech  is  often  slow,  but  articulation  and  deglutition  are  definitely 
impaired  only  when  the  pons  is  the  seat  of  suppuration  or  is  compressed. 

Mental  disturbance  is  among  the  most  frequent  of  the  terminal 
symptoms — stupor,  deepening  to  coma,  and  often  preceded  by  delirium, 
or  by  conspicuous  mental  depression  or  failure,  which  may  terminate 
the  latent  stage.  When  the  abscess  is  seated  on  the  left  side,  cere- 
bral impairment  of  speech  is  occasionally  observed. 

Of  the  symptoms  outside  the  nervous  system,  pyrexia  is  the  most 
important.  It  is  very  frequent  during  the  terminal  stage,  and  some- 
times precedes  it ;  while  in  cases  of  acute  abscess  it  is  present,  in 
greater  or  less  degree,  throughout  the  disease.  Rigors  often  accom- 
pany it,  followed  by  sweating,  so  that  the  case  resembles  inter- 
mittent fever.  The  pulse  may  be  frequent,  especially  when  there 
VOL.  II.  31 


482  BKAIN. 

is  fever,  but  towards  the  end  (and  sometimes  throughout)  it  may  be 
infrequent,  falling  to  50,  40,  or  30.  A  dry  brown  tongue  and  con- 
stipation are  sometimes  attended  by  profound  anorexia,  and  often  by 
vomiting.     The  sphincters  are  rarely  affected  until  the  final  period. 

Symptoms  according  to  Seat. — The  general  symptoms,  headache, 
delirium,  terminal  coma,  optic  neuritis,  &c,  are  irrespective  of  the 
seat  of  the  abscess,  and  the  chief  local  symptoms  have  been  already 
mentioned.  It  is  important  to  remember  that  they  are  seldom 
present  when  the  abscess  is  in  the  pre-central  region  of  the  frontal 
lobe,  or  in  the  temporo-sphenoidal  lobe,  and  when  an  abscess  in  the 
central  ganglia  is  small.  Otherwise  the  statements  to  be  made 
regarding  tumour  apply  also  to  abscess. 

The  headache  due  to  a  cerebellar  abscess  is  usually  occipital,  often, 
in  ear  disease,  darting  from  the  ear  to  the  occiput,  and  sometimes  it  is  very 
severe.  Vomiting  is  frequent,  and  occasionally  there  is  typical  cere- 
bellar inco-ordination,  probably  in  consequence  of  pressure  on  the 
middle  lobe.  The  symptoms  that  may  be  caused  by  compression  of 
the  pons  have  been  already  mentioned.  Rigidity  of  the  neck,  pro- 
bably due  to  slight  meningitis,  occurs  without  rupture. 

A  small  abscess  in  the  pons  usually  causes  no  symptoms  till  it 
bursts,  but  alternate  hemiplegia,  or  even  bilateral  paralysis  of  limbs 
and  face,  has  been  observed,  and  is  common  if  the  abscess  is  large. 

When  several  abscesses  are  present,  unless  they  are  very  small,  one 
is  usually  much  larger  than  the  rest,  and  determines  the  symptoms. 
The  minute  abscesses  which  are  occasionally  scattered  through  the 
brain  in  great  numbers  in  pyseinia  seldom  cause  definite  symptoms. 

Rupture. — The  grave  disturbance  which  marks  the  terminal  period  is 
usually  due  to  the  occurrence  of  inflammatory  oedema  and  softening 
round  the  abscess,  induced  by  its  extension,  and  sometimes  by  some 
secondary  influence,  such  as  a  blow  on  the  head,  or  exposure  to  cold. 
Death  is  sometimes  due  to  the  rupture  of  the  abscess,  the  frequency 
of  which  has  been  already  mentioned.  External  rupture  of  a  cerebral 
abscess  may  cause  symptoms  of  violent  meningitis,  rapidly  fatal,  but 
frequently  the  adhesions  of  the  membranes  prevent  the  escape  of  the 
pus  on  the  surface  of  the  brain.  A  cerebellar  abscess  more  often 
ruptures  into  the  membranes ;  and  the  acute  purulent  inflammation 
which  results  around  the  pons  and  medulla  usually  causes  rigidity 
of  the  neck,  retraction  of  the  head,  slight  opisthotonos,  and  even 
rigidity  of  the  masseters  and  convulsive  shocks. 

Rupture  into  the  lateral  ventricles  occurs  in  abscesses  in  all  parts 
of  the  cerebrum,  but  is  especially  frequent  in  those  of  the  temporo- 
sphenoidal  lobe.  The  symptoms  produced  bear  considerable  resem- 
blance to  those  of  ventricular  haemorrhage,  consisting  of  convulsions 
and  coma  ;  they  rapidly  deepen  to  death. 

Occasionally  a  patient  with  abscess  of  the  brain  dies  suddenly,  and 
the  post-mortem  examination  fails  to  reveal  the  mechanism  by  which 
death  was  produced.     A  similar  event  occurs  in  tumour. 


ABSCESS.  483 

CouitsE. — The  varieties  which  the  disease  presents  in  its  course 
have  been  already  mentioned.  Thej  may  be  divided  into  the  following 
groups,  between  which,  however,  intermediate  forms  occur : 

I.  Acute  abscess,  with  the  early  inflammatory  symptoms  progress- 
ing without  considerable  diminution  into  a  terminal  stage,  and  the 
whole  affection  running  its  course  in  from  one  to  four  weeks. 

II.  Chronic  abscess,  in  which  a  latent  period  intervenes  between  the 
early  and  late  cerebral  disturbance,  and  in  which  the  early  symptoms 
are  often  so  slight  as  to  be  unnoticed. 

(a)  The  latency  is  incomplete  ;  some  chronic  cerebral  symptoms 
occur — headache,  convulsions,  or  mental  depression  ;  and  these  increase 
and  pass  gradually  into  the  more  severe  terminal  stage. 

(6)  The  latency  is  complete,  and  the  existence  of  any  cerebral  mis- 
chief may  be  unsuspected  until — 

1.  The  terminal  stage  develops,  usually  suddenly. 

2.  Or  death  occurs  from  the  cause  of  the  abscess,  or  from  some 
sudden  effect  of  the  cerebral  lesion.  For  instance,  a  boy  was  struck 
on  the  head  by  a  cricket  ball ;  after  a  day  or  two  he  seemed  well. 
Some  months  later  he  was  found  on  his  face  in  bed,  dead,  a  sure  sign 
of  death  from  a  convulsion.  Post  mortem  an  abscess  of  the  brain  was 
found. 

3.  Or  death  occurs  from  some  intercurrent  disease.  Such  cases 
are  very  rare.  The  abscess  has  remained  stationary  for  a  long 
time ;  the  capsule  has  become  thick  and  even  calcified,  and  the 
contents  have  become  inspissated,  Such  cases  are  the  nearest  known 
approximation  to  recovery  from  an  abscess.  But  the  disease  is  still 
there,  and  its  quiescence  can  hardly  be  accepted  as  proof  of  entire 
innocuity,  since  death  has  resulted  from  an  abscess  after  a  latent 
period  of  twenty  years. 

When  nervous  symptoms  are  once  developed  they  usually  run  a  rapid 
course.  Taking  all  cases  in  which  the  duration  was  noted,  the  symptoms 
last  less  than  five  days  in  a  fifth,  in  a  third  they  do  not  exceed  ten 
days,  in  about  half  the  cases  they  do  not  exceed  a  fortnight,  and  in 
three  quarters  of  the  cases  they  do  not  exceed  a  month.  On  the 
whole,  the  symptoms  are  more  often  rapid  in  chronic  abscess  from 
ear  disease  (in  which  they  usually  succeed  a  latent  stage)  than  in 
traumatic  cases  (in  which  there  is  often  no  latency).  Of  traumatic 
cases,  only  an  eighth  lasted  less  than  five  days,  a  quarter  did  not 
exceed  ten  days,  and  five  eighths  did  not  exceed  a  month.  On  the 
other  hand,  of  cases  secondary  to  ear  disease,  in  no  less  than  a  quarter 
the  symptoms  lasted  less  than  five  days,  in  a  third  they  did  not  exceed 
ten  days,  and  in  only  one  eighth  did  they  exceed  a  month. 

Diagnosis. — The  extreme  variability  and  frequeut  latency  of  the 
course  of  cerebral  abscess  often  render  its  diagnosis  difficult  and  even 
impossible,  and  no  brain  disease  of  equal  gravity  so  often  escapes 
recognition.     The  cerebral  symptoms  are  in  themselves  equivocal,  and 


484  BEAIN. 

are  common  to  other  diseases,  from,  simple  inflammation  on  the  one 
hand  to  a  tumour  on  the  other.  They  often  derive  significance  from  their 
association  with  general  symptoms  suggesting  a  suppurative  process, 
especially  fever  and  rigors,  but  the  most  important  point  is  their  combi- 
nation with  a  cause  which  is  known  to  be  capable  of  giving  rise  to  cere- 
bral abscess,  as  injury,  chronic  ear  disease,  or  distant  suppuration,  espe- 
cially in  the  lungs.  Such  indications  are  present  in  about  three  quar- 
ters of  the  cases.  The  greatest  difficulty  is  presented  by  those  in  which 
latency  is  complete,  and  the  terminal  symptoms  are  sudden  in  onset 
and  rapid  in  course  ;  the  indications  of  a  chronic  cerebral  disease  are 
then  absent,  and  the  terminal  symptoms  resemble  those  of  apoplexy. 
If  sudden  rupture  into  the  ventricles  causes  merely  convulsions,  coma, 
and  death,  the  nature  of  the  case  can  be  suspected  only  when  a  cause 
for  abscess  exists.  It  is  of  great  importance,  therefore,  to  make  a 
careful  inquiry  or  search  for  the  slight  but  significant  symptoms  that 
so  often  precede  the  terminal  attack.  In  many  cases,  moreover,  au 
ophthalmoscopic  examination  would  reveal  optic  neuritis,  which  is  of 
weight,  although  not  actually  conclusive  in  cases  of  chronic  ear  disease, 
by  which  it  seems  sometimes  to  be  produced  even  without  the  mechan- 
ism of  meningitis. 

When  chronic  brain  symptoms  are  pronounced,  the  chief  distinction 
has  to'  be  from  tumour.  The  absence  of  a  cause  of  abscess  is  in 
favour  of  tumour.  Although  injury  may  give  rise  to  either  disease, 
a  orowth  is  a  much  rarer  consequence  than  abscess,  is  later  in  develop- 
ment, more  uniformly  progressive  in  course,  and  it  more  often 
involves  the  cranial  nerves.  The  rapid  development  of  severe 
cerebral  symptoms  is  in  favour  of  abscess,  especially  if  accompanied 
by  considerable  fever  and  by  rigors.  The  diagnosis  is  of  greatest 
importance  when  the  disease  is  deeply  seated,  since  an  operation 
would  be  justified  in  cases  of  abscess  when  it  would  be  impracti- 
cable in  tumour. 

Meningitis  "and  abscess  may  readily  be  confounded,  and  not  without 
reason,  since  meningitis  may  cause  the  terminal  symptoms  of  abscess,. 
and  it  may  result  alone  from  the  most  frequent  causes  of  abscess, 
injury  and  caries  of  bone.  The  distinction,  therefore,  cannot  always- 
be  absolute.  Preceding  symptoms  are  of  longer  duration  in  abscess, 
and  meningitis  affects  the  cranial  nerves  in  greater  degree,  unless  the 
abscess  is  seated  in  the  pons.  The  terminal  meningitis  which  results 
from  abscess  is  usually  purulent  and  due  to  rupture  ;  it  is  more  rapid 
in  its  course  than  that  which  exists  alone,  often  begins  locally,  and 
preceding  cerebral  symptoms  may  materially  assist  the  diagnosis. 
When  these  are  absent,  the  diagnosis  may  be  as  impossible  as  in  the 
cases  in  which  there  are  only  terminal  symptoms  of  apoplectic 
character. 

The  distinction  from  simple  inflammation  of  the  brain  has  to  be  made 
chiefly  in  the  cases  of  injury,  and  then  consists  less  in  a  distinction 
between  the  two  than  in  the  recognition  of  the  indications  of  suppu- 


ABSCESS.  *485 

ration  over  and  above  those  of  inflammation.  One  of  these  is  afforded 
by  the  duration  of  the  symptoms.  Prolonged  traumatic  inflammation 
of  the  substance  of  the  brain  usually  results  in  suppuration,  and 
hence,  if  severe  local  symptoms  continue  for  more  than  a  week,  the 
formation  of  pus  is  probable.  Another  is  the  presence  of  the 
general  symptoms,  especially  rigors,  that  usually  attend  suppuration. 
A  third  is  the  subsidence  of  the  acuter  disturbance,  while  slighter 
symptoms  persist  and  subsequently  increase. 

The  difficulty  of  distinguishing  the  existence  of  abscess  in  a  case  of 
chronic  ear  disease  is  sometimes  very  great,  because  some  general 
cerebral  symptoms  are  occasionally  produced  by  the  ear  disease,  and, 
as  we  have  seen,  these  may  include  distinct  optic  neuritis.  It  is, 
indeed,  impossible  to  lay  down  any  absolute  diagnostic  rules  for  these 
cases.  The  important  fact  is  that  such  cerebral  symptoms,  and  espe- 
cially considerable  optic  neuritis,  are  exceedingly  rare  results  of 
simple  ear  disease,  and  in  the  great  majority  in  which  they  are  found 
an  abscess  exists. 

The  seat  of  an  abscess  is  inferred,  when  due  to  injury,  by  the  posi- 
tion of  this,  subject  to  the  facts  mentioned  above,  and  also  to  localis- 
ing indications,  which,  when  present,  have  the  same  significance  as  in 
cases  of  tumour.  In  abscess  from  ear  disease  the  chief  difficulty  is  the 
distinction  of  the  temporo-sphenoidal  lobe  and  cerebellum  as  seats. 
It  depends  chiefly  on  the  position  of  the  ear  disease,  in  the  middle  ear  or 
mastoid  cells,  and  also  on  the  definite  symptoms  of  cerebellar  disease, 
including,  especially,  pronounced  occipital  headache,  attention  to  which 
will  often  prevent  error. 

Functional  diseases  and  abscess  can  only  be  confounded  in  the  rare 
cases  in  which  slight  general  disturbance,  such  as  convulsions  or 
melancholia,  attend  the  latent  stage ;  and  the  distinction  can  only  be 
made  by  the  recognition  of  some  other  symptom,  such  as  persistent 
and  severe  headache  or  optic  neuritis. 

Cerebral  abscess  can  only  be  mistaken  for  a  general  disease,  febrile 
or  septic,  in  cases  in  which  such  general  brain  symptoms  alone  are 
present  as  might  be  produced  by  a  toxic  blood- state.  Usually,  how- 
ever, the  co-existence  of  headache  with  delirium  and  stupor,  and 
retardation  of  the  pulse,  will  prevent  this  error,  if  the  general  relation 
of  the  symptoms  is  carefully  watched  and  duly  weighed. 

Prognosis. — In  a  case  of  abscess,  the  diagnosis  of  which  is  certain, 
the  prognosis  is  most  grave  unless  the  surgeon  can  give  relief.  This 
conclusion  is  not  invalidated  by  the  very  long  latency  occasionally 
met  with,  because,  in  the  few  cases  in  which  this  has  continued  for 
several  years,  symptoms  have  been  completely  absent  during  the 
stationary  period,  so  that  the  diagnosis  and  prognosis  of  the  disease 
were  impossible.  Only  in  the  extremely  rare  cases  in  which  slight 
but  characteristic  symptoms  subside  into  absolute  latency  can  the 
prognosis  be  at  all  hopeful.     The  longer  a  stationary  abscess  lasts,  the 


486  BRAIN. 

thicker  is  its  capsule,  and  the  less  easily  is  fresh  mischief  excited,  and 
therefore  the  better  is  the  prospect.  The  pi'oved  occurrence  of  calci- 
fication of  the  wall  and  iuspissatiou  of  the  contents,  together  with 
the  fact  that  an  abscess  may  remain  latent  for  as  long  as  twenty 
years,  permits  the  hope  that,  in  some  cases  at  least,  the  abscess  may 
not  shorten  life  ;  and  such  hope*  may  reasonably  be  somewhat  stronger 
if  the  cause  of  the  abscess  has  ceased  to  be  active,  and  the  patient 
can  be  preserved  from  influences,  such  as  injury,  which  may  again 
excite  the  quiescent  process.  Indications  of  the  rupture  of  an 
abscess  leave  little  hope  that  life  can  he  preserved. 

Treatment. — Although  almost  beyond  the  range  of  direct  treat- 
ment, abscess  of  the  brain  is  not  altogether  beyond  the  range  of  pre- 
vention when  due  to  its  most  frequent  cause,  local  bone  disease. 
This  should  be  subjected  to  treatment,  sedulous  and  perse vei'ing,  and, 
above  all,  the  free  discharge  of  the  products  of  suppuration  should  be 
carefully  secured,  by  due  and  constant  attention  to  the  freedom  of 
exit.  This  remark  applies  especially  to  ear  disease,  in  which  the  first 
cerebral  symptoms  have  often  followed  an  arre&t  of  the  discharge. 
These  measures  should  be  continued  even  when  there  is  reason  to 
fear  that  suppuration  in  the  brain  has  already  occurred,  for  the 
unfavorable  course  of  cerebral  abscess  has  been  certainly  accele- 
rated by  subsequent  increase  in  the  inflammatory  and  septic  mischief 
in  the  ear. 

The  impi'ovement  of  the  health  of  the  patient  is  of  the  greatest 
importance.  Tonics,  cod-liver  oil,  and  fresh  air  tend  thus  to  lessen 
the  tendency  of  the  cerebral  disease  to  spread.  Of  especial  importance 
also  is  the  avoidance  of  exposure  to  cold,  and  of  blows  or  falls  on  the 
head.  Each  of  these  causes,  in  several  recorded  instances,  has  dis- 
tinctly excited  the  disease  to  fresh  progress.  If  the  symptoms  should 
fortunately  become  quiet,  and  complete  latency  be  developed,  the  same 
care  must  be  maintained  for  years. 

Acute  cerebral  symptoms  must  be  treated  in  the  same  way  as  those 
that  are  due  to  simple  inflammation.  Rest,  cold  to  the  head,  some- 
times counter-irritation,  as  by  a  blister  to  the  occiput,  are  the  most 
important  measures.  The  treatment  of  special  symptoms  must  be  con- 
ducted on  the  same  principles  as  in  the  case  of  cerebral  tumour. 

Surgery  has  endeavoured,  and  with  success,  to  afford  the  direct 
relief  which  medicine  is  unable  to  give.  The  pus  has  been  evacuated 
by  means  of  trephining,  and  the  patients  have  recovered,  provided 
antiseptic  precautions  were  carefully  ohserved,  and  the  cavity,  if  neces- 
sary, drained  for  a  time.  But,  until  recently,  success  has  been 
obtained  almost  exclusively  in  cases  of  traumatic  abscess.  In  these 
the  abscess  is  seated,  as  a  rule,  beneath  the  place  of  injury,  and  the 
guidance  thus  afforded  enables  the  operation,  as  a  rule,  to  be  correctly 
localised.  For  instance,  a  boy  struck  his  forehead  and  suffered  after- 
wards from  headache  and  retching.     At  the  end  of  seven  weeks  heini- 


ABSCESS. 


487 


Fig   128. 


plegia  came  on,  with  double  optic  neuritis.  The  frontal  bone  was 
trephined ;  the  dura  mater  beneath  was  healthy,  but,  an  aspirator 
needle  being  pluuged  into  the  brain,  three  drachms  of  pus  escaped. 
The  boy  recovered,  but  with  loss  of  sight  from  the  optic  neuritis.* 
This  case  illustrates  forcibly  a  rule  which  is  also  indicated  by  the  facts 
of  many  unsuccessful  cases.  If  pus  is  not  found  on  the  surface  of  the 
brain  a  fine  trocar  should  be  plunged  into  the  cerebral  substance.  In 
more  than  one  case  of  unsuccessful  trephining,  the  post-mortem  showed 
that  this  procedure  would  have  reached  the  abscess.  But  sometimes, 
when  such  an  abscess  is  some  distance  from  the  surface,  every  effort  to 
find  the  pus  may  fail.  Occasionally  the  operation  has  merely  aided 
a  process  which  nature  was  endeavouring  to  effect.  For  instance,  a 
girl,  aged  eight,  fell  and  cut  her  forehead.  The  wound  healed  quickly, 
but  four  months  afterwards  an  abscess  formed  over  the  bone,  and 
opened  spontaneously.  A  probe  passed  through  carious  bone  into  the 
interior  of  the  skull.  The 
trephine  was  applied,  a 
wine-glassful  of  pus  escaped, 
and  the  patient  recovered. f 
In  any  other  than  trau- 
matic cases  it  is  seldom 
that  the  symptoms  are  so 
localised  as  to  indicate  with 
precision  the  seat  of  the 
abscess,  but  when  they  are 
an  operation  has  been  some- 
times successful,  since  their 
significance  has  been  better 
understood  during  the  last 
few  years.  The  evacuation 
of  an  abscess  causing  cor- 
tical convulsions  has  been 
followed  by  permanent 
arrest  of  the  latter,  without 
excision  of  the  discharging 
centres. 

Until  recently  no  case  of 
abscess  from  ear  disease 
had  been  cured  by  trephin- 


W 


m  w 


e.a.T?u 


Fig.  129. 


ing,  because  the  guidance  of    Figs.    128    and    129. — Dissections   showing   the 

localising  svirmtoms  is  as  a  g"ide  adoPted  hJ  Mr-  Barker  in  successful 
localising  symptoms  is,  as  a       trephining  for  abscess  from  ear  disease. 

rule,  absent  on  account  of 

the  position  of  the  abscess.  The  practicability  of  the  surgical  treat- 
ment of  these  cases  has  now,  however,  been  proved  by  several  success- 
ful operations,  the  surgeon  being  guided  by  the  most  frequent  seat  of 

*  Hulke,  '  Medico-Chirurgical  Trans.,5  vol.  bm.  1879. 
t   Watson,  ib.,  1870,  p.  353. 


488  BRAIN. 

suppuration  produced  by  such  disease  as  the  patient  presents.  One 
of  the  earliest  of  these  was  that  of  a  patient  under  my  care  at  Univer- 
sity College  Hospital,  in  whom  Mr.  Barker  trephined  over  the  tem- 
poro-sphenoidal  lobe,  in  which  an  abscess  was  supposed  to  be,  and 
the  trocar,  on  its  first  introduction,  reached  the  pus  ;  the  abscess  was 
emptied,  and  the  patient  made  a  good  and  permanent  recovery.  The 
cerebral  symptoms  were  slight,  as  in  most  cases  of  abscess  in  this 
situation,  and  consisted  only  in  inequality  of  the  pupil,  vomiting, 
and  optic  neuritis  of  considerable  intensity  and  very  rapid  deve- 
lopment. With  these  symptoms  the  patient  had  had  several 
rigors.  The  precise  seat  for  the  trephining  was  determined  by  Mr. 
Barker  by  means  of  a  careful  dissection,  represented  in  Figs.  128 
and  129,  and  was  at  a  point  one  inch  and  a  quarter  behind  the 
external  auditory  meatus,  and  the  same  distance  above  its  level.  This 
point  is  over  the  second  temporal  convolution,  and  a  trocar  plunged 
in  at  this  spot  and  directed  forwards  will  probably  enter  an  abscess 
due  to  caries  of  the  petrous  bone.*  The  details  of  the  surgical  pro- 
cedure will  be  found  in  the  paper  in  which  this  case  is  related.f 


INTRA-CRANIAL    TUMOURS. 

The  brain  is  often  damaged  by  new  growths  which  arise  in  its 
substance,  or  spring  from  the  enclosing  membranes  or  from  the  bone 
of  the  skull.  Almost  all  forms  of  tumour  are  met  with,  but  some — 
simple  fatty  tumours,  for  instance — that  are  common  elsewhere  are 
extremely  rare  in  this  situation.  Others,  such  as  massive  tubercular 
growths,  are  more  common  in  the  brain  than  in  other  parts.  Sar- 
coma is  not  rare  ;  and  one  growth,  glioma,  is  almost  confined  to  the 
brain  and  spinal  cord,  being  met  with  elsewhere  only  in  the  retina. 
Besides  these,  the  list  of  intra-cranial  tumours  includes  syphilitic 
growths,  which  are  also  common,  cancer,  fibroid  and  bony  tumours, 
cholesteatoma,  vascular  or  erectile  growths,  psammomata  or  tumours 
containing  brain-sand,  and  parasitic  tumours,  echinococci  and  cysti- 
cerci.     Intra-cranial  aneurisms  are  considered  in  a  separate  chapter. 

Etiology. — The  cause  of  most  of  these  tumours  is  not  less  obscure 
than  that  of  similar  gi'owths  in  other  situations.     But  the  comparison 

*  Dean  has  pointed  out  that  by  trephining  the  same  distance  behind  the  meatus, 
and  only  a  quarter  of  an  inch  above  its  level,  the  lateral  sinus  is  exposed,  and  by 
extending  the  opening,  the  temporo-sphenoidal  lobe  above,  and  the  cerebellum  below, 
can  be  explored  with  the  trocar — a  rule  that  may  be  useful  when  it  is  doubtful  in 
which  structure  an  abscess  is  situated;  it  enabled  him  to  empty  successfully  a 
cerebellar  abscess  ('  Lancet/  1892). 

t  '  British  Medical  Journal,'  1886,  ii,  Dec.  11th,  p.  1154.  In  a  preceding  case, 
trephined  successfully  by  Schede,  a  fistulous  track  led  from  the  surface  to  the 
abscess. 


TUMOURS.  489 

of  a  series  of  cases  brings  out  certain  general  etiological  facts.  The 
liability  of  males  to  suffer  is  twice  as  great  as  that  of  females.  Of 
650  cases  of  various  forms  of  intra-cranial  tumour,  440  occurred  in 
males,  210  in  females.*  The  greater  liability  of  males  is  not  due, 
as  might  be  imagined,  to  the  influence  of  syphilis,  for  it  is  true 
(as  will  be  seen)  of  all  forms  of  tumour,  with  the  apparent  excep- 
tion of  sarcoma.  The  difference  has  been  ascribed  to  the  influence 
of  traumatic  causes,  but  it  is  not  probable  that  this  accounts  for 
more  than  a  small  part  of  the  excess,  since  it  is  rarely  to  be  traced, 
and  the  difference  in  the  sexual  liability  is  as  marked  in  the  case  of 
children  as  in  that  of  adults. 

This  difference  is  not,  however,  equally  marked  in  all  forms  of 
tumour.  It  is  greatest  in  the  case  of  tubercle  and  of  glioma.  Of  the 
tubercular  tumours  and  of  gliomata,  nearly  two  thirds  of  each  were  in 
males,  and  the  same  proportion  of  cases  of  cancer.  On  the  other 
hand,  of  56  cases  of  sarcoma  26  were  in  males  and  25  in  females. 

No  time  of  life  is  exempt,  unless  it  be  the  first  six  months ;  but 
cerebral  tumours  are  not  common  in  old  age.  The  largest  number  of 
cases  occur  in  childhood  and  in  the  active  period  of  adult  life.  The 
first  twenty  years  furnish  one  third  of  the  cases,  the  second  two  fifths, 
and  the  third  one  fifth.  The  proportion  in  the  first  decade,  18-5  per 
cent.,  falls  to  14  in  the  second,  and  rises  to  a  maximum  of  20  in  the 
third.  In  the  fourth  it  is  the  same  as  in  the  first,  18'5  per  cent.,  and 
it  falls  to  14  per  cent,  in  the  fifth,  while  after  fifty  years  of  age  the 
cases  rapidly  become  less  numerous.  The  frequency  in  early  life  is 
largely  due  to  the  fact  that  at  this  period  tubercular  growths  are  so 
common  ;  if  these  are  excluded,  the  proportion  in  the  first  twenty 
years  of  life  falls  to  one  fifth,  while  that  in  the  second  rises  to  one 
half,  and  that  in  the  third  to  one  quarter  of  the  total  number.  A^e 
has  little  influence  in  relation  to  sex.  The  relative  affection  of  males 
and  females  is  nearly  the  same  in  each  period  of  life,  but  there  is  a 
marked  tendency,  as  in  so  many  diseases,  for  the  sexual  difference  of 
the  early  and  adult  periods  to  disappear  in  the  decline  of  life;  over 
fifty  the  two  sexes  suffer  equally. 

Tubercular  tumours  of  the  brain  occur  at  all  ages  up  to  seventy,  but, 
as  just  mentioned,  they  are  most  frequent  in  early  life.  Three  quarters 
of  the  cases  occur  during  the  first  twenty  years,  and  in  one  half 
of  the  whole  the  patients  are  under  ten  years  of  age.  Glioma  is  most 
common  during  active  adult  life  ;  one  half  of  the  cases  occur  between 
twenty  and  forty,  one  quarter  between  forty  and  sixty,  and  one  fifth 
during  the  first  twenty  years.  The  relative  distribution  of  the 
cases  of  sarcoma  is  nearly  the  same  as  that  of  glioma.  Parasitic 
tumours  are  most  common  between  ten  and  twenty,  next  between 

*  This,  and  the  other  statistical  conclusions  given  in  the  text,  have  been  obtained 
by  a  combination  of  the  cases  contained  in  the  collections  made  by  Ladame  ('  Him- 
geschwulste,'  Wurzburg,  1865)  and  Bernhvrdt  ('  Hirngeschwulste,'  Berlin,  1881). 
They  agree,  in  the  main,  with  the  valuable  collection  of  facts  made  by  Dr.  Allen  Starr. 


490  BRAIN. 

twenty  and  thirty,  while  under  ten  and  over  thirty  they  are  very  rare. 
The  youngest  sufferer  was  aged  six,  the  oldest  sixty-six.  Tumours 
diagnosed  as  carcinoma  have  been  met  with  at  all  ages,  but  one  half 
were  in  patients  between  forty  and  sixty  years  of  age,  and  only  two  in, 
the  first  twenty  years  of  life.  The  other  forms  of  tumour  are  too  rare 
to  permit  their  relation  to  age  to  be  stated,  further  than  the  fact  that 
none  of  them  seem  to  have  been  met  with  hitherto  in  patients  under 
twenty. 

Two  forms  of  cerebral  tumour,  tubercular  and  syphilitic  growths, 
depend  upon  diathetic  influences.  In  most  cases  of  tubercular, 
tumours  there  is  a  family  history  of  phthisis ;  the  patients  are 
frequently  ill-nourished,  and  if  adults,  often  present  evidence  of 
chronic  lung  disease.  Syphilitic  growths,  although  not  unknown  in 
the  inherited  form,  occur  chiefly  in  the  acquired  disease.  The  period 
after  infection  at  which  they  develop  is  especially  from  the  fifth  to 
the  twelfth  year,  but  they  have  been  met  with  as  early  as  twelve 
months  and  as  late  as  fifteen  years  after  the  primary  sore. 

Little  is  known  of  the  influences  which  determine  the  occurrence  of 
other  forms  of  infra-cranial  tumour.  It  is  rare  for  any  indication  to 
be  obtained  of  an  inherited  tendency  to  morbid  growths  elsewhere. 
There  is  little  doubt,  however,  that  traumatic  influences,  falls  and 
blows  on  the  head,  are  occasionally  the  immediate  excitants  of  a 
growth,  since  the  symptoms  have  been  observed  to  follow  a  blow,  and 
the  tumour  is  found  to  correspond  in  position  to  the  seat  of  the  injury. 
Such  a  relation  has  been  observed  in  almost  all  forms  of  tumour, 
especially  in  syphilitic  and  tubercular  growths,  and  in  sarcomata  of 
the  dura  mater.  Traces  of  the  traumatic  mischief  may  or  may  not 
be  visible  after  death,  and  apparently  the  nutritive  changed  conse- 
quent on  a  mere  concussion  may  be  the  starting-point  of  a  tumour. 
In  some  cases  local  symptoms  of  irritation,  which  were  continuous 
with  those  of  a  subsequent  tumour,  commenced  two  or  three  days 
after  the  injury,  and  must  have  been  due  to  inflammation,  by  which 
the  growth  was  presumably  started.  But  the  cases  in  which  a  trau- 
matic cause  can  be  traced  form  a  very  small  proportion  of  the  total 
number,  and  the  extent  of  this  influence  may  readily  be  overx'ated. 
It  should  be  remembered  that  a  fall  may  evoke  symptoms  of  an  early 
growth  which  existed  before  the  accident. 

Pathology. — Yarious  classifications  of  intra-cranial  growths  have 
been  proposed,  founded,  for  the  most  part,  on  the  structures  in  which 
they  originate,  but  such  classifications  are  of  small  practical  value. 
It  is  more  convenient  to  describe  the  various  growths  in  the  order  of 
their  frequency.  If  they  are  grouped,  as  an  aid  to  memory,  they 
may  be  placed  in  seven  categories. 

I.  Diathetic  : — Tubercular  and  syphilitic. 

II.  Sarcomatous  : — Glioma,  sarcoma,  myxoma. 

III.  Carcinoma. 


TUMOURS.  491 

IV.  Osteofibroid  : — Fibroma,  osteoma,  osteofibroma. 
Y.  Miscellaneous : — Cholesteatoma,    lipoma,    vascular    or   erectile 
tumours,  psammoma,  neuroma. 

VI.  Parasitic  : — Ecbinococcus  and  cysticereus. 

VII.  Simple  cysts,  either  connected  "with  the  choroid  plexus,  or 
very  rarely  in  the  substance  of  the  brain. 

Excluding  syphilitic  growths  (the  frequency  of  which  is  not  fairly 
represented  in  published  lists  of  fatal  cerebral  tumours),  tubercular 
growths  constitute  more  than  half  the  total  number  of  cases,  and 
gliomata  and  sarcomata  together  about  a  third,  glioma  being  rather 
more  frequent  than  sarcoma.  Thus  the  two  groups,  tubercular  and 
sarcomatous,  constitute  together  about  four  fifths  of  non- syphilitic 
tumours  of  the  brain.  Carcinoma  is  much  less  common,  but  its  actual 
frequency  is  uncertain,  since  many  cases  of  glioma  and  of  sarcoma 
have  certainly  been  recorded  as  cancer  by  older  writers.  The  state- 
ment sometimes  made,  that  cancer  is  one  of  the  most  common  forms 
of  cerebral  tumour,  is  entirely  unsupported  by  authenticated  facts. 
According  to  published  cases,  parasitic  tumours  axe  nearly  as  frequent 
as  carcinoma,  but  their  actual  frequency  doubtless  varies  much  in 
different  localities,  and  they  are  more  likely  to  be  published  than  are 
cases  of  cancer.  The  other  forms  of  tumour  are  rare  ;  all  that  can  be 
said  is  that  fibroma,  cholesteatoma,  and  osteoid  tumours  are  more 
common  than  vascular  tumours  (angioma),  psammoma,  lipoma,  or 
neuroma,  the  last  two  being  the  most  rare  of  all  the  tumours  of  the 
brain. 

The  relative  frequency  with  which  tumours  are  situated  in  different 
parts  of  the  brain  is  as  follows  : — Cerebral  hemispheres  (excluding 
central  ganglia),  297 ;  cerebellum,  179  ;  pons,  59  ;  central  ganglia, 
48;  medulla  oblongata,  31;  corpora  qu;idrigemina,  13;  crus  cerebri, 
10.  Thus  the  cerebral  hemispheres  are  the  most  frequent  seat  of  new 
growths,  but  when  the  smaller  bulk  of  the  cerebellum  is  considered, 
its  tissue  is  evidently  far  more  prone  to  give  rise  to  neoplasms  than 
is  that  of  the  cerebrum. 

If  we  take  all  forms  of  intra-cranial  tumour,  the  relative  frequency 
with  which  the  lesion  affects  the  different  parts  of  the  brain  is  as 
follows.  Of  718  separate  growths  (several  existing  in  some  instances), 
the  order  of  damage  was — cerebral  hemispheres  (white  substance 
and  cortex),  297;  cerebellum,  179;  base  of  brain,  76;  pons,  59; 
central  ganglia,  48  ;  medulla  oblongata,  31 ;  corpora  quadrigcmina, 
13  ;  crus,  10.  Growths  are  also  occasionally  met  with  in  the  pineal 
gland,  pituitary  body,  and  the  choroid  plexus. 

Tubercular  tumours  of  the  brain  occur  in  the  form  of  solid,  firm 
rounded  masses,  having  little  resemblance  to  tubercle  in  its  miliary 
form.  They  commonly  vary  in  size  from  that  of  a  pea  to  that  of  a  walnut, 
and  occasionally  attain  still  larger  dimensions,  that  of  a  hen's  egc 
or  even  of  the  closed  fist.  Their  section  presents  a  uniform,  opaque 
cheesy  aspect,  sometimes  softened  here  and  there,  but  never  in  a  laro-e 


492 


BKAIN. 


ai*ea.  The  periphery  of  the  mass  is  softer,  greyish,  and  translucent, 
and  the  adjacent  brain  tissue  may  be  softened.  Hence  they  are  readily 
detached.  It  is  in  this  grey  zone  that  the  growth  of  the  tumour  occurs 
by  the  development  and  coalescence  of  miliary  granulations,  which 
quickly  degenerate  and  blend  with  the  caseous  mass.  The  growth 
apparently  takes  place  in  the  lymphatic  sheaths  of  vessels  and  within 
the  vessels  thrombosis  may  occur.  Hence  the  absence  of  vessels  within 
the  mass,  and  the  quick  and  uniform  degeneration  of  its  elements. 
If  such  a  tumour  ceases  to  grow,  the  peripheral  layer  may  undergo  a 
fibroid  change  so  as  to  form  a  capsule.  Occasionally  the  degenerated 
mass  undergoes  partial  calcification.  Rarely  the  tissue  softens,  and  a 
collection  of  pus  results,  increased  perhaps  by  adjacent  inflammation. 
Usually  miliary  tubercle  is  found  elsewhere  in  the  body,  sometimes  in 
the  meninges.  Occasionally  these  growths  (like  bone  disease)  may  be 
the  sole  lesion,  and  hence  they  are  sometimes  called  "  scrofulous  " 
tumours,  but  of  their  tubercular  nature  there  is  no  doubt.  They 
compress  the  brain  tissue,  which  atrophies  before  the  growth  (Fig. 
130) ;  they  do  not  infiltrate  like  some  other  tumours.  They  generally 
occur  within  the  cerebral  substance,  without  apparent  connection  with 

the  membranes;  it  has,  indeed,  been 
maintained  that  they  are  always 
connected  with  and  spring  from 
a  fold  of  the  pia  mater,  but  this 
cannot  be  distinctly  traced  in  many 
cases.       When     such  a    tumour 

t^-^ggsj^^:";-  reaches   the    pia    mater,   this  is 

t:-:^&^^0^  jj-'.i.. ■  ~  ~.  --"I  thickened  and  often  adherent  to 
the  dura  mater.  Now  and  then 
tubercular  tumours  spring  from 
the  dura  mater,  and  merely  com- 
press the  brain  without  invad- 
ing it. 

The  most  frequent  seat  of  such 
cerebellum  (in 
which  one  third  occur),  either  the 
hemisphere  or,  as  in  Eig.  130,  the 
middle  lobe,  next  (and  almost  as  frequent)  the  cerebrum  ;  while  the 
other  parts  are  affected  less  frequently  and  in  the  following  order : 
pons,  central  ganglia,  crura  cerebri,  medulla  oblongata,  and  corpora 
quadrigemina.  There  is  frequently  more  than  one  tumour.  Of  183 
cases,  in  83  there  was  only  one  tumour,  in  100  there  were  more  than  one. 
It  is  equally  frequent  for  two  or  more  than  two  to  exist,  and  there 
may  be  many — ten,  twelve,  or  even  twenty,  of  various  sizes.  When 
there  are  more  than  one  it  is  equally  frequent  for  the  tumours  to 
occupy  the  same  or  different  parts  of  the  brain  (the  white  substance 
and  cortex  of  the  cerebral  hemispheres  being  considered  as  one  part). 
In  very  rare  cases  there  has  been  no  mass  of  tubercle,  but  the  whole 


Fro.    130. — Tubercular    tumour    of    the 
middle   lobe   of   the    cerebellum.     The 
patient,  a  young  child,  was   admitted 
into  University  College  Hospital,  dying    growths    is    the 
from  general  tuberculosis.     P.  Pons. 


TUMOURS.  493 

brain  was  infiltrated  with,  minute  miliary  concretions,  none  exceeding 
a  barleycorn  in  size  (Gee,  Baly). 

Syphilitic  groivths  (sypbilomata,  gummata)  are  certainly  more 
common  than  is  suggested  by  the  frequency  with  which  they  are  found 
post  mortem,  because  they  are  more  amenable  to  treatment  than  any 
form  of  tumour.  They  usually  vary  in  size  from  that  of  a  hazel-nut  to 
that  of  a  chestnut ;  in  shape  they  are  somewhat  irregular  and  nodular. 
Their  consistence  is  not  uniform;  they  are  firm,  but  not  equally  so  in 
all  parts.  The  section  presents  an  irregular  caseation  ;  cheesy  spots, 
isolated  or  coalescing  into  irregular  tracts,  are  separated  by  a  firm  grey 
or  reddish-grey  fibrous  tissue.  The  growing  surface  is  usually  grey 
and  gelatinous.  The  adjacent  brain-substance  is  softened  and  more 
or  less  displaced,  but  is  not  infiltrated  by  the  growth.  The  more  ir- 
regular surface  and  the  irregular  caseation  are  distinctions  from  tuber- 
cular tumours.  Sometimes  these  tumours  are  met  with  in  a  state  of 
more  advanced  degeneration,  probably  under  the  influence  of  treatment ; 
they  are  shrunken,  very  hard,  and  fibroid,  and  may  be  surrounded  by 
an  indurated  capsule.  The  process  of  obsolescence  may  go  so  far  that 
only  an  indurated  cicatrix  is  left.  Syphilomata  are  rarely  met  with  in 
the  cerebellum  or  the  corpus  striatum,  but  are  commonly  situated  in 
the  cerebral  hemispheres  or  the  pons.  They  are  usually  superficial  in 
position  and  attached  to  the  pia  mater ;  even  when  apparently  more 
deeply  seated  a  connection  may  usually  be  traced  with  a  fold  of  pia 
mater  between  two  convolutions.  The  dura  mater  is  often  adherent 
to  the  growth,  which  sometimes  has  obviously  commenced  in  this- 
membrane  and  thence  invaded  the  brain.  In  such  a  case  the  invasion 
may  be  clearly  observed  to  take  place  along  the  walls  of  vessels,  pro- 
bably in  the  perivascular  sheaths.  Hence  it  is  probable  that  in  the 
very  rare  cases  in  which  no  connection  with  membranes  can  be  traced, 
the  growth  proceeds  from  the  vessels.  "Although  these  tumours  are 
rarely  met  with  in  the  central  ganglia,  they  occasionally  occur  beneath 
the  optic  thalamus,  as  an  ingrowth  from  the  neighbourhood  of  the  crus. 
When  the  growth  is  superficial,  the  membranes  in  the  vicinity  often 
present  the  indication  of  chronic  inflammation  with  much  thickening. 

The  Sarcomatous  group  compreheuds  a  variety  of  tumours  differing 
much  in  structure,  but  all  connected  by  intermediate  forms.  They 
consist  of  round,  oval,  or  spindle  cells,  varying  in  delicacy,  and  with 
more  or  less  intercellular  and  fibroid  tissue.  There  is,  however, 
an  important  difference  in  their  mode  of  growth.  Some  infiltrate 
without  displacing  the  cerebral  substance,  and  have  no  sharp  outline. 
Others  displace  rather  than  invade  the  brain,  have  a  well-marked 
outline,  and  are  surrounded  by  a  zone  of  softening  in  consequence  of 
the  destruction  of  the  nerve-elements  before  the  morbid  growth.  The 
former,  from  their  infiltrating  character,  must  grow  in  the  neuroglia, 
and  arise  by  a  modification  of  its  elements.  Hence  they  are  termed 
gliomata,  and  the  tumours,  before  which  the  brain  tissue  undergoes 
destruction  or  displacement,  are  alone  to  be  regarded  as  true  sarcomata. 


494 


BRAIN. 


/W%W- 


w 


T.R. 


/I 


L.P.S. 


y 


The  former  are  composed  of  more  delicate,  the  latter  of  less  delicate 
tissue  elements. 

Gliomata. — The  infiltrating  character  of  gliomata  was  not  that  on 
which  their  designation  was  primarily  based.  Their  elements  were 
supposed  to  resemble  those  of  the  neuroglia;  but  the  resemblance  is 
never  close,  and  they  rarely  present  the  stellate  cells  which  characterise 
the  normal  interstitial  tissue  of  the  brain.  Their  elements  vary  as 
much  as  do  those  of  other  forms  of  sarcoma;  sometimes  round,  oval, 

or  fusiform  cells  predominate 
or  may  alone  be  visible.  But 
the  cells  are  always  delicate  ; 
their  outlines  are  difficult  to 
recognise,  and  they  are  easily 
destroyed;  so  that  their  round 
or  oval  nuclei  may  alone  be 
visible  in  a  scraping.  The 
interstitial  tissue  varies  in 
amount ;  it  is  usually  very  de- 
licate and  homogeneous,  but 
sometimes  is  so  abundant  that 
the  tumour  has  a  mucoid  cha- 
racter (myxo-glioma),  rarely 
fibrous  (fibro-glioma) .  Their 
tint  is  grey  or  reddish  grey, 
and  often  closely  resembles 
that  of  the  brain  tissue,  being 
a  little  paler  than  the  grey 
matter  of  the  cortex,  and  their 
consistence  is  nearly  that  of 
the  cerebral  substance.  The 
rare  fibroid  form  is  firmer, 
the  mucoid  forni  softer  than 
the  brain.  Moreover  they 
are  prone  to  undergo  soften- 
ing, which  may  be  so  con- 
siderable and  extensive  as  to  convert  the  growth  into  a  cyst,  the  wall 
composed  of  new  growth,  and  containing,  in  its  cavity,  only  the  debris 
of  its  cells.  The  tint  of  the  tumour  depends  on  the  varying  amount 
of  vessels  which  it  contains.  In  soft  tumours  the  vessels  easily  rupture 
and  give  rise  to  haemorrhage,  so  that  extravasation  may  infiltrate  a 
large  part  of  the  growth  (as  in  Fig.  133),  or  an  extensive  haemorrhage 
may  occupy  a  cavity  within  it.  It  is  rare,  however,  for  the  haemorrhage 
to  escape  beyond  the  limit  of  the  growth.  Prom  the  infiltrating 
character  of  a  glioma,  it  usually  causes  simple  enlargement  of  the 
part  of  the  brain  in  which  it  occurs  ;  adjacent  parts  may  be  compressed 
by  the  enlargement,  and  may  be  displaced  to  some  extent  (as  in  Pig. 
135),  but  there  is  not  such  simple  displacement  as  by  non-infiltrating 


PiO.  131. — Infiltrating  glioma  of  the  cortex  of 
the  left  superior  parietal  lobe. 


TUMOUKS. 


495 


growths.  When  the  pons  is  the  seat  of  the  new  growth,  the  whole  of 
the  pons  may  be  greatly  enlarged ;  the  basilar  artery  may  restrain  the 
swelling,  and  ultimately  be  concealed  in  the  bottom  of  a  deep  fissure 


Fig.  132. 


Fig.  133. 
Figs.  132  and  133. — Infiltrating  glioma  of  the 
pons.     The  dotted  shading  on  the  upper  sur- 
face indicates  the  position  of  a  hsemorrhagic 
infiltration. 


Fig.  134.— Glioma  of  the  pons.  V,V, 
vertebral  arteries ;  the  basilar  is  en- 
tirely concealed  in  the  deep  groove 
between  the  projecting  growth  on 
each  side.  On  the  right  an  extension 
downwards  has  compressed  the  right 
side  of  the  medulla;  C,  C,  crura 
cerebri;  3,  3,  third,  and  5,  fifth 
nerve.  The  patient  was  a  boy,  aged 
eight,  who  presented  during  life 
paralysis  of  the  right  fifth,  sixth, 
and  seventh  nerves,  and  of  the  left 
arm  and  lea:. 


between  the  two  parts,  as  in  Fig.  134.  When  a  glioma  reaches  the 
surface,  outgrowths,  sometimes  pedunculated,  often  form.  Sometimes 
small  separate  growths  are  met  with  on  the  surface,  as  in  Pig.  135. 
It  is  rare  for  adhesions  to  the  dura  mater  to  occur.  The  degree  and 
rapidity  of  the  destruction  of  the  nerve-elements  by  the  infiltration 
varies  much  in  different  cases.  Sometimes  nerve-fibres  persist,  and 
retain  their  conducting  power  even  in  a  part  which  is  almost  entirely 
infiltrated  with  the  new  growth.  As  already  stated,  there  is  no  sharp 
boundary  to  the  tumour,  and  it  is  only  in  the  white  substance  of  the 
bi-ain  that  the  difference  in  tint  enables  its  limit  to  be  recognised  by 
the  naked  eye.  In  consequence  of  these  characters,  curious  errors  in 
pathological  diagnosis  sometimes  occur.  Cases  of  uniform  infiltration 
of  the  pons  with  a  myxoid  glioma  have  been  described  as  "hypertrophy 
of  the  pons."*  In  cases  in  which  the  growth  has  broken  down,  or  has 
been  the  seat  of  haemorrhage,  the  existence  of  the  tumour  may  readily 
be  overlooked,  and  such  cases  have  been  described  as  simple  softening 
*  It  is  certain  that  all  the  alleged  examples  of  hypertrophy  of  the  pons  are  cases 
of  infiltrating  glioma  (see  Money,  '  Med.-Chir.  Trans.,5  vol.  lxvi,  1883). 


496  BEAIN. 

or  simple  haemorrhage.  Most  of  the  cases  in  which  optic  neuritis  has 
been  described  as  accompanying  haemorrhage  or  softening  have  been 
cases  of  glioma.     A  microscopical  examination  of  the  margin  of  the 

^**fZ^-':~*:'    f   ■■■•       ■'•   '■■-     ■ ' ""'T";"^^-~.^ 

^a&£  '  .    ,    .       X       -  ■     -  ■  ,        >  ,"K 


@? 


FlG.  135. — Tumours,  gliomata  of  left  hemisphere,  a  large  one  infiltrating  the  supe- 
rior parietal  lohule,  two  smaller  growths,  one  pedunculated,  on  and  just  behind 
the  middle  of  the  ascending  parietal  convolution.  At  *  another  growth  lay 
beneath  the  cortex.  The  symptoms  were  right-sided  convulsions,  beginning 
with  pain  in  the  elbow  or  shoulder,  and  affecting  the  arm  chiefly,  a  few  limited  to 
the  leg.  There  was  also  general  right-sided  weakness.  See  Hughlings  Jackson,. 
'  Med.  Times  and  Gaz/  1875,  i,  p.  661. 

softened  part  will  always  prevent  error.  On  the  other  hand,  the  rare 
fibroid  forms  have  been  mistaken  for  sclerosis  of  the  brain. 

G-liomata  are  single  nine  times  out  of  ten  (sixty-three  out  of 
seventy  cases).  Rarely  several  co-exist  (multiple  glioma).  The 
order  of  frequency  with  which  they  occupy  the  several  parts  of  the 
brain  is  as  follows  : — cerebral  hemispheres  (in  one  half  of  the  cases), 
cerebellum  (in  one  quartet1),  central  ganglia,  pons.,  medulla  oblongata, 
crus  cerebri,  corpora  quadrigemina. 

Sarcomata  may  occur  within  the  substance  of  the  brain,  or  may 
spring  from  the  membranes,  pia  mater  or  dura  mater,  or  from  the 
bone,  especially  at  the  base.  When  they  commence  in  the  bone  they 
may  perforate  the  dura  mater,  but  in  this  case,  and  also  when  they 
commence  in  the  dura  mater,  they  do  not  usually  invade  the  pia  mater, 
but  merely  compress  the  adjacent  part  of  the  brain,  sometimes  causing 
a  depression  of  considerable  size.  Within  the  cerebral  substance  they 
do  not  infiltrate  like  gliomata,  but  have  a  well-marked  limit,  beyond 
which  the  brain  tissue  is  usually  softened,  so  that  the  tumour  can  be 
easily  detached.  In  each  situation  they  may  be  hard  or  soft  in  consist- 
ence ;  the  softer  forms  are  often  very  vascular,  and  constitute  one  form 
of  "  fungus  haematodes."  Such  tumours,  growing  from  the  duramater 
or  bone,  may  perforate  the  skull  and  be  felt  as  swellings  on  the  surface,. 


TUMOUBS. 


497 


softer  than  nodes,  for  which  they  are  sometimes  mistaken.  Occasion- 
ally these  growths  have  a  spongy  section.  Those  which  grow  from  the 
dura  mater  over  the  convexity  often  attain  a  large  size  ;  I  have  seen  one 
that  had  the  dimensions  of  a  turkey's  egg.  Those  which  spring  from 
the  membranes  at  the  base  are  usually  small,  firm,  and  more  or  less 
rounded.  The  softer  forms  may  consist  chiefly  of  round  cells,  but  the 
firmer  varieties  are  composed  of  spindle-cells,  varying  in  size,  less 
delicate  than  those  of  glioma,  and  often  separated  by  tracts  of  fibrous 


%;m 


FlQ-.  136. — Tumour,  beginning  between  tbe  right  optic  thalamus  and  first 
temporal  convolution  and  extending  inwards  from  the  temporal  lobe,  so 
as  to  compress  the  optic  tract  (Fig.  71,  p.  145).  A,  horizontal  section 
through  the  posterior  parts  of  both  hemispheres ;  T,  tumour,  with  small 
irregular  cavities,  due  to  softening  of  its  tissues ;  B,  transverse  section 
through  the  middle  of  the  thalamus ;  C,  through  the  posterior  part  of 
the  thalamus.  The  patient  suffered  from  hemianopia,  fits  beginning 
with  an  auditory  aura  (sound  of  bells  referred '  to  the  opposite  ear), 
optic  neuritis,  and  hemiplegia. 

vol.  ii.  32 


498  BRAIN. 

tissue.  Occasionally  the  spindle-cells  are  arranged  in  concentric 
nests.*  They  may  contain  nucleated  cells,  such  as  are  so  abundant 
in  the  so-called  "  myeloid  "  tumours.  In  the  substance  of  the  brain 
these  growths  are  usually  single,  but  occasionally  more  than  one 
exists ;  when  they  spring  from  the  dura  mater  or  the  base  they  are 
often  multiple.  They  are  more  frequent  outside  than  within  the 
brain,  but  may  occur  in  any  position,  and  are  seated  in  the  central 
ganglia  more  frequently  than  gliomata. 

Carcinoma  of  the  brain,  almost  always  soft,  may  be  primary  or 
secondai'y.  It  may  spring  from  the  dura  mater  or  grow  within  the 
brain  in  any  situation,  but  especially  in  the  cerebral  hemispheres. 
It  is  relatively  more  frequent  in  the  central  ganglia  than  other  forms 
of  tumour.  It  partly  infiltrates  and  partly  displaces  the  brain  tissue. 
Usually  single,  carcinoma  is  sometimes  multiple,  and  now  and  then  a 
symmetrical  growth  occurs  in  each  hemisphere.  In  one  case,  for 
instance,  a  large  secondary  tumour  was  situated  in  the  central  ganglia 

Fig.  137.  Fig.  138. 


Fig.  137. — Cancerous  growth  in  the  cortex  of  the  brain. 

Fig.  138. — Tumour  (cysto-myxoma)  of  corp.  quadrigernina  with  a  cyst  in  the 
superior  vermiform  process  of  the  cerebellum.  The  tumour  seemed  to  have  sprung 
from  the  posterior  quadrigeminal  body,  and  had  involved  the  medullary  velum.  The 
patient  was  a  boy,  aged  seven,  who  suffered  from  unsteadiness  of  gait  and  divergent 
strabismus.  Acute  symptoms,  occipital  headache  and  vomiting,  with  a  tendency  to 
fall  forwards  or  backwards,  and  optic  neuritis  supervened  after  a  fall.  (Kohts, 
•  Virchow's  Archiv,'  lxvii,  p.  425,  and  pi.  xiv.) 

on  each  side.  Cerebral  cancer  is  usually  vascular,  and  forms  sharply 
limited  tumours,  containing  large  cells  which  sometimes  have  several 
nuclei.  When  seated  in  the  dura  mater  the  tumours  are  usually 
small  and  vascular,  and  may  perforate  the  bone,  or  grow  into  the 
brain,  and,  like  the  similar  form  of  sarcoma,  are  often  termed 
"fungus  hsematodes." 

The  rarer  forms  of  tumour  may  be  briefly  described.  The  so-called 
myxomata  are  merely  mucoid  forms  of  glioma.  Melanotic  tumours 
have  been  met  with,  always  associated  with  similar  growths  elsewhere. 

*  See  '  Medico-Chirurgical  Trans.,'  vol.  lix,  1876,  p.  217. 


TUMOUES.  499 

Fibroid  tumours  are  very  rare,  and  have  been  met  with  chiefly  in  the 
cerebellum  or  cerebellar  peduncle,  small  in  size,  usually  single,  but  in 
one  case  multiple.     Bony  tumours  are  usually  partly  fibroid,  "  osteo- 
fibromata."     They  have  been  met  with  chiefly  in  the  cerebral  hemi- 
spheres,— once  in  the  cerebellum,  once  in  the  central  ganglia,  and 
once  were  multiple.     (It  must  be  remembered  that  calcification  may 
occur  in  any   degenerating  tumour,  tubercle,   glioma,  or  sarcoma.) 
Psammomata  are  small  tumours  which  may  consist  of  fibrous  tissue 
mingled  with  particles  of  "  brain  sand,"  such  as  occurs  in  the  pineal 
gland  or  choroid  plexus — calcareous  particles,  which  are  sometimes 
aggregated  into   larger  irregular   masses.      These  growths   usually 
spring  from  the  dura  mater  at  the  base  of  the  brain,  or  from  the 
choroid  plexus,  and  form  small  hemispherical  tumours,  reddish  grey, 
smooth,  and  hard.     Cholesteatomata  are  small  hard  bodies,  which  are 
usually  found  in  recesses  in  the  base  of  the  skull,  and  are  composed 
of  epidermoid  cells  arranged  in  concentric  layers.     They  are  perfectly 
innocent  in  this  situation,  but  they  have  also  been  met  with  of  con- 
siderable size,  as  large  as  a  hen's  egg  or  even  as  a  fist,  growing  into 
the  cerebral  substance,  and  even  arising  within  the  hemisphere,  in  the 
central  ganglia,  or  the  pons.     They  are  said  to  contain  cholesterine 
and  stearine ;  hence  their  name.     Among  the  rarest  of  intra-cranial 
tumours   are  neuromata,  small  growths   containing   nerve-elements. 
Lipomata  have  been  observed  on  the  surface  of  the  corpus  callosum 
and  corpora  quadrigemina,  in  the  ventricles  and  on  the  dura  mater  ;• 
and  vascular  or  erectile  tumours  have  been  met  with,  once  or  twice,  in 
the  substance  of  the  cerebral  hemispheres.     Fcetal  tumours,  teratoma, 
are  among  the  most  rare.f 

Cysts  in  the  brain  are  generally  the  relics  of  an  acute  destroying 
lesion,  haemorrhage  or  softening  ;  the  effused  blood  or  degenerated 
nerve-elements  having,  in  the  course  of  time,  become  absorbed.  Such 
cavities  have  usually  an  irregular  shape,  and  no  well-defined  wall. 
Simple  serous  cysts,  of  more  regular  form  and  with  a  fibrous  wall,  are 
sometimes  met  with  in  the  membranes,  the  cerebral  hemispheres,  or 
the  cerebellum  ;  their  origin  is  uncertain.  Small  cysts  are  often 
found  in  the  choroid  plexuses,  and  now  and  then  these  attain  a 
considerable  size.  More  frequently  cystic  cavities  are  developed  in 
connection  with  morbid  growths,  especially  glioma  and  sarcoma. 
Such  a  growth  may  contain  one  or  more  cavities  within  it,  or  a  cyst 
may  be  attached  to  one  side  of  a  growth,  or  may  occupy  almost 
the  whole  area  of  the  tumour,  its  walls  only  consisting  of  the  new 

*  And  (as  fat  enclosed  in  a  fibrous  wall)  between  the  two  layers  of  the  anterior 
part  of  the  falx  (Rolleston,  *  Trans.  Path.  Soc.,'  1892). 

f  In  a  case  recorded  by  Hugo  Beck  ('  Zeitschrift  fur  Heilkunde,'  1884)  a  walnut- 
sized  tumour  occupied  the  position  of  the  pituitary  body,  and  contained  bony  and 
cartilaginous  tissues  and  teeth.  The  patient  was  a  woman  aged  seventy-four,  and 
the  tumour  had  caused  no  symptoms.  Dermoid  cysts  containing  hair  have  also  been 
found  in  the  lateral  ventricle. 


500  BKAIN. 

growth.  We  have  seen  that  a  glioma  often  breaks  down  in  part,  so 
as  to  form  a  cavity,  containing  debris  of  its  elements ;  in  process  of 
time  the  debris  may  be  removed,  and  it  is  probable  that  the  cyst 
thus  formed  may  enlarge  by  the  flow  of  liquid  into  it.  Such  cystic 
tumours  are  met  with  especially  in  tbe  cerebellum,  occasionally  in  the 
white  substance  of  the  hemispheres,  very  rarely  in  other  parts  of  the 
brain.     Dermoid  cysts  have  been  already  mentioned. 

Parasitic  cysts  may  be  either  hydatid  or  cysticercous,  the  former 
usually  single ;  the  latter,  which  are  less  common,  are  often  multiple. 
Hydatid  tumours  have  been  found  outside  the  dura  mater,  but  their 
usual  position  is  the  cerebral  hemisphere,  either  in  the  white  substance 
or  within  the  ventricles.  Cysticerci  are  most  common  in  the  mem- 
branes or  the  cortex,  but  have  been  found  in  the  central  ganglia,  the 
crus,  pons,  cerebellum,  medulla  oblongata,  or  at  the  base.  Occasionally 
as  many  as  fifty  or  a  hundred  cysticerci  have  been  found  in  various 
parts  of  the  brain. 

The  pineal  gland  may  be  invaded  by  tumours  springing  from  the 
corpora  quadrigemina,  and  has  occasionally  been  found  the  seat  of 
independent  growths,  usually  firm  and  hard,  attaining  the  size  of  a 
nut  or  a  pigeon's  egg.  In  one  case  the  body  was  the  seat  of  a  cystoid 
enlargement  which  occupied  the  whole  of  the  third  ventricle. 

Tumours  of  the  base  of  the  brain  deserve  special  mention.  They 
usually  spring  from  the  dura  mater,  sometimes  from  the  bone.  Sar- 
coma and  carcinoma  are  most  frequent ;  less  common  are  psammoma, 
cholesteatoma,  syphilitic  gumma,  enchondroma,  fibroid  growth,  and 
hydatid  cyst.  The  petrous  part  of  the  temporal  bone,  or  the  dura 
mater  over  it,  is  the  part  from  which  growths  most  frequently  spring  ; 
the  neighbourhood  of  the  sella  turcica  is  another  common  seat,  and 
sometimes  they  originate  in  the  posterior  fossa,  adjacent  to  the  foramen 
magnum.  They  may  spring  from  the  bone  in  this  part  (Fig.  139). 
They  often  attain  a  considerable  size,  even  that  of  a  hen's  egg,  and 
compress  the  superjacent  brain.  From  their  position,  the  cranial 
nerves  are  frequently  damaged  by  basal  tumours,  which  in  the 
anterior  fossa  often  compi'ess  or  invade  the  optic  chiasma  and  nerves 
to  the  eyeball,  and,  in  the  posterior  fossa,  the  pons  (Fig.  140),  medulla, 
and  the  nerves  which  arise  from  them.  The  fifth  nerve  and  Gasserian 
ganglion  are  affected  with  especial  frequency  by  the  growths  which 
originate  from  the  petrous  part  of  the  temporal  bone. 

Intra-cranial  growths  entail  certain  pathological  effects,  to  which 
their  symptoms  are  due.  (1)  By  the  process  of  growth  they 
destroy  directly  the  adjacent  nerve-elements.  This  destruction  is 
partly  the  result  of  pressure,  partly  the  effect  of  the  growth  of  the 
morbid  tissue-elements.  In  the  infiltrating  tumours,  these  tissue- 
elements  grow  between  and  enclose,  and  gradually  destroy,  the  nerve- 
elements.  In  the  non-infiltrating  growths  the  nerve-elements  perish 
before  the  compressing  tumour,  and  the  zone  of  softening  around  these 


TUMOURS. 


501 


CCJ.  adndX  d. 


FlG.  139. — Growth  from  the  occipital  bone  encroaching  on  the  foramen  magnum 
and  compressing  the  medulla.     (Drawn  by  the  late  Mr.  C.  E.  Jecks.) 


^  ,  Mm 


FlG.  140. — Tumour,  containing  cysts,  compressing  the  right  side  of 
the  pons  Varolii. 


502 


BEAIN. 


growths  is  due  to  this  destruction.  In  both  cases,  however,  the  slower 
the  process  of  growth  the  less  extensive  and  less  complete  is  the 
damage.  Nerve-fibres  may  persist  within  a  slowly  growing  glioma,  or 
may  long  resist  the  pressure  of  a  slowly  growing  tubercle  or  sarcoma. 
(2)  Intra-cranial  tumours  also  exert  distant  pressure.  A  growth 
is  a  new  mass  within  the  skull,  which  occupies  more  space  than  the 
tissue  which  it  has  destroyed,  and  so  exerts  pressure  on  all  parts  in 
that  region  of  the  skull.  The  nearer  the  parts  are  to  the  growth  the 
greater  is  the  effect  of  pressure  upon  them.     The  more  the  pressure  is 


Fig.  141. — Large  infiltrating  tumour  of  the  right  frontal  lobe  causing 
displacement  of  the  falx,  and  compression  of  the  opposite  hemisphere. 
(Prom  a  photograph.) 


limited  in  range  by  resisting  structures  the  greater  is  its  immediate 
effect.  The  falx  offers  some  resistance  to  the  extension  of  pressure 
from  one  cerebral  hemisphere  to  the  other,  but  is  often  displaced  by 
it.  More  effective  is  the  resistance  of  the  tentorium,  and  tumours  in 
the  small  space  beneath  it  may  compress  all  the  structures  therein 
contained.  Thus  the  pons  is  often  considerably  damaged  by  tumours 
of  the  cerebellum. 

One  pressure  effect  is  of  especial  importance,  that  by  which  internal 
hydrocephalus  is  produced.  The  cerebro-spinal  fluid  is  chiefly  secreted 
by  the  choroid  plexuses  of  the  lateral  ventricle,  and  passes  thence  by 
the  third  ventricle,  aqueduct  of  Sylvius,  and  fourth  ventricle.  This 
passage  may  be  closed  by  tumours  of  the  pons,  corpora  quadrigemina, 


TUMOURS.  503 

third  ventricle,  or  of  the  middle  lobe  of  the  cerebellum,  and  the 
foramina  of  exit  may  be  closed  by  secondary  meningitis.  The  fluid  is 
still  secreted,  but,  unable  to  escape,  distends  the  ventricles  above  the 
obstruction.  Moreover,  the  veins  of  G-alen,  which  return  the  blood 
from  the  choroid  plexuses  to  the  straight  sinus  in  the  tentorium,  are 
often  compressed  by  tumours  of  the  middle  lobe  of  the  cerebellum  or 
corpora  quadrigemina.  It  is  not  probable  that  the  compression  of 
these  veins  will  alone  cause  internal  hydrocephalus,  but  it  certainly 
increases  the  distension  of  the  ventricles  when  the  exit  is  closed. 
The  convolutions  ai*e  flattened,  the  bones  become  thin,  and  even  the 
sutures  of  the  skull  may  be  separated  by  the  powerful  distending  force. 

(3)  The  growth  of  a  tumour  causes  irritation,  due  in  part  to  the 
pressure,  in  part  to  the  vascular  disturbance  which  attends  it,  in  part, 
perhaps,  to  the  influence  of  the  process  of  new  cell  formation.  The 
acute  destruction  of  the  nerve-elements  is  an  irritative  process,  some- 
times even  inflammatory  in  nature.  To  this  irritation  the  circumjacent 
softening  is  chiefly  due,  and  by  it  some  of  the  most  characteristic 
symptoms  are  produced.  But  the  irritation  is  not  confined  to  the 
brain-substance.  The  meninges,  especially  the  pia  mater,  are  more 
prone  to  inflammation  than  any  other  intra-cranial  structure.  Hence, 
if  the  growth  reaches  the  surface  of  the  brain,  there  is  usually  distinct 
evidence  of  meningitis  over  it.  The  pia  mater,  if  not  invaded,  is 
vascular,  opaque,  and  thickened,  and  adhesions  form  between  it  and 
the  dura  mater.  Traces  of  inflammation,  recent  or  old,  sometimes 
extend  for  a  considerable  distance  from  the  tumour,  often  more  in 
one  direction  than  in  another.  Now  and  then  there  is  evidence  of 
meningitis  at  a  distance,  without  any  traceable  connection  with  the 
growth,  so  that  it  must  apparently  be  ascribed  to  distant  pressure 
Thus  in  a  case  of  tumour  of  the  corpora  quadrigemina,  which  had 
caused  internal  hydrocephalus,  there  were  signs  of  inflammation, 
beneath  each  orbital  lobule,  and  nowhere  else.  In  the  diathetic  forms 
of  tumour,  syphilitic  and  tubercular,  meningitis  is  especially  frequent 
and  important,  because  it  also  results  from  the  constitutional  con- 
dition. In  tubercular  tumours  the  meningitis  is  usually  general  and 
acute,  in  syphilitic  growths  it  is  local  and  chi-onic.  The  tubercular 
meningitis  is  frequently  the  immediate  cause  of  death  in  cases  of 
tubercular  tumour,  especially  in  children.  In  syphilitic  tumours,  the 
adjacent  pia  mater  and  arachnoid  are  often  extensively  thickened  by 
a  mixed  process  of  inflammation  and  growth,  matting  together  the 
structures,  and  damaging  nerve-roots  at  some  distance  from  the 
growth. 

An  occasional  effect  produced  by  tumours  of  the  brain  is  to  cause  a 
remarkable  thinning  of  the  cranial  bones.*  It  is  sometimes  local, 
corresponding  to  the  position  of  the  growth ;  more  often  it  involves 

*  See,  on  this  subject,  a  valuable  paper  by  Hale  White  in  tlie  '  Guy's  Hosp.  Rep./ 
vol.  xliii,  1886. 


504  BRAIN. 

the  roof  and  sides  of  the  skull,  less  commonly  the  bones  of  the  base 
also.  In  extreme  cases  the  bone  may  be  reduced  to  the  thinness  of 
cardboard.  Actual  perforation  has  been  observed  only  over  the  tym- 
panum (Hale  White).  The  inner  surface  of  the  bone  is  rough,  in 
consequence  of  the  unequal  erosion.  The  outer  surface  of  the  dura 
mater  may  present  corresponding  inequalities,  and  the  membrane  is 
often  thickened.  The  atrophy  occurs  when  the  tumour  is  within  the 
substance  of  the  brain  as  well  as  when  it  is  at  the  surface,  but  the 
condition  is  only  found  when  the  tumour  is  large  or  there  is  internal 
hydrocephalus.  It  seems  to  be  the  result  of  the  increase  of  intra- 
cranial pressure,  which  slowly  causes  an  atrophy  of  bone  similar  to 
that  produced  by  aneurism. 

Symptoms. — The  nerve  disturbances  produced  by  intra-cranial 
tumours  are  commonly  grouped  into  two  classes,  general  or  diffuse,  and 
local  (see  p.  74).  The  former  are  those  symptoms  which  are  produced 
by  growths  in  various  situations,  and  are  of  various  kinds.  Such  are 
headache,  vomiting,  giddiness,  general  convulsions,  optic  neuritis,  &c. 
The  local  symptoms  (focal  symptoms ;  German,  Herdsywvptomen)  are 
those  which  depend  on,  and  afford  some  indication  of,  the  position  of 
the  tumour  ;  they  comprehend  the  local  palsy  and  spasm,  the  affec- 
tions of  sensibility  and  of  cranial  nerves,  which  are  the  effects,  more 
or  less  direct,  of  the  existence  of  the  tumour  in  a  certain  situation.  It 
is  important  to  remember  that  the  division  is  not  absolute.  Some  of 
the  general  symptoms  may  be  produced  to  a  greater  extent  by  disease 
in  one  situation  than  in  another,  and  so  may  have  a  focal  significance 
(see  p.  74). 

In  most  cases  the  general  symptoms  precede  the  local,  and  the  onset 
of  both  is  usually  slow  and  gradual.  Sometimes  they  are  trifling 
compared  with  the  size  of  the  growth,  and  in  rare  cases  they  may  be 
absent,  or,  at  any  rate,  so  slight  as  to  have  attracted  no  attention, 
and  a  tumour  is  found  post  mortem,  the  existence  of  which  was  not 
suspected  during  life.  This  is  especially  the  case  with  tumours 
springing  from  the  membranes  and  merely  compressing  the  brain,  it 
may  be  to  a  considerable  degree,  but  with  slowness.  Thus  a  globular 
fibroma,  attached  to  the  dura  mater,  although  it  was  over  the  upper 
part  of  the  central  convolutions,  two  inches  in  diameter,  and  had 
caused  a  deep  depression  in  the  brain,  produced  no  symptoms  during 
life.* 

Of  the  general  symptoms,  headache  is  the  most  constant,  absent  only 
in  very  rare  cases.  It  is  usually  constant,  with  paroxysmal  exacer- 
bations ;  less  frequently  it  intermits.  In  character  the  pain  varies 
much  ;  it  may  be  dull  or  acute ;  somelimes  it  is  described  as  rending, 
tearing,  stabbing,  boring.  Its  severity  is  usually  such  that  sleep  is 
more  or  less  disturbed  by  it,  and  in  the  acute  paroxj  sms  the  mind 

*  Willett,  '  Trans.  Path.  Soc.,'  1892. 


TUMOTJBS.  505 

may  be  unhinged  by  the  intense  agony.  It  is  usually  increased  by 
whatever  causes  passive  congestion  of  the  brain,  as  a  cough,  or  mus- 
cular effort.  It  may  be  general,  felt  equally  in  all  parts  of  the 
cranium,  or  chiefly  in  the  front  or  in  the  back  of  the  head,  or 
•on  one  side,  or  it  may  even  be  referred  to  a  limited  area.  The 
locality  of  the  pain  does  not  always  correspond  to  the  locality  of  the 
disease.  It  may  be  referred  to  the  forehead,  when  the  disease  is  in 
the  cerebellum,  or  to  one  side  when  the  disease  is  on  the  other.  But 
when  the  tumour  is  at  the  surface  of  the  brain,  the  pain  usually  corre- 
sponds to  the  diseat-e  in  situation.  When  the  growth  is  in  the  white 
substance,  the  pain  is  often  frontal,  whether  the  disease  is  in  the 
frontal  or  parietal  lobe.  When  the  disease  is  beneath  the  tentorium 
the  pain  is  usually  occipital,  and  often  seems  to  pass  down  the  neck. 
Unilateral  occipital  pain  usually  corresponds  in  side  to  the  disease. 
If  the  tumour  is  superficial,  gentle  tapping  causes  pain  over  the 
seat  of  the  disease,  and  not  elsewhere.  Neuralgic  pain  in  the  region 
of  the  fifth  nerve  indicates  irritation  of  the  nerve,  and  is  not  a 
"  general  "  symptom  ;  but  this  pain,  when  in  the  first  division  of  the 
fifth,  often  blends  with  headache  on  the  same  side.  The  local  pain 
produced  by  superficial  tumours  is  doubtless  due  to  irritation  of  the 
meninges.  The  more  general  headache  has  been  referred  to  the  in- 
fluence of  the  increased  intra-cranial  pressure  on  the  sensitive  mem- 
branes, and  the  relief  afforded  in  some  cases  by  trephining,  with  or 
without  puncture  of  the  lateral  ventricle,  gives  support  to  the  opinion, 
but  it  does  not  explain  the  headache  in  all  cases,  since  this  may  be 
severe  when  a  small  growth  causes  no  increase  of  intra-cranial  pressure, 
and  the  latter  may  be  great  without  headache. 

Optic  neuritis  occurs  in  a  large  proportion  (probably  about  four 
fifths)  of  the  cases  of  intra-cranial  tumour,  whatever  be  the  seat  01 
nature  of  the  growth,  whether  it  commences  in  the  brain  or  membranes. 
Nevertheless  it  is  certainly  less  frequent  when  the  growth  is  in  the 
membranes  over  the  convexity,  and  merely  compresses  the  brain,  than 
when  the  cerebral  tissue  is  actually  invaded.  The  size  of  the  tumour, 
per  se,  seems  to  have  little  influence,  and  the  optic  neuritis  is  certainly 
not  produced  simply  by  the  mechanism  of  increased  intra-cranial  pres- 
sure. It  has  been  caused  by  a  tubercle  of  the  pons  no  larger  than  a 
cherry,  and.  was  absent  in  a  case  which  I  watched  throughout,  in 
which  a  sarcoma,  the  size  of  the  closed  fist,  growing  from  the  dura 
mater,  had  compressed  but  not  invaded  the  middle  of  one  hemisphere, 
and  must  have  raised  the  intra-cranial  pressure  as  much  as  it  is  ever 
raised  by  the  direct  agency  of  an  intra-cranial  growth.  It  is  probable 
that  the  neuritis  is  due  to  more  than  one  mechanism,  which  vary  in 
relative  degree  in  different  cases.  One  of  these  is  the  extension  of  a 
process  of  tissue  irritation  to  the  optic  tract  and  nerves  which,  reaching 
the  papilla,  lights  up  a  more  considerable  inflammation.  Another  is 
the  distension  of  the  sheath  of  the  optic  nerve  and  lymphatic  spaces 
of  the  pupilla,  by  subarachnoid  fluid,  containing,  it  may  be,  irritating 


50(5  BRAIN. 

products ;  possibly  this  determines  the  intensity  of  the  inflammation. 
A  third  is  the  meningitis  which,  as  we  have  seen,  often  occurs  in  cases 
of  intra-cranial  tumour,  and  may  extend  directly  to  the  optic  nerves. 
The  neuritis  is  usually  a  transient  event  in  the  course  of  the  tumour, 
which  may  exist  for  a  considerable  time,  even  for  years,  without  any 
affection  of  the  optic  discs,  and  then  neuritis  may  be  rapidly  developed, 
run  its  course,  and  pass  into  atrophy,  and  the  symptoms  of  the  tumour 
go  on  as  before.  Often,  however,  the  occurrence  of  the  neuritis  coincides 
with  an  obvious  increase  in  the  other  symptoms  of  the  growth,  and 
probably  always  indicates  progress  of  the  disease.  In  the  majority 
of  cases  both  eyes  are  affected,  one  sometimes  more  than  the  other. 
Rarely  the  neuritis  is  unilateral,  and  this  although  the  disease  may 
be  one  which  usually  causes  bilateral  neuritis  ;  it  may  be  on  the  side 
of  the  tumour  or  opposite  to  it. 

The  course  of  neuritis  varies  considerably  in  different  cases.  It  may 
develop  rapidly,  with  extravasations  and  great  distension  of  veins, 
and  subside  in  a  few  weeks  to  "  consecutive  atrophy."  On  the  other 
hand,  it  may  develop  slowly,  without  distension  of  the  veins,  and  be 
stationary  for  months,  or  even  for  a  year,  before  it  subsides.  The 
course  of  the  neuritis  is  some  indication  of  the  course  of  the  tumour. 
Although  a  rapid  neuritis  is  sometimes  developed  in  the  course  of  a 
slowly  growing  tumour,  a  chronic  neuritis  never  results  from  a  rapidly 
growing  tumour.  If  the  neuritis  is  acute  and  the  tumour  is  not  influ- 
enced by  treatment,  the  neuritis  usually  goes  on  to  atrophy.  It  often 
does  so  also  in  the  chronic  form,  but  now  and  then  a  slight  neuritis, 
slowlv  developed,  may  subside,  although  the  tumour  continues  to 
increase.  But  if  the  moi-bid  process  within  the  skull  can  be  influenced 
by  treatment,  the  neuritis  may  subside  and  leave  little  trace  of  its 
presence,  and  the  recovery  of  normal  vision  may  be  perfect.  The 
diminution  in  the  intra-ocular  affection  may  be  the  first  indication  of 
the  improvement  that  is  taking  place  within  the  skull.  For  other 
particulars  regarding  the  mechanism,  symptoms,  and  consequences 
of  neuritis,  the  reader  is  referred  to  the  special  account  of  "  Optic 
Neuritis,"  but  it  may  be  again  pointed  out  that  sight  may  be  unim- 
paired as  long  as  the  inflammation  is  moderate  in  degree,  and  often 
fails  much  more  while  this  is  subsiding  than  during  the  active 
stage.  The  stage  of  atrophy  is  never  reached  until  after  many  months, 
and  this  fact  often  affords  very  important  indications.  A  tumour,  for 
instance,  may  have  caused  marked  symptoms  for  only  a  short  time,  but 
the  condition  of  the  optic  disc  may  prove  that  the  growth  must  have 
existed  for  many  months  before  the  other  symptoms  were  manifest. 

Mental  Disturbance. — Stupor  and  coma  are  common  as  terminal 
phenomena  in  most  forms  of  intra-cranial  tumour,  immediately  pre- 
ceding death.  Apart  from  this  final  state,  during  the  course  of  the 
disease,  psychical  symptoms  are  not  unfrequent.  The  most  common 
form  is  simple  mental  failure,  loss  of  memory,  depression,  sometimes 
with  emotional  mobility,  now  and  then  varied  by  excitement.     This 


TUMOURS.  507 

condition  may  accompany  tumours  in  any  situation.  It  is  sometimes, 
in  tumours  of  the  mesencephalon,  produced  through  the  agency  of 
internal  hydrocephalus  compressing  the  cortex.  Occasionally  there  is 
more  pronounced  mental  disturbance,  hallucinations  and  delusions,  or 
actual  dementia,  in  some  cases  simulating  simple  insanity.  The  tumour 
is  then  generally  in  the  anterior  portion  of  the  frontal  lobe,  or  in 
the  temporo- sphenoidal  lohe.  A  man  with  a  large  tumour  beginning 
in  the  temporal  lobe  had  vivid  hallucinations  that  his  wife,  who  had 
died  two  years  before,  was  committing  adultery  in  the  ward  before  his 
eyes.  In  another  case  of  glioma  of  the  frontal  lobe  the  only  symptoms 
were  headache,  optic  neuritis,  attacks  of  petit  mal,  and  mental  dis- 
turbance with  childish  acts.  The  patient  would  strip  the  bedclothes 
off  other  patients  who  were  in  bed,  turn  pictures  to  the  wall,  &c.  It 
is  important  to  remark,  moreover,  that  cerebral  tumour,  like  every 
other  form  of  brain  disease,  may  evoke,  in  predisposed  persons,  the 
manifestations  of  hysteria.  This  is  an  important  and  common  event, 
to  which  attention  has  been  of  late  frequently  directed.  Many  errors 
of  diagnosis  have  occurred  in  such  cases  ;  the  unmistakable  sym- 
ptoms of  hysteria  have  had  their  frequent  consequences  in  causing 
.the  physician  to  overlook  the  symptoms  of  organic  disease. 

Vomiting  is  a  common  effect  of  tumour  in  all  parts  of  the  brain, 
especially  in  the  medulla  oblongata,  the  middle  lobe  of  the  cerebellum, 
and  the  corpora  quadrigemina ;  it  is  rather  less  frequently  caused  by 
tumours  of  the  cerebellar  hemispheres,  the  pons,  the  base,  or  the  central 
ganglia.  It  is  still  less  common  (occurring  in  about  a  quarter  of  the 
cases)  when  the  growth  is  in  the  cerebral  hemispheres. 

Giddiness,  constant  or  paroxysmal,  attends  tumours  in  various  situa- 
tions. It  is  sometimes  produced  through  the  agency  of  the  paralysis 
of  an  ocular  muscle,  or  derangement  of  the  auditory  nerve  (see 
chapter  on  "Vertigo  ").  Without  any  distinct  peripheral  mechanism, 
it  is  most  severe  and  frequent  in  cases  of  disease  of  the  pons,  corpora 
quadrigemina,  cerebellum,  and  middle  cerebellar  peduncle.  In  the 
latter  case  it  is  sometimes  very  intense,  and  is  frequently  associated  with 
a  tendency  to  a  corresponding  motion  of  the  head  or  body.  It  is  less 
frequent  in  tumours  of  the  cerebral  hemispheres  than  in  those  of  the 
central  ganglia,  but  unsteadiness,  like  that  of  cerebellar  disease,  has 
been  observed  in  tumours  of  the  pre-frontal  lobes.* 

Affections  of  Speech. — A  peculiar  slowness  of  speech  is  sometimes 
met  with  in  association  with  tumours  in  almost  every  position,  but 
with  especial  frequency  in  tumours  of  the  cerebrum.  A  tendency  to 
separate  the  syllables  is  conspicuous  in  some  cases  of  tumour  of  the 
pons.  "With  mental  dulness  from  tumours  in  any  situation,  it  is  not 
infrequent  for  words  to  be  clipped,  or  syllables  run  together  in  "  con- 
fluent articulation."  Marked  difficulty  of  articulation  occurs  chiefly 
when  the  growth  is  situated  in  the  pons  or  medulla,  or  in  the  posterior 
fossa  of  the  base.  It  is  also  produced,  now  and  then,  by  tumours  of 
*  Brims, '  Neur.  Cent..'  1891.      The  cerebellum  is  connected  with  these. 


508  BEAIN. 

the  cerebellum  -when  these  cornpvess  the  pons  or  medulla.  Aphasic 
difficulties  of  speech  are  chiefly  due  to  tumours  of  the  left  cerebral 
hemisphere,  cortex  or  white  substance ;  as  a  permanent  symptom 
onlv  when  the  growth  directly  damages  the  speech-centres  already  de- 
scribed (p.  109),  when  the  impairment  may  be  of  the  motor  or  the 
sensory  type,  but  it  is  often  much  slighter  than  would  be  expected 
from  the  size  of  the  growth,  and  is  sometimes  paroxysmal.*  It 
occurs  also  as  a  variable  and  intermitting  symptom  in  disease  of 
neighbouring  parts,  even  of  the  upper  part  of  the  central  region, 
•chiefly  in  association  with  convulsions,  and  probably  as  an  effect  of 
irritative  inhibition. f  It  may  thus  be  caused  indirectly  by  growths 
still  lower  in  various  parts  of  the  central  ganglia  and  even  in  the 
pons  ;  the  defect  of  speech  mentioned  on  p.  318  was  caused  by  a  tumour. 
Motor  Disturbance. — Paralysis  occurs — (1)  Under  the  form  of 
ordinary  hemiplegia,  almost  always  gradual  in  onset,  affecting  the 
lower  part  of  the  face,  the  arm,  and  the  leg,  from  tumours  situated  in, 
or  pressing  on,  the  upper  part  of  the  pons,  crus,  internal  capsule,  or 
the  cortex.  Its  degree  and  extent  vary  much,  according  to  the 
slowness  or  rapidity  with  which  the  pressure  is  exerted. 

(2)  Partial  hemiplegia,  paralysis  of  the  arm,  or  arm  and  face,  less> 
commonly  of  the  leg,  is  usually  the  result  of  growths  in  or  beneath 
or  adjacent  to  the  motor  part  of  the  cortex,  and  is  often  associated 
with  convulsions  beginning  locally  on  the  paralysed  side.  Both  the 
local  palsy  and  the  local  convulsion  usually  commence  in  the  extremity 
of  the  affected  limb,  and  have  the  same  significance.  The  position 
of  the  growths  causing  such  limited  symptoms  has  been  already 
described  in  the  chapter  on  "  Localisation." 

When  the  tumour  is  seated  below  the  hemispheres,  in  the  crus, 
pons,  or  medulla,  the  hemiplegia  is  often  accompanied  by  paralysis  of 
one  or  more  cranial  nerves  on  the  side  corresponding  to  the  tumour, 
and  opposite  to  the  affected  limbs,  as  described  at  p.  317. 

Basal  tumours  ouly^cause  hemiplegia  when  they  are  seated,  or 
extend,  so  far  back  as  to  compress  the  crus,  the  pons,  or  medulla ;  and 
the  character  of  the  hemiplegia  is  similar  to  that  produced  by  tumours 
in  these  parts,  but  the  nerve-palsy  is  usually  more  extensive,  and 
occurs  earlier,  than  in  the  case  of  growths  within  the  brain-substance. 

(3)  The  paralysis  produced  by  iutra-cranial  tumours  is  sometimes 
not  unilateral,  but  bilateral.  This  may  result  (a)  in  rare  instances  from 
symmetrical  tumours  on  both  sides  of  the  brain,  generally  in  the 
central  ganglia  or  white  substance ;  one  tumour  may  be  larger  than 
the  other,  and  may  cause  the  chief  symptoms;  (6)  from  a  single 
tumour  in  such  a  position  that  it  compresses  the  motor  tracts  of  both 

*  E.g.  a  cyst  in  the  left  temporo-sphenoid;d  lobe  caused  frequent  long  ai tacks 
of  unconsciousness,  followed  by  inability  to  "find  the  desired  word."  (Franks, 
*  Brit.  Med.  Journ.,'  1888.) 

f  It  was  probably  by  this  mechanism  that  a  solitary  tubercle  in  the  right  lower 
motor  region  of  a  right-handed  patient  caused  aphasia.  (Oppenheim,  « Neur.  Cent./ 
1890.) 


TUMOURS.  509 

sides.  This  can  only  happen  when  the  tumour  is  situated  in  or  near 
the  mesencephalon,  where  the  two  motor  tracts  are  still  contiguous, 
and  it  is  generally  due  to  a  tumour  in  or  compressing  the  pons  or 
the  medulla  oblongata.  In  the  latter  situation  the  weakness  may  be 
chiefly  in  the  legs,  causing  paraplegia,  usually  greater  in  one  leg  than 
in  the  other,  but  rarely  limited  to  them,  and  distinguished  by  the 
affection  of  cranial  nerves.  When  the  damage  to  the  motor  tracts 
is  by  pressure  from  a  distance  (as  in  the  case  of  tumours  of  the 
cerebellum  or  corpora  quadrigemina)  the  bilateral  weakness  is*  often 
slight  in  degree,  but  an  increased  knee-jerk  and  a  foot-clonus  are  sel- 
dom absent.  (The  exceptional  loss  in  some  cerebellar  tumours  has 
been  mentioned  at  p.  321.) 

Contracture,  persistent  tonic  spasm,  with  excess  of  myotatic  irrita- 
bility, is  frequently  associated  with  the  paralysis  in  the  limbs,  and  has 
no  special  significance.  Confined  to  one  limb,  it  usually  indicates  that 
the  disease  is  in  or  near  the  motor  cortex.  The  chief  difference  from 
the  contracture  which  follows  other  lesions  is  that  it  often  accom- 
panies, instead  of  following,  the  loss  of  power,  doubtless  because  the- 
damage  to  the  motor  tract  is  not  only  gradual,  but  irritative  in  its- 
character,  and  descending  degeneration  occurs  readily.  From  the  same 
cause  the  contracturecl  muscles  often  waste  early,  but  in  moderate  de- 
gree, the  more  irritative  degeneration  of  the  pyramidal  fibres  involving 
the  finer  nutrition  of  the  spinal  motor  nerve-cells  (seep.  84).  General 
tetanic  rigidity,  without  paralysis,  may  occur  from  tumours  of  the  pons 
or  cerebellum  ;  in  the  latter  case  there  is  occasionally  retraction  of  the 
head,  with  rigidity  of  the  neck, 
but  it  is  uncertain  whether  this 
is  caused  directly,  or  through 
the  agency  cf  basal  meningitis, 
or  of  pressure  on  the  medulla 
oblongata.  Bilateral  tumours 
in  the  cerebral  hemispheres,  in- 

volvingthe  paths  for  the  mus-     ^Jt^TJo^^ T^  °^FT (V' 
&  J-  ana  left  crus  cerebri,  snowing-  a  tubercle 

cles  of  the  neck  and  trunk,  have  (t)    in   the   crus,   beneath    the   corpora 

also    caused    rigidity     of     these  quadrigemina  (c  q).     The  patient  was  a 

#  ehild,  and  the  first  symptom  was  jeiky 

Parts-  inco-ordination  of  the  rig-lit  arm  exactly 

Spontaneous        choreoid        or  like  that  of  disseminated  sclerosis,  fol- 

"  athetoid  "   spasm    also  occurs        }™e15y  iKy  £  the  ,"£'  tb,e£  °!,-h! 
.     .      l  leg   and   lace,   then   of    the   left    third 

in    association   with    hemiplegic         nerve  (in),  and  later  of  the  right  also, 
weakness  and    contracture,  but 

less  commonly  than  after  some  other  cerebral  lesions.  It  is  accom- 
panied by  a  slow  spastic  inco-ordination.  It  has  been  sometimes 
observed  in  cases  of  tumour  of  the  parietal  lobe,  and  of  the  neigh- 
bourhood of  the  optic  thalamus.  One  form  of  inco-ordination  in 
the  arm  is  not  at  all  infrequent  in  cases  of  tumour  (especially 
tubercle)  of  the  pons  or  crus,  as  in  the  case  shown  in  Tig.  142.  It  is. 
*  See  Ormerod,  '  British  Med.  Journ.,'  1889. 


510  BRAIN. 

a  coarse,  jerky  incoordination,  precisely  resembling  that  which  is  seen 
in  disseminated  sclerosis.*  The  limb,  apart  from  voluntary  move- 
ment, is  free  from  spasm.  This  symptom,  in  disseminated  sclerosis, 
seems  to  be  due  to  the  wasting  of  the  Avhite  substance  of  the  nerve- 
fibres,  by  which  the  conducting  power  of  their  axis-cylinders  is  less- 
ened unequally.  The  pressure  of  a  tumour  on  the  motor  tract  may 
cause  a  similar  interference  with  structure,  and  the  phenomenon,  which 
is  certainly  identical  in  aspect,  may  thus  be  due  to  a  similar  mechan- 
ism in  each  case.  A  finer  tremor  is  not  an  uncommon  accompani- 
ment of  the  movement  of  weak  limbs,  and  has  no  special  significance. 

Unsteadiness  in  the  upright  posture,  most  marked  on  walking,  is  a 
common  symptom  in  tumour  of  the  cerebellum,  especially  of  the  middle 
lobe.  The  body  sways  like  that  of  a  drunken  person,  and  the  patient 
may  tend  to  fall  forwards,  backwards,  or  to  one  side.  The  movements 
of  the  arms  are  usually  steady. 

A  tendency  to  the  assumption  of  forced  positions,  or  to  certain 
involuntary  movements,  is  occasionally  seen.  When  there  is  vertigo 
the  patient  may  tend  to  one  side  in  walking,  irrespective  of 
the  cause  of  the  giddiness,  A  tendency  to  rotation  of  the  body 
has  been  noted  as  an  extremely  rare  symptom  of  tumour  of  the 
middle  peduncle  of  the  cerebellum.  Rotation  of  the  head  to  one  side, 
with  corresponding  conjugate  deviation  of  the  eyes,  occurs  in  some 
cases  of  cerebral  tumour.  Deviation  towards  the  side  of  the  lesion,  so 
frequent  at  the  onset  of  cerebral  haemorrhage,  occurs  in  tumours  of 
various  positions,  although  not  frequently.  Occasionally  there  is  a 
deviation  from  the  side  of  the  cerebral  lesion,  due  to  irritation  and 
spasm  when  the  disease  is  in  the  cei'ebral  hemispheres,  or  to  paralysis 
when  it  is  in  the  pons  (see  p.  78). 

Convulsive  attacks  are  frequent,  and  are  of  four  chief  forms.  Two 
are  of  merely  general  significance,  occurring,  like  headache  and  optic 
neuritis,  from  tumours  of  various  seat ;  while  two  are  of  local  signi- 
ficance, met  with  chiefly  when  the  growth  occupies  certain  situations. 

(1)  Attacks  of  general  convulsion  with  initial  loss  of  consciousness, 
resembling  the  fits  of  ordinary  epilepsy,  occur  in  tumours  of  every  part, 
but  are  not  common  when  the  medulla  oblongata  or  cerebellum  is  the 
seat  of  the  disease.  They  are  more  frequent  in  tumours  of  the  poste- 
rior fossa  of  the  base  than  in  tumours  of  the  anterior  or  middle  fossa. 
The  mechanism  by  which  these  convulsions  are  produced  is  uncertain. 
They  are  often  ascribed  to  the  general  increase  of  intra-cranial  pressure 
caused  by  the  growth,  on  the  ground  that  similar  convulsions  are  pro- 
duced in  animals  when  the  intra-cranial  pressure  is  raised  (to  130  mm. 
of  mercury,  Ley  den).  But  it  is  scarcely  justifiable  to  conclude  that, 
because  a  rapid  increase  in  the  pressure  causes  convulsions,  these  are, 
therefore,  thus  produced  by  a  slowly  growing  tumour ;  and  the  expla- 

*  It  is  exceedingly  probable  that  some  cases  published  as  examples  of  dissemi- 
nated sclerosis  in  childhood  have  really  been  cases  of  stationary  tubercle  of  the 
brain. 


TUMOUES.  511 

nation  is  not  easy  to  reconcile  with  many  clinical  facts,  which  show, 
first,  that  large  tumonrs  do  not  necessarily  cause  convulsions  ;  and, 
secondly,  that  even  in  the  most  severe  form  such  convulsions  may 
be  produced  when  there  is  no  increase  of  intra-cranial  pressure.  An 
instance  of  the  latter  was  afforded  by  a  case  in  which  general  con- 
vulsions persisted  after  other  symptoms  of  syphilitic  brain  disease 
had  been  removed  by  treatment,  and  yet  the  patient  actually  died  from 
the  violence  of  the  fits.  The  only  disease  discovered  was  a  small, 
shrunken  gumma  in  the  anterior  part  of  the  right  frontal  lobe. 

(2)  Attacks  of  brief  loss  of  consciousness,  resembling  the  petit  mal 
of  epilepsy,  occur  occasionally,  but  not  frequently,  also  from  tumours  in 
various  situations,  especially  in  the  cerebral  hemispheres.  They  are 
often  associated  with  the  general  convulsions  just  described,  and,  like 
them,  are  of  only  general  significance. 

(3)  The  convnlsions  may  commence  in  a  manner  which  indicates  that 
the  discharge  begins  deliberately  at  some  one  part  of  the  brain,  and 
remains  limited  to  it,  or  slowly  spreads  to  other  parts.  The  characters 
and  significance  of  such  convulsions  have  been  already  described. 
They  are  generally  dne  to  a  morbid  growth  in  or  near  the  motor  region 
of  the  cortex,  and  especially  the  place  in  which  is  represented  the  part  in 
which  the  warning  of  the  fit  begins,  whether  the  commencement  is  by 
motion  or  by  a  sensation.  If  the  convulsion  commences  in  the  foot, 
the  tumour  is  probably  in  the  upper  part  of  this  region  ;  if  in  the  face, 
it  is  probably  in  the  lower  part ;  if  in  the  arm,  it  may  be  in  or  near 
the  middle  region.  Commencement  in  the  hand  has,  however,  been 
observed  when  the  tumour  is  not  contiguous  to  the  central  convolu- 
tions, which  must  then  be  influenced  indirectly.  The  commencement 
of  the  fit  sometimes  varies  in  a  way  not  easy  to  explain,  except  as  a  result 
of  "  irritation  "  in  the  various  structures  towards  which  the  growth 
is  extending.  The  discharge  begins  less  often  in  structures  that  are 
much  damaged  (so  as  to  cause  paralysis)  than  in  those  adjacent,  and 
merely  irritated;  the  loss  of  power  indicates  the  actual  seat  of  the 
growth  more  surely  than  the  initial  convulsion.  Thus  in  one  case  in 
which  some  fits  began  in  the  face,  some  in  the  arm,  some  in  the  foot, 
the  last  only  was  permanently  paralysed,  and  the  tumour  occupied  the 
highest  part  of  the  central  convolutions.*  Fits  which  begin  locally 
often  leave  transient  weakness  in  the  part  first  convulsed,  and  this,  if 
the  attacks  are  frequent,  may  persist  during  the  intervals,  passing  away 
when  they  cease.  The  frequency  of  these  local  fits  is  sometimes  very 
great.  In  the  case  just  mentioned  a  hundred  or  a  hundred  and  fifty 
fits  sometimes  occurred  daily,  and  in  the  course  of  eleven  months  the 
patient  had  17,000  fits  (carefully  recorded).  Occasionally  local  clonic 
spasm  may  continue  for  several  hours  or  even  days. 

*  A  similar  case  has  been  recorded  by  Osier  ('Ainer.  Journ.  of  Med.  Science,' 
18S5,  p.  31).  The  fits  began  in  the  left  hand  but  the  palsy  was  in  the  leg, 
and  the  tumour  was  just  beneath  the  highest  part  of  the  ascending  frontal  con- 
volution. 


512  BRAIN. 

The  local  coinuienceinent  is  sometimes  by  a  sensation,  tingling, 
"pins  and  needles,"  or  pain,  in  the  hand  or  in  the  foot,  as  mentioned  at 
p.  92.  As  already  stated,  this  sensory  commencement  has  the  same 
significance  as  the  motor  commencement,  and  the  part  in  which  the 
sensory  discharge  begins  is  that  in  which  the  chief  irritation  exists ; 
the  secondary  spasm  is  not  of  localising  significance. 

A  cerebral  tumour  may  cause  fits  which  commence  by  a  special 
sense  warning.  It  is  probable  that,  in  these  cases,  the  tumour  is 
situated  in  the  cerebral  cortex,  in,  near,  or  beneath  that  part  in  which 
the  special  sense-centre  is  situated.  Some  instances  of  this  are  men- 
tioned on  p.  92. 

(4)  Attacks  of  brief  tetanic  rigidity  with  retraction  of  the  head  have 
been  observed  in  some  cases  of  tumour  of  the  cerebellum.  Like  the 
persistent  rigidity,  it  is  uncertain  whether  they  are  due  to  the  irrita- 
tion of  the  cerebellum  or  to  pressure  on  the  pons  or  medulla. 

Sensory  Symjrtoms. — (1)  Loss. — Motor  hemiplegia  from  tumour  is 
often  accompanied  with  unilateral  diminution  of  sensibility  of  various 
distribution  and  character,  according  to  the  seat  of  the  disease,  as 
described  in  a  preceding  section  (p.  94).  Well-marked  heruianaes- 
thesia,  extending  up  to  the  middle  line,  and  usually  with  impairment 
of  all  the  special  senses  on  that  side,  occurs  in  cases  of  tumour  damaging 
the  posterior  part  of  the  internal  capsule  and  subthalamic  region,  a 
not  uncommon  seat  of  syphilitic  growths.  Affections  of  sensation 
are  rare  and  trifling  in  tumours  of  the  antei'ior  and  middle  fossa?,  of 
the  base,  the  corpora  quadrigemina,  and  the  cerebellum.  Bilateral 
loss  may  occur,  like  bilateral  motor  palsy,  from  growths  in  the  pons 
and  medulla. 

(2)  Sensory  irritation,  pain,  tingling,  and  other  paresthesia?  often 
accompany  the  anaesthesia  produced  by  cerebral  tumour,  just  as  spasm 
often  accompanies  the  motor  palsy,  in  consequence  of  the  irritating 
character  of  the  lesion.  Pain  in  the  limbs  is  most  frequent  in  tumour 
near  the  sensory  tract  or  the  central  cortex,  and  is  often  felt  in  the- 
limb  which  is  chiefly  paralysed  or  convulsed.  The  pain  may  be  in- 
creased by  movement,  active  or  passive,  and  local  convulsions  may  be 
sometimes  induced  by  movements  that  cause  pain.  Other  paresthesia? 
are  especially  frequent  in  tumours  of  the  pons  and  medulla. 

Cranial  Nerves :  Olfactory. — Loss  of  smell  has  been  noted  in  rare 
cases  of  tumour  in  various  parts  of  the  brain,  but  with  singular  infre- 
quency  in  any  part,  even  in  tumour  of  the  anterior  fossa  of  the  base. 
Its  occurrence  in  tumour  elsewhere,  even  in  the  cerebellum,  has  sug- 
gested that  its  loss  may  depend  on  an  olfactory  neuritis,  analogous  to 
optic  neuritis ;  but  this  is  a  mere  hypothesis,  at  present  unconfirmed. 

Optic  Nerve. — The  frequency  of  optic  neuritis  renders  impairment 
of  sight  a  very  common  symptom  of  intra-cranial  tumours,  irrespective 
of  their  seat.  Apart  from  this  affection,  which  has  been  already  con- 
sidered, sight  may  be  damaged  by  tumours  situated  in  or  near  the 
visual  path.     The  characters  of  the  loss,  according  to  the  seat  of  the 


TUMOTJES.  513 

disease,  have  been  already  described.  Symptoms  of  irritation  of 
the  optic  nerve  are  extremely  rare,  except  as  the  aura  of  convulsions, 
in  tumour  of  the  occipital  lobe. 

Third  Nerve. — Isolated  paralysis  of  the  whole  of  one  or  both  third 
nerves  occurs  only  in  tumours  of  or  adjacent  to  the  crus  cerebri,  first 
on  the  side  opposite  to  the  hemiplegia.  Both  third  nerves  may  be 
affected  by  an  interpeduncular  growth,  as  probably  in  the  case  shown 
in  Fig.  95,  p.  181.  Partial  paralysis  usually  involves  chiefly  the 
levator  or  the  internal  rectus. 

The  fourth  nerve  rarely  suffers  alone,  and  chiefly  in  tumours  in  or 
compressing  the  corpora  quadrigemina. 

The  sixth  nerve  is  frequently  paralysed  alone,  on  one  or  both  sides, 
by  subtentorial  disease,  which  exerts  pressure  on  the  nerve  on  account 
of  its  long  and  exposed  course.  It  is  also  damaged,  together  witi 
other  nerves,  by  tumours  of  the  pons,  medulla  oblongata,  and  in  the 
posterior  fossa  of  the  base. 

Combined  paralysis  of  ocular  muscles,  slight  and  various,  occurs 
in  tumours  of  various  situation,  that  exert  pressure  on  the  base 
— tumours  of  the  deeper  parts  of  the  hemispheres,  corpora  quadri- 
gemina, pons,  and  basal  tumours.  All  the  muscles  of  one  eye  are 
only  paralysed  by  growths  in  the  neighbourhood  of  the  sella  turcica, 
which  usually  cause  also  loss  of  sight. 

Conjugate  deviation  of  the  eyes  and  head  towards  the  side  of  a 
cerebral  lesion  (paralytic)  or  from  it  (spasmodic)  has  been  alreadv 
described.  Its  characteristic  is  that  the  axes  of  the  eyeballs  remain 
parallel  in  all  positions.  It  must  not  be  confounded  with  their  asso- 
ciated paralysis,  caused  by  tumours  within  the  pons,  described  at 
p.  186,  in  which  the  external  rectus  on  one  side  and  the  internal 
rectus  on  the  other  are  affected  together,  so  that  the  eyes  cannot  be 
moved  towards  the  side  of  the  lesion  beyond  the  middle  line.  The 
variations  in  this  symptom,  and  their  localising  significance,  have  been 
already  considered.  Tumour  is  by  far  its  most  common  cause.  Defec- 
tive movement  upwards  or  downwards  is  sometimes  observed  in  cases 
of  cerebral  growths  (as  well  as  in  those  of  the  mid-brain),  but  its  exact 
significance  is  uncertain  (see  p.  185).  Nystagmus  is  an  occasional 
symptom  of  tumour  in  many  parts,  but  is  not  frequent  in  tumours  of 
the  cerebellum.  An  un symmetrical  position  of  the  eyes,  one  directed 
upwards  and  inwards,  the  other  outwards  and  dowuwards.  has  been 
observed  as  an  extremely  rare  symptom  of  tumour  of  the  middle 
peduncle  of  the  cerebellum.  The  pupils  are  often  unequal,  dilated  or 
contracted,  but  alone  their  irregularity  is  of  little  significance,  except 
as  evidence  of  some  intra-cranial  disease. 

The  fifth  nerve  is  almost  constantly  affected  in  tumours  of  the 
middle  fossa  of  the  skull,  frequently  in  tumours  of  the  pons  and  of 
the  posterior  fossa,  occasionally  and  in  slight  degree  from  growths  in 
the  cerebellar  hemisphere  which  exert  distant  pressure.  Both  the 
sensory  and  motor  parts  of  the  nerve  are  usually  affected  (especially  by 
vol.  n.  33 


514  BEA1X.  * 

tumours  outside  tlie  pons)  ;  sometimes  the  sensory  only,  rarely  the 
motor  part  alone.  All  divisions  of  the  nerve  mav  be  involved,  or  only 
the  upper  and  middle.  Neuro-paralytic  ophthalmia  is  frequent  from 
basal  tumours,  which  damage  the  Gasserian  ganglion,  but  the  eye 
often  escapes  when  the  tumour  is  situated  within  the  pons.  The 
gradual  damage  to  the  sensory  part  usually  causes  irritation;  and 
neuralgic  pain,  sometimes  most  intense  and  accompanied  by  hyper- 
esthesia, precedes  loss  of  sensibility.     Taste  is  often  also  lost. 

Facial  Nerve. — Paralysis  of  all  parts  supplied  by  the  facial  nerve, 
with  the  reaction  of  degeneration  in  the  muscles,  occurs  only  in 
tumours  of  the  pons  or  posterior  fossa,  very  rarely,  and  in  sight 
degree,  from  the  distant  pressure  of  a  cerebellar  tumour,  and  is  asso- 
ciated with  paralysis  of  the  limbs  on  the  opposite  side.  Sometimes 
both  facial  nerves  are  paralysed.  The  significance  of  association  of 
paralysis  of  the  facial  and  other  nerves  is  described  at  p.  245. 

Auditory  Nerve:  Hearing. — Deafness  is  an  occasional  symptom  in 
tumours  of  the  lower  part  of  the  pons,  of  the  medulla  oblongata,  and 
of  the  posterior  fossa  of  the  base.  Its  localising  significance  has  been 
mentioned  at  p.  260.  Bilateral  deafness  bas  been  produced  by 
growths  in  the  corpora  quadrigemina  which  had  damaged  the  upper 
laver  of  the  tegmentum,  in  which  probably  the  auditory  path  ascends 
to  the  hemisphere.  Subjective  sensations  of  hearing  have  been 
produced  by  tumours  of  the  pons  and  base,  and  also  by  growths  in 
the  temporal  lobe.  In  the  former  case  they  are  referred  to  the  ear  of 
the  same  side,  in  the  latter  to  the  opposite  side,  and  may  occur  iu 
paroxysmal  form  as  the  warning  of  epileptiform  fits.  The  sounds  pro- 
duced by  cortical  tumours  are,  as  a  rule,  not <;  elaborate  "  in  character. 

The  Hypoglossal  Nerve. — Besides  the  general  relations  of  palsy  of  the 
tongue  mentioned  at  p.  302,  the  nerve  may  be  paralysed  on  the  side 
opposite  to  the  hemiplegia  limbs  by  tumours  of  the  posterior  fossa  of  the 
base,  sometimes  by  tumours  of  the  pons,  and  especially  by  those  of  the 
medulla  oblongata.  The  paralysis  is  sometimes  an  early  symptom 
of  a  morbid  growth  on  the  front  of  the  occipital  bone,  or  of  one 
springing  from  adjacent  structures  and  extending  into  the  foramen 
magnum.  In  these  cases  there  is  often  conspicuous  wasting  of  the 
paralysed  half  of  the  tongue. 

The  Sinnol  Accessory  nerxeisalso  occasionally  paralysed  from  tumours 
in  or  near  the  medulla,  especially  by  those  just  mentioned  as  involving 
the  hypoglossal  nerves.  Only  those  outside  the  medulla  impair  the 
action  of  the  muscles  of  the  neck,  but  more  frequently  the  vocal  cord 
on  one  side  is  paralysed  ;  much  less  commonly  both  vocal  cords  are 
involved.  The  palate  usually,  and  the  tongue  often,  suffer  at  the 
same  time.  Bilateral  palsies  are  occasionally  met  with,  and  the  lips 
mav  also  be  involved,  causing  symptoms  similar  to  those  of  progres- 
sive bulbar  paralysis.  Very  rarely  the  same  combination  of  symptoms 
has  resulted  from  symmetrical  tumours  of  the  cortex  in  the  lower  part 
of  the  central  convolutions. 


TUMOURS.  515 

The  pulse  is  often  infrequent  in  tumours  anywhere  within  the  skull, 
and  the  symptom  has  no  special  significance.  Respiratory  disturbance 
is  chiefly  met  with  in  growths  near  the  medulla,  and  these  have  also 
caused  extreme  frequency  of  the  pulse. 

The  Sphincters  are  not  often  paralysed  from  intra-cranial  tumour, 
and  the  loss  of  power  over  them  is  of  no  special  significance.  Untimely 
evacuation  of  bladder  and  of  rectum  is,  however,  very  common  in 
association  with  the  mental  apathy  and  dulness  which  are  so  common 
in  tumours  of  all  parts.  An  increased  secretion  of  urine,  and  the 
presence  in  it  of  sugar  and  of  albumen,  have  been  met  with  in  rare 
cases  of  tumour  in  various  parts  of  the  brain  ;  glycosuria  occurs  most 
frequently  in  association  with  tumours  of  the  pons  and  medulla,  but 
not  so  frequently  as  to  have  any  strong  significance  apart  from  other 
symptoms. 

External  Symptoms. — Intra-cranial  tumours  rarely  manifest  their 
existence  except  by  the  symptoms  already  described.  Only  those 
growths  which  spring  from,  or  invade,  the  bone  of  the  skull  are 
recognisable  externally  ;  swellings  on  the  surface  of  the  skull  occur  in 
rapidly  growing  tumours  springing  from  the  dura  mater.  Growths  in 
the  bone  of  the  middle  fossa  of  the  skull  are  sometimes  recognisable 
on  the  under  surface,  in  the  palate.  More  commonly  tumours  of  the 
anterior  or  middle  fossa  invade  the  orbit,  and  cause  bulging  forwards 
of  the  eyeball. 

Regional  Symptoms. — The  symptoms  of  tumours  in  various  parts  of 
the  brain  are,  in  general,  those  that  have  been  described  in  the  chapter 
on  "Localisation,"  p.  308,  and  need  not  be  here  repeated  in  detail. 
The  chief  deviation  from  the  typical  facts  there  enumerated  arises 
from  the  comparatively  slight  degree  of  symptoms  due  to  pressure,  a 
deviation  that  is  proportioned  to  the  slowness  with  which  the  pressure 
is  exerted.  The  effects  of  destructive  invasion  are  alwaj  s  greater  than 
those  of  compression. 

The  symptoms  of  tumours  of  the  base,  however,  need  brief  enume- 
ration. Growths  in  the  posterior  fossa  canse  nearly  the  same  symptoms 
as  tumours  of  the  pons  or  medulla,  subject  to  the  same  variations 
according  to  their  seat.  The  most  important  difference  is  that  the 
cranial  nerves  suffer  earlier  than  the  motor  tract,  and  the  combination 
of  the  uerves  affected  is  somewhat  different.  Thus  the  facial  and 
auditory  suffer  together  from  external  pressure,  rarely  from  internal 
disease.  The  sixth  (abducens)  is  paralysed  without  the  conjugate 
internal  rectus,  which  suffers  with  it  in  disease  of  the  centre.  The 
combination  of  palsy  of  one  half  of  the  tongue,  palate,  and  glottis  is 
especially  frequent  from  tumours  beside  the  medulla.  Neuro- paralytic 
ophthalmia,  probably  from  implication  of  the  Gasserian  ganglion, 
sometimes  occurs,  but  less  frequently  than  in  disease  of  the  middle 
fossa.  Lastly,  pressure  on  the  middle  peduncle  of  the  cerebellum 
often  gives  rise  to  intense  vertigo,  and  an  inclination  to  deviate  to  one 
side  in  walking.     Convulsions  occur  in  cases  in  which  the   pons  is 


516  BRAIN. 

compressed,  and  are  rather  more  frequent  than  when  the  tumour  is 
within  the  pons. 

Middle  Fossa. — The  course  of  the  fifth  nerve,  and  the  position  of 
the  Gasserian  ganglion,  render  it  very  liable  to  suffer  in  tumours  of 
the  middle  fossa,  and  symptoms  of  its  irritation  and  paralysis,  including 
inflammation  of  the  eyeball,  often  rapid  and  destructive,  are  frequent 
effects  of  disease  in  this  region.  From  extension  backwards  of  the 
growth,  or  by  meningeal  inflammation  excited  by  it,  the  facial  and 
auditory  nerves  may  likewise  suffer.  Other  nerves  are  rarely  affected 
unless  the  growth  is  situated  near  the  sphenoidal  fissure,  when  all 
those  to  the  eyeball  may  be  involved.  Hemiplegia  is  rare  and  slight, 
and  is  produced  by  the  extension  of  the  growth  to  the  neighbourhood 
of  the  crus.  Convulsions  are  extremely  rare,  and  it  is  not  common 
for  there  to  be  conspicuous  mental  symptoms. 

Anterior  Fossa. —  Tumours  are  rarely  limited  to  the  anterior  fossa  of 
the  skull,  and  the  chief  symptoms  they  produce  are  by  their  extension 
beyond  it,  backwards  to  the  optic  nerve  (unilateral  loss  of  sight),  to 
the  chiasma  (temporal  hemianopia,  or  irregular,  even  transverse 
hemianopia,  probably  from  damage  to  all  the  higher  fibres  of  the 
chiasma),  and  even  as  far  as  the  crura,  causing  paralysis  of  the  limbs, 
usually  on  one  side  only.  From  compression  or  invasion  of  the  frontal 
lobes  of  the  brain,  mental  symptoms  occasionally  result,  and  a  peculiar 
childishness  has  been  thought  to  have  some  diagnostic  value.  Loss 
of  smell  is  common,  in  most  cases  limited  to  one  side. 

Tumours  of  the  pituitary  body  cause  usually  vague  symptoms,  resem- 
bling those  just  mentioned,  but  frequently  with  failure  of  sight,  and 
with  indications  of  a  lesion  of  the  chiasma.  Sometimes,  however, 
the  tumour  causes  very  slight  symptoms,  and  may  run  an  almost 
latent  course,  even  when  the  size  attained  is  considerable.*  Glycosuria, 
has  been  sometimes  observed. 

Basal  tumours  may  extend  horizontally  over  a  large  area ;  occasion- 
ally a  growth  has  occupied  almost  the  whole  of  one  half  of  the  base 
of  the  skull.  The  symptoms,  when  the  growth  has  been  soft,  have 
often  been  few,  and  a  correct  diagnosis  has  been  impossible. 

Mtdtiple  cerebral  tumours  sometimes  cause  only  "  general  "  cerebral 
symptoms,  or  one  growth  causes  conspicuous  disturbance,  and  there  is 
no  evidence  during  life  of  the  existence  of  the  others,  or  only  equi- 
vocal indications  of  their  presence.  Occasionally  two  or  moi-e  growths 
exist  in  the  same  part  of  the  brain,  and  cause  extensive  but  connected 
symptoms  ;  this  is  especially  the  case  with  tumours  in  the  posterior 
fossa  of  the  base.  On  the  other  hand,  tumours  in  different  parts  of 
the  brain  sometimes  cause  symptoms  so  distinct  as  to  afford  clear 
evidence  of  their  separate  influence. 

Course. — The  great  characteristic  of  cerebral  tumours  is  that  their 
symptoms  ai'e  gradual  in  onset  and  slowly  progressive  in  course.  The 
earliest  symptoms  vary,  but  are  often  general,  and  no  one  is  so  frequent 

*  E.  ff.  case  recorded  by  Cunningham,  '  Journ.  of  Anat.  and  Phys./  July,  1879. 


TUMOUKS.  517 

as  headache,  although  optic  neuritis  is  sometimes  a  very  early  effect, 
especially  of  tumours  of  the  cerebellum.  Convulsions  may  first  indicate 
the  existence  of  brain  disease,  when  a  tumour  is  in  or  near  the  motor 
cortex  ;  and  they  may  be  excited  by  some  accessory  influence  in  a 
manner  that  makes  it  easy  to  mistake  the  nature  of.  the  disease.  The 
first  fits  due  to  a  tumour  of  the  right  motor  cortex  followed  a  painful 
injury  to  the  left  arm,  in  which  the  fits  began,  with  similar  pain. 
Symptoms  of  irritation  or  paralysis  of  some  cranial  nerve  often  occur 
early,  but  hemiplegic  weakness  very  rarely  precedes  headache. 

Although  the  course  of  the  symptoms  is  usually  slow  and  gradual, 
it  is  rarely  quite  uniform,  and  exceptions  to  the  gradual  course  arc 
occasionally  met  with.  In  slowly  growing  tumours  the  progress  may 
intermit,  stationary  intervals  alternating  with  periods  in  which  the 
symptoms  increase.  A  rapid  increase,  followed  by  partial  sub- 
sidence, probably  results  from  secondary  meningitis  or  local  neu- 
ritis. The  traces  of  past  meningitis  may  be  distinct  after  death, 
unless  a  long  time  has  elapsed.  In  a  case  of  tumour  occupying 
the  third  ventricle,  and  compressing  the  corpora  quadrigemina,  the 
patient  suffered,  six  months  before  death,  from  an  attack  attended 
with  severe  occipital  headache,  vomiting,  and  paralysis  of  the  right 
fifth  nerve,  the  left  half  of  the  face  and  tongue,  the  right  half  of  the 
palate,  and  right  vocal  cord,  and  much  difficulty  in  swallowing.  These 
symptoms  lasted  for  a  few  weeks,  and  then  passed  away  almost 
entirely,  slight  weakness  of  the  right  masseter  alone  remaining.  No 
evidence  of  meningitis  could  be  discovered  at  the  post-mortem 
examination  six  months  later,  but  such  transient  symptoms  of  damage 
to  nerve-roots  extending  as  far  back  as  the  medulla  oblongata  could 
only  have  been  due  to  intercurrent  meningitis. 

Hemiplegic  weakness  often  follows  unilateral  convulsions  as  a 
transient  effect  of  the  "  discharge,"  and  is  most  marked  in  (and  some- 
times limited  to)  the  limb  in  which  the  convulsion  commenced.  It 
may  also  follow,  apparently  as  the  result  of  inhibition,  sensory  dis- 
charges which  do  not  cause  spasm.  But  sudden  and  persistent  hemi- 
plegia may  occur  in  the  course  of  cerebral  tumours  without  preceding 
convulsion.  In  rare  cases  it  is  the  result  of  associated  or  independent 
vascular  disease,*  or  of  vascular  occlusion  from  the  effect  of  the 
growth  on  adjacent  vessels.  It  may  also  be  the  result  of  a  haemor- 
rhage into  the  growth,  such  as  is  common  in  the  case  of  soft  glioma. 
This  is  also  rare,  because  the  haemorrhage  is  into,  and  not  outside  the 
tumour,  and  does  not  cause  paralysis  unless  the  growth  occupies  the 
motor  region,  but  a  growth  so  situated  has  usually  caused  paralysis 
from  its  size,  before  the  haemorrhage  occurred.  Lastly,  sudden  hemi- 
plegia occasionally  occurs  in  the  course  of  a  cerebral  tumour,  without 

*  As  in  the  case  of  a  man  who  had  a  firm  tumour  three  quarters  of  an  inch  in 
diameter  below  the  floor  of  the  left  lateral  ventricle,  and  had  independent  haemor- 
rhages in  both  right  and  left  corpora  striata  (Mitchell,  '  Edin.  Med.  Journal, '  Nov., 
1883). 


518  BRAIN. 

there  being  any  mechanism  discoverable  after  death  by  which  the 
sudden  onset  can  be  explained.  The  fact  is  important,  its  explana- 
tion obscure.* 

In  the  majority  of  cases,  the  progressive  course  of  an  intra-cranial 
tumour  ends  in  death.  But  the  rapidity  of  progress  varies  much, 
according  to  the  character  and  position  of  the  tumour ;  the  former 
determining  the  rate  of  growth,  the  latter  the  symptoms  which  the 
increase  iu  size  produces.  Thus  a  tumour  of  the  same  kind  and  size 
in  the  anterior  part  of  the  cerebral  hemisphere  may  cause  far  slighter 
symptoms  than  if  seated  in  the  pons.  Other  things  being  equal,  the 
slower  the  growth  of  a  tumour,  the  slighter  are  the  symptoms,  since 
the  slower  the  pressure,  the  better  is  it  borne. 

The  duration  of  the  symptoms  varies  from  a  few  weeks  to  many 
years,  but  it  is  generally  between  six  months  and  two  years.  The 
most  rapid  cases  are  tubercle,  soft  sarcoma,  cancer,  rapidly  growing 
glioma,  and  syphiloma.  The  cases  of  longer  duration  are  tubercle, 
firm  sarcoma,  slowly  growing  glioma,  and  the  various  hard  tumours, 
fibroma,  enchondroma,  &c.  Tubercles  furnish  some  of  the  cases  of 
shortest  and  also  of  longest  duration. 

The  most  common  causes  of  death  are — (1)  Exhaustion,  induced 
especially  by  the  violence  of  the  pain,  and  the  interference  with  nutri- 
tion entailed  by  the  frequent  vomiting,  and  the  difficulty  of  feeding 
occasioned  by  mental  dulness  or  by  dysphagia.  (2)  Coma  coming  on 
oraduallv,  and  usually  due  to  the  general  increase  of  intra-cranial 
pressure,  sometimes  also  produced  by  hydrocephalus.  The  lower 
centres  participate  in  the  apathy  of  the  higher,  and  from  the  lowered 
sensibility  of  the  respiratory  centre,  mucus  accumulates  in  the  lungs, 
and  the  resulting  interference  with  respiration  is  generally  the  imme- 
diate cause  of  death.  (3)  Death  is  sometimes  sudden.  This  occurs 
moat  frequently  in  tumours  of  the  medulla  oblongata,  almost  as  fre- 
quently in  tumours  of  the  cerebellum,  next  in  tumours  of  the  central 
ganglia,  occasionally  in  tumours  of  the  cerebral  lobes,  corpora  quadri- 
gemina,  pons,  and  base,  but  rarely  in  tumours  of  the  cortex  (Bern- 
hardt). It  is  apparently  sometimes  due  to  pressure  on  the  respiratory 
or  cardiac  centres  of  the  medulla,  sometimes  to  the  mere  intensity  of 
exhausting  symptoms,  while  it  occasionally  occurs  in  a  mysterious 
way,  without  discoverable  mechanism.  (4)  Lastly,  death  may  occur 
from  some  other  effect  of  the  cause  of  the  tumour.  There  may  be 
intra-cranial  or  tubercular  meningitis  in  tubercular  tumours  of  the 
brain,  or  syphilitic  disease  of  the  vessels  in  cerebral  syphiloma. 
Other  fatal  effects  of  the  cause  of  the  tumour  are  extra-cranial,  as 
general  tuberculosis  in  cases  of  tubercular  tumour,  or  cancer  else- 
where when  there  is  a  secondary  cerebral  growth.  The  subjects  of 
very  chronic  tumours  often  die  from  intercurrent  unrelated  diseases. 

But  cerebral  tumours  are  not  invariably  fatal.     Syphilitic  growths 

*  I  have  elsewhere  i-ecorded  some  cases  illustrating  the  phenomenon,  "  On  Sudden 
Paralysis  in  Cerebral  Tumour,"  'Brain/  vol  i,  1879,  p.  48. 


TUMOURS.  519 

are  more  amenable  to  treatment  than  any  other  form  or  intra-cranial 
disease  due  to  the  same  cause;  the  symptoms  often  pass  away,  and 
usually  lessen,  the  degree  of  improvement  depending  on  the  extent  to 
which  they  are  due  to  interference  with  function  by  pressure,  and  not 
to  actual  destruction  of  nerve- elements.  Symptoms  of  irritation, 
such  as  convulsions,  may,  however,  persist  in  spite  of  treatment,  the 
nerve-elements  retaining  the  functional  disposition  resulting  from  the 
irritative  damage,  although  the  cause  of  this  has  been  removed. 
Tubercular  tumours  may  also  cease  to  grow,  and,  as  already  stated, 
may  become  inert,  and  the  symptoms  may  not  only  cease  to  increase, 
but  even  lessen,  from  the  recovery  of  the  nerve-elements  damaged 
only  by  irritation  or  by  pressure.  When  arrest  is  once  obtained,  the 
symptoms  may  remain  stationary  for  an  indefinite  period.  It  is 
certain  that  a  similar  arrest  occurs  occasionally  in  some  other 
tumours,  in  which  degenerative  changes,  often  calcareous,  take 
place,  and  the  residual  mass  gives  rise  to  no  symptoms  except  those 
which  result  from  the  damage  caused  during  its  active  growth.  But 
the  result  is  rarer  than  in  tubercular  growths.  A  girl  of  fifteen 
suffered  from  left  hemiplegia,  defect  of  sensation,  left  hemianopia, 
headache,  and  double  optic  neuritis,  all  of  gradual  onset,  in  the  course 
of  three  months.  Under  treatment,  first  the  neuritis  subsided,  then 
the  headache,  then  the  leg  improved,  and  lastly  the  arm,  but  with  the 
development  of  a  spastic  state  in  the  latter,  which  has  continued  with 
the  hemianopia ;  otherwise  she  has  been  now  for  six  years  perfectly 
well.*  In  this  case  it  is  probable  that  a  tubercular  tumour  existed  in 
or  near  the  optic  thalamus.  In  another  case,f  a  girl  of  twenty-three 
suffered  from  severe  headache,  double  optic  neuritis,  slight  bilateral 
weakness  in  the  limbs,  aud  paralysis  of  the  upward  movement  of  both 
eyes,  cycloplegia,  vomiting,  and  some  opisthotonic  convulsions.  All 
the  symptoms  disappeared  except  the  headache,  and  for  three  years 
there  was  no  recurrence ;  she  then  died  suddenly.  A  tumour  in  the 
corpora  quadrigemina  or  anterior  part  of  the  middle  lobe  of  the  cere- 
bellum had  been  assumed  to  exist,  and  a  small  degenerated  growth 
was  found  in  the  front  of  the  valve  of  Vieussens.  I  have  seen  a  con- 
siderable number  of  other  cases  with  well- marked  symptoms  of  a 
tumour,  probably  tubercular,  which  passed  away  permanently  under 
treatment. 

Diagnosis. — The  problem  of  the  diagnosis  of  a  case  of  cerebral 
tumour  includes  four  questions  :  (1)  Is  there  organic  disease  ?  (2)  Is 
it  a  tumour  ?  If  so,  what  are  (3)  its  seat,  and  (4)  its  nature  ?  Of 
these  questions,  to  the  first  an  answer  can  be  given  almost  always,  to 
the  second  generally,  to  the  third  often,  and  to  the  fourth  sometimes. 

1.  As  evidence  of  organic  disease  the  focal  symptoms  are  of  more 
importance  than  the  "general"   (diffuse)   symptoms.     Of  the  latter, 

*  '  Medical  Ophthalmoscopy,'  Case  2,  p.  282  (2nd  ed.). 
t  Loc.  cit.,  Case  52,  2nd  ed. 


o20  BRAIN. 

optic  neuritis  is,  alone,  the  most  significant  (although  not  in  itself 
conclusive)  ;  next,  vomiting  -without  gastric  cause ;  while  headache, 
giddiness,  and  general  convulsions  are  of  significance  chiefly  when 
combined  with  other  symptoms.  Convulsions  beginning  locally  are 
of  the  nature  oi  "focal"  symptoms,  but  are  not  alone  conclusive  of 
the  existence  of  organic  disease,  since  they  may  occur  in  idiopathic 
epilepsy.  Both  headache  and  giddiness  are  extremely  common  with- 
out organic  disease ;  nevertheless  headache  is  a  suspicious  symptom 
if  so  severe  as  to  keep  the  patient  awake  at  night,  and  severe  vertigo 
is  also  suspicious  if  there  is  no  indication  that  it  depends  on  disturb- 
ance  of  the  labyrinth.  As  a  rule,  other  symptoms  exist  to  give  siguifi- 
cance  to  those  which,  alone,  are  equivocal.  Two  conditions  are  most 
likely  to  give  rise  to  diagnostic  error.  One  of  these  is  the  presence  of 
diffuse  symptoms,  due  to  a  blood-state,  which  may  simulate  those 
produced  by  intra- cranial  tumour.  Headache  and  optic  neuritis  may 
be  produced  together  by  three  general  conditions — anaemia,  kidney 
disease,  and  lead-poisoning.  In  the  first  of  these  the  poverty  of 
blood  is  always  extreme ;  other  symptoms  of  anaemia  are  obtrusive ; 
the  patients  are  usually  young  girls ;  optic  neuritis  develops  with  a 
rapidity  unusual  in  tumour  ;  all  focal  symptoms  are  absent ;  and  the 
headache  and  neuritis  rapidly  subside  under  the  influence  of  iron, 
especially  if  the  patient  is  kept  at  rest  in  bed,  and  is  well  fed  with 
easily  digested  food.  In  kidney  disease,  in  which  there  is  conspicuous 
neuritis,  this  is  rarely  very  great  in  degree,  and  a  sufficiently  minute 
scrutiny  of  the  retina  will  usually  reveal  degenerative  changes,  only 
caused  by  neuritis  alone  if  it  has  been  intense.*  The  urine  contains 
not  only  albumen  (which  may  be  present  also  in  cerebral  tumour),  but 
also  casts  ;  while  the  tension  of  the  pulse,  and  hypertrophy  of  the  heart, 
add  significance  to  the  other  symptoms.  Attention  to  these  points, 
and  to  the  absence  of  signs  of  focal  disease,  will  usually  prevent  an 
error,  in  spite  of  the  fact  that  headache  is  often  considerable  in  these 
cases.  The  cerebral  symptoms  which  occur  in  lead-poisoning — head- 
ache, optic  neuritis,  delirium,  and  convulsions— would  be  very  liable 
to  mislead  if  it  were  not  that  they  are  almost  invariably  preceded  by 
other  symptoms  of  saturnism,  too  conspicuous  to  be  overlooked,  and 
too  distinctive  to  mislead. 

The  second  condition,  likely  to  give  rise  to  error,  is  that  in  which  a 
partial  functional  affection  of  the  brain  causes  symptoms  which  simu- 
late those  of  organic  disease.  Hysterical  hemiplegia,  spasm,  contrac- 
ture, or  anaesthesia  may  be  thought  to  be  due  to  such  a  lesion ;  the 
more  readily  if  headache  or  vomiting  accompany  them.  The  prin- 
ciples of  their  distinction  are  considered  in  the  chapter  on  hysteria. 
The  unilateral  affections  possess  characters  of  their  own,  which  differ 
from  those  of  organic  disease,  and  they  often  come  on  after  emotional 
disturbance  or  a  hysteroid  convulsion,  or  in  those  who  have  watched 
the  genuine  symptoms  of  organic  disease.  The  absence  of  a  one- 
*  Compare  f  iled.  Oph.,'  pi.  viii,  fig.  2. 


TUMOUJiS.  521 

sided  alteration  of  the  reflexes,  and.  of  optic  neuritis,  constitute 
additional  evidence,  although  of  less  weight,  because  of  negative 
character. 

It  is  much  more  frequent  for  the  symptoms  of  a  tumour  to  be 
ascribed,  to  hysteria,  either  because  the  patient  is  of  the  female  sex, 
or  because  definite  hysterical  disturbance  is  evoked  by  the  organic  dis- 
ease. A  mistake  is,  however,  readily  avoided  by  attention  to  the 
simple  rule,  which,  mentioned  already  more  than  once,  cannot  be  too 
often  repeated,  that  symptoms  of  hysteria  do  not  lessen  the  signifi- 
cance of  any  symptoms  of  organic  disease,  the  absence  of  which  should, 
be  definitely  ascertained. 

When  convulsions  are  the  chief  symptom,  the  disease  may  be  con- 
founded, with  idiopathic  epilepsy.  The  mistake  is  most  likely  to 
occur  in  cases  of  slowly  growing  tumour  in  or  near  the  central  con- 
volutions ;  in  one  recorded  case  the  fits  recurred  during  fourteen 
years,  and  there  were  long  periods  of  freedom.  The  fits  which  thus 
recur  almost  always  begin  locally,  as  "cortical  epilepsy;"  but  local 
commencement,  whilst  it  suggests  organic  disease,  does  not  prove  it. 
The  most  important  indication  is  the  presence  of  other  symptoms 
besides  the  convulsion.  Occasionally,  in  the  absence  of  other  sym- 
ptoms, causal  indications  may  be  allowed  weight;  e.  g.  a  history  of 
inherited  tendency  to  epilepsy  on  the  one  hand,  or,  on  the  other,  of:  a 
cause  of  tumour,  such  as  syphilis.  The  probability  of  epilepsy  is  in- 
creased if  convulsions,  existing  alone,  begin  sometimes  on  one  side, 
sometimes  on  the  other,  and  also  by  the  length  of  the  time  during 
which  they  have  been  the  only  symptom. 

As  stated  above,  the  existence  of  organic  disease  can  almost  always 
be  recognised.  In  rare  cases,  the  presence  of  a  tumour  has  been 
unsuspected  until  revealed  by  a  post-mortem  examination.  This  has 
been  especially  the  case  with  tubercular  growths  ;  sometimes  because 
the  symptoms  have  been  masked  by  those  of  some  other  grave  disease, 
or  are  of  a  subjective  character,  like  hemianopia,  readily  overlooked. 

2.  If  the  symptoms  are  such  as  to  indicate  the  presence  of  organic 
disease,  the  second  question  presents  itself, — is  their  cause  a  tumour  ? 
To  this  question  their  gradual  mode  of  onset  usually  supplies  a  ready 
answer.  In  the  rare  cases  of  tumour  in  which  sudden  symptoms  occur, 
these  are  always  preceded  by  others  of  gradual  development.  The 
fact  that  the  symptoms  never  attain  a  high  degree  in  the  course  of  a 
few  hours  excludes  at  once  the  common  vascular  lesions,  cerebral 
haemorrhage  and  acute  softening  of  the  brain.  The  other  lesions  of 
slow  development  are  few  and  rare. 

Cases  of  general  paralysis  of  the  insane  can  only  be  confounded  with 
the  rare  cases  of  cerebral  tumour  in  which  symptoms  such  as  mental 
failure,  general  weakness,  and  slow  speech  exist  alone.  The  absence 
of  headache,  optic  neuritis,  vomiting,  and  the  presence  of  the  tremor 
in  the  muscles  of  the  lips  and  face,  and  of  exalted  ideas,  will  generally 
suffice  for  the  diagnosis. 


522  BEAIN. 

The  very  rare  forms  of  chronic  inflammation  of  the  brain  (see  p.  468) 
may  cause  symptoms  identical  with  those  that  result  from  cerebral 
tumour  ;  the  distinctions,  as  far  as  they  exist,  have  been  already  men- 
tioned. 

Intra-crauial  aneurism  is,  in  fact,  a  tumour,  and  often  produces  sym- 
ptoms closely  resembling  those  of  a  growth.  The  distinction  is  con- 
sidered in  the  chapter  on  this  disease. 

Abscess  of  the  brain  sometimes  causes  symptoms  which  closely  re- 
semble those  of  tumour,  and  give  rise  to  real  difficulty.  Headache, 
vomiting,  mental  dulness,  and  optic  neuritis  are  common  to  the 
two  diseases,  but  the  last  is  rather  less  common  in  abscess  than  in 
tumour.  Focal  symptoms  are  also  comparatively  rare.  Slowly  pro- 
gressing symptoms,  of  uniform  course,  are  characteristic  of  tumour, 
while  in  abscess  there  is  usually  a  rapid  development  of  acute  ;in-  i 
grave  cerebral  disturbance,  after  a  "latent"  period,  in  which  sym- 
ptoms are  trifliug  or  absent.  The  presence  of  a  cause  of  abscess  (pre- 
vious injury,  ear  disease,  or  suppuration  elsewhere)  increases  the 
probabihty  of  its  existence,  but  it  must  be  remembered  that  injury 
may  cause  either  a  tumour  or  an  abscess,  The  points  of  distinction 
between  the  two  are  described  more  fully  in  the  chapter  on  the  latter 
disease. 

Acute  meniugitis  can  rarely  be  confounded  with  cerebral  tumour. 
The  only  difficulty  arises  in  cases  of  tubercular  meningitis,  in  which 
tubercular  growths  in  the  brain  co-exist,  but  cause  few  symptoms 
before  the  onset  of  the  meningitis.  One  important  indication  in  such 
cases  is  the  degree  of  optic  neuritis  That 'which  results  from  the 
meningitis  alone  is  rarely  considerable,  and  if  the  swelling  of  the 
papilla  is  great,  and  haemorrhages  exist — especially  if  such  a  change 
is  found  soon  after  the  onset  of  the  symptoms  of  meningitis, — it 
is  probable  that  there  are  tubercular  growths  ;  the  more  so  if  head- 
ache or  vomiting  had  long  preceded  the  onset  of  the  symptoms  of 
inflammation. 

Occasionally  an  acute  increase  (or  even  apparent  onset)  of  the  sym- 
ptoms may  be  occasioned  by  exposure  to  some  general  or  special 
morbid  influence — cold,  the  heat  of  the  sun,  or  a  blow  on  the  head, — 
an  influence  which  may  conceivably  excite  meningitis,  but  the  nature 
of  the  case  may  often  be  decided  by  the  indications  just  mentioned. 
It  must  be  remembered  that  tubercular  tumours  may  run  an  almost 
latent  course  for  a  time,  and  may  then  cause  symptoms  so  rapidly  as 
to  render  the  diagnosis  a  matter  of  great  difficulty.  In  some  cases  a 
comparison  of  the  relative  degree  and  extent  of  the  symptoms  may 
help  the  decision.  For  insta.nce,  an  ill-nourished  child,  five  months 
old,  came  under  treatment  for  right-sided  weakness  and  rigidity,  with 
complete  paralysis  of  the  left  third  nerve.  These  symptoms  were 
said  to  have  come  on  a  week  before,  and  the  child  was  thought  to  be 
suffering  from  tubercular  meningitis.  But  it  was  unlikely  that  so 
extensive  a  process  as  meningitis  would  completely  paralyse  one  third 


TUMOUKS.  523 

nerve  and  leave  the  other  cranial  nerves  unaffected.  Tbe  symptoms 
pointed  rather  to  a  focal  lesion  of  the  left  crus  cerebri,  probably  a 
tubercular  tumour,  running  at  first  a  latent  course  ;  the  diagnosis  was 
verified  a  few  days  later.  It  must  be  remembered  also  that  a  tuber- 
cular tumour  and  meningitis  often  co-exist.  In  such  cases  time  alone 
can  render  the  diagnosis  approximately  sure.  If  symptoms  continue 
for  four  or  six  weeks  they  are  almost  certainly  due  to  a  tumour. 

Chronic  meningitis  is  exceedingly  rare  except  as  a  result  of  syphilis 
or  alcoholism.  In  the  latter  case  tbe  symptoms  are  diffuse,  and 
too  slight  to  be  really  confusing,  while  the  cause  is  commonly 
obtrusive.  Syphilitic  meningitis,  when  local,  may  be  indistinguishable 
from  tumour*,  except  in  tbe  rate  of  the  development  of  its  symptoms. 

Only  those  cases  of  cerebral  tumour  in  which  there  is  jerky  inco- 
ordination can  be  confounded  with  disseminated  cerebrospinal 
sclerosis.  A  sufficient  distinction  is  afforded  by  the  fact  that  in 
sclerosis  the  inco-ordination  is  usually  bilateral ;  in  tumour  it  is 
always  unilateral ;  in  the  former  there  is  neitber  much  headache, 
vomiting,  nor  considerable  optic  neuritis. 

3.  If  the  disease  is  a  tumour,  the  next  question  is,  where  is  it? 
The  answer  depends  on  the  symptoms  present,  the  localising  signifi- 
cance of  wbich  has  been  already  described,  and  need  not  be  here 
recapitulated.  It  is  important  to  remember  that  the  diagnosis  must 
depend,  as  a  rule,  on  the  grouping  of  symptoms  rather  than  on  the 
presence  or  absence  of  any  one  symptom.  There  is  hardly  any  sym- 
ptom which  may  not  be  absent,  wherever  a  tumour  is  seated,  and  almost 
every  individual  symptom,  may  be  produced  by  disease  in  more  tban 
one  position.  It  must  also  be  remembered  that,  although  the  general 
region  in  which  the  growth  is  placed  may  be  determined  in  the 
majority  of  instances,  it  is  not  often  tbat  its  exact  situation  can  be 
confidently  affirmed. 

4.  The  exact  nature  of  the  tumour  can  sometimes  be  determined 
with  a  high  degree  of  probability,  now  and  then  with  practical 
certainty.  Much  more  frequently  hardly  more  than  a  guess  can  be 
made — a  guess  that  is  almost  as  likely  to  be  wrong  as  right.  The 
most  important  indications  are  the  following: 

(1)  Tbe  presence  of  morbid  growths  elsewhere,  the  nature  of  whicb 
can  be  determined.  When  symptoms  of  cerebral  tumour  are  con- 
secutive to  an  infecting  growth  elsewhere,  e.  g.  cancer  of  the  mamma, 
&c,  it  is  practically  certain  tbat  the  intra-cranial  disease  is  of  tbe  same 
nature.  In  rare  cases  the  presence  of  an  hydatid  tumour  in  another 
part  indicates  that  the  cerebral  tumour  is  of  the  same  nature. 

(2)  The  presence  of  a  distinct  general  disease  of  which  intra-cranial 
tumour  is  a  common  consequence.  These  diseases  are  tubercle  and 
syphilis.  In  adults,  the  signs  of  phthisis  are  rarely  absent  when  tbere 
is  tubercular  tumour  of  the  brain,  and  their  presence  is  strongly  in 
favour  of — their  absence  against — the  tubercular  nature  of  tbe  cerebral 
growth.     In  children,  however,  signs  of  tubercular  disease  elsewhere 


c24  BRAIN. 

are  often  wanting,  and  then:  absence  is  of  much  less  significance  than 
their  presence.  The  same  is  true  of  a  family  history  of  phthisis  or 
tubercular  disease.  A  physical  configuration,  such  as  often  co- 
exists with  a  tubercular  tendency,  is  also  in  favour  of  this  nature 
of  the  growth.  The  symptoms  or  history  of  syphilis,  congenital  or 
acquired,  render  it  highly  probable  that  the  tumour  is  of  syphilitic 
nature.  The  absence  of  a  history  of  constitutional  syphilis,  if  the 
patient  has  had  a  chancre,  should  not  receive  much  weight,  because 
it  is  not  uncommon  for  the  secondary  symptoms  to  have  been  absent  or 
overlooked.  Moreover,  in  an  adult,  the  possibility  of  the  syjxhilitic 
nature  of  the  disease  cannot  be  excluded,  unless  we  can  feel  sure  that 
the  patient  has  never  been  exposed  to  the  risk  of  infection  in  the 
ordinary  way,  and,  in  the  case  of  a  woman,  the  assurance  must  include 
her  husband.  Undoubted  syphilitic  disease  is  occasionally  met 
with  where  there  is  no  history  or  indication  of  primary  or  secondary 
disease,  the  former  having  been  unnoticed,  the  latter  absent  or  dis- 
regarded. But  in  both  cases,  of  tubercular  and  syphilitic  indications, 
the  diaguosis  is  a  matter  of  probability  only,  since  a  cerebral  growth 
of  different  nature  sometimes  co-exists  with  either  diathesis. 

(3)  The  sex  of  the  patient  affords  little  indication  of  the  probable 
nature  of  the  tumour,  and  that  afforded  by  age  is  very  limited.  If 
the  patient  is  under  fifteen,  and  presents  no  indication  of  inherited 
syphilis,  the  tumour  is  certainly  not  of  syphilitic  nature.  If  the 
patient  is  an  adult,  and  presents  no  signs  of  phthisis,  it  is  very 
unlikely  to  be  tubercular. 

(4)  The  help  afforded  by  the  seat  of  the  tumour  is  also  small,  and 
is  practically  limited  to  the  following  facts.  Ceteris  paribus,  if  the 
disease  is  within  the  cerebellum  or  pons  there  is  some  probability  that 
it  is  tubercle  or  glioma;  it  is  unlikely  to  be  syphilitic  if  in  the  cere- 
bellum, but  it  may  be  if  in  the  pons.  If  in  the  cortex,  the  probability 
that  it  is  syphilitic  is  considerable,  but  is  less  if  it  is  situated  in  the 
deeper  parts  of  the  hemisphere.  A  tumour  outside  the  brain  tissue  is 
probably  sarcoma. 

(5)  The  course  of  the  tumour  is  sometimes  suggestive.  A  very 
slowly  growing  tumour  in  the  hemispheres  is  probably  glioma,  and  if 
the  development  of  the  symptoms  is  extremely  gradual,  it  is  most 
unlikely  that  the  growth  is  syphilitic.  A  tumour  which  grows  rapidly 
at  the  onset  and  then  becomes  stationary  is  probably  tubercular. 
The  occurrence  of  a  sudden  apoplectic  seizure  of  moderate  severity  in 
the  course  of  the  symptoms  is  rare  except  in  glioma. 

(6)  The  effect  of  treatment  is  of  diagnostic  value  only  in  the  case 
of  syphilitic  and  tubercular  tumours.  A  disappearance  of  symptoms 
(especially  headache,  optic  neuritis,  and  recent  paralytic  symptoms), 
under  iodide  of  potassium  and  mercury,  makes  it  highly  probable  that 
the  tumour  is  syphilitic.  Improvement  under  general  tonics  is  some 
evidence  that  the  tumour  is  tubercular,  but  the  value  of  this  indi- 
cation is  at   present   somewhat   dubious,  since  the  nature  of  most 


'IOI0QES.  525 

tumours  which  thus  improve  is   uncertain,  and  it  is   possible  that 
other  than  tubercular  growths  may  be  thus  influenced. 

(7)  Multiplicity  affords  little  indication  of  nature,  because  tuber- 
cular, syphilitic,  gliomatous,  and  cancerous  tumours  are  multiple  often 
or  occasionally. 

Prognosis. — Only  when  the  tumour  is  of  syphilitic  nature  can  a 
reasonably  good  prognosis  be  given.  Even  in  such  a  case  it  is  only 
the  disappearance  of  the  diffuse  symptoms,  and  of  recent  paralyses, 
that  can  be  confidently  predicted.  Palsy  of  more  than  a  few  months' 
duration  may  persist,  although  the  growth  is  removed;  and  convul- 
sions sometimes  continue,  but  it  is  not  uncommon  for  all  symptoms 
to  pass  away.  In  tubercular  tumours  arrest  is  not  uncommon,  and 
the  patient  may  live  on  indefinitely,  for  general  tuberculosis  exists 
less  frequently  than  might  be  expected.  The  symptoms  lessen,  but 
in  what  degree  depends  on  the  seat  of  the  disease;  hemiplegia 
usually  persists,  but  the  symptoms  of  a  cerebellar  tubercle  may 
disappear.  In  all  cases  a  diminution  in  the  headache  and  subsi- 
dence of  optic  neuritis  which  is  moderate  in  degree  (and  has 
not,  as  it  were,  exhausted  itself  by  its  violence)  usually  precede 
other  indications  of  improvement ;  they  are  therefore  distinctly 
favorable  signs,  the  recognition  of  which  is  very  important.  Con- 
versely, the  persistence  of  optic  neuritis  is  of  grave  significance. 
These  rules  are,  however  (as  we  shall  see),  true  only  when  no  opera- 
tion is  performed. 

In  other  forms  of  tumour  the  prognosis  is  serious.  As  a  rule 
they  progress  to  a  fatal  termination,  and  the  probable  duration  of 
life  can  only  be  estimated  from  the  rate  of  the  progress  in  the  past 
and  present.  It  is  libely,  however,  to  be  longer  in  tumours  of  the 
cerebrum  or  cerebellum  than  in  those  of,  or  pressing  on,  the  pons  or 
medulla.  Considerable  mental  dulness,  obstinate  vomiting,  severe 
and  frequent  general  convulsions,  apoplectic  seizures,  and  rapidlv 
developed  and  intense  optic  neuritis,  are  all  indications  which  render 
the  prognosis  grave  as  to  the  near  future.  On  the  other  hand,  the 
absence  of  these  symptoms  indicates,  other  things  being  equal,  that 
the  danger  is  more  remote.  Very  chronic  optic  neuritis  is  of  especial 
significance  as  an  indication  that  the  course  of  the  disease  will  be 
slow  and  prolonged.  It  is  probable  that,  in  most  forms  of  tumour, 
arrest  of  growth  now  and  then  occurs,  but  it  cannot  be  anticipated. 
Even  when  the  growth  of  the  tumour  ceases,  ventricular  effusion  may 
cause  persistent  general  symptoms,  which  must  be  expected  to  con- 
tinue unless  relief  can  be  afforded  by  the  surgeon.  The  recent  deve- 
lopment of  cerebral  surgery  has,  however,  improved  the  prospect  in 
many  cases,  as  regards  the  growth  itself,  to  an  extent  that  will  appear 
from  the  next  section. 

Treatment. — The  treatment  of  new  growths,  in  such  a  position 


526  BRAIN. 

that  they  are  "beyond  the  reach  of  the  knife,  and  of  such  a  nature  that 
they  cannot  he  influenced  by  drugs,  is  always  a  sufficiently  gloomy 
subject,  and  not  least  so  when  they  are  seated  in  an  organ  like  the 
brain,  in  which  they  cause  peculiar  and  varied  suffering,  and  in  which 
their  development,  even  to  a  moderate  degree,  is  seldom  compatible 
with  life.  Too  often  all  that  can  be  done  is  to  afford  some  slight 
relief  to  symptoms,  and  even  this  is  frequently  trifling  in  degree. 
The  only  case  in  which  a  considerable  effect  on  the  growth  can  be 
produced  by  drugs  is  that  of  syphilitic  tumour.  Whenever  there  is 
even  a  possibility  that  the  tumour  is  syphilitic,  iodide  of  potassium 
should  be  given  in  increasing  doses  up  to  half  a  drachm  three  times 
a  day,  followed,  if  the  effect  is  inadequate,  by  mercury. 

If  it  is  probable  or  possible  that  the  tumour  is  tubercular,  general 
tonics  are  of  paramount  importance,  and  of  these  ccd-liver  oil.  iron, 
and  an  adequate  supply  of  food,  are  more  often  distinctly  beneficial 
than  any  other  agents.  Cod-liver  oil  is  of  especial  importance.  Fresh 
country  air  is  very  useful,  but  does  not,  alone,  exert  such  an  influence 
as  do  tonics.  A  tonic  treatment  is  indeed  desirable  in  most  cases  ; 
arrest  of  symptoms  occasionally  occurs  under  its  influence  when  there 
is  no  reason  to  think  that  the  tumour  is  tubercular.  There,  is  no 
evidence  that  any  other  drugs  are  capable  of  arresting  the  progress  of 
morbid  growths,  and  the  chief  practical  question  is  the  possibility  of 
excision. 

Apart  from  this  problem  is  that  of  the  relief  of  symptoms  which  we 
are  powerless  to  remove.  Those  that  depend  on  meningitis — which 
extend  beyond  the  original  range  of  mischief,  and  are  characterised 
by  subacute  onset,  with  increased  headache  and  vomiting,  and  often  by 
fever — may  sometimes  be  relieved  by  counter-irritation  and  by  leeches, 
if  the  patient  is  in  a  condition  to  bear  them.  Of  other  symptoms,  head- 
ache is  one  which  most  often  calls  urgently  for  mitigation.  Relief  can 
usually  be  obtained  by  the  hypodermic  injection  of  morphia,  but  the 
ready  habituation  to  the  narcotic  renders  its  use  admissible  only  in  the 
most  acute  paroxysms.  Indian  hemp  is  sometimes  useful,  but  hyo- 
scine  and  especially  antipyrin  are  more  often  effective.  Sometimes 
counter-irritation  to  the  neck  gives  re'ief  to  occipital  pain,  but  no  local 
application  is  so  effective  as  ice,  which  often  influences  not  only  the 
pam,  but  the  vomitiug  and  convulsions.  For  the  latter,  bromide  of 
potassium  is  less  useful  than  chloral.  In  all  cases,  as  much 
brain-rest  as  possible  should  be  secured;  active  physical  exeition,  con- 
stipation, heavy  meals,  and  alcohol  should  be  avoided,  since  all  these 
tend  to  increase  the  cerebral  disturbance. 

There  remains  the  important  question  of  operative  measures,  a 
subject  which  has  become  so  extensive  and  complex  as  to  have  passed 
almost  out  ol  the  domain  of  medicine.  Only  the  salient  features  can, 
therefore,  be  noted  here.  Although  it  constitutes  a  step  in  thera- 
peutic progress  of  signal  interest,  second  to  none  in  importance  and 
in  the  power  of  saviug  life,  it  has  limits  that  are  quickly  reached  and 


TUMOURS.  527 

may  be  easily  overlooked.  It  is  to  MacEwen,  G-odlee,  and  especially 
to  Horsley  that  we  owe  the  discovery  of  the  comparative  safety  with 
which  even  extensive  operations  on  the  brain  may  be  undertaken, 
provided  strict  antiseptic  precautions  are  observed.  Without  these, 
the  danger  is  great  of  rapidly  fatal  inflammation  ;  and  even  with  them 
the  dura  mater  cannot  be  opened  without  some  risk  of  this  event,  or 
of  fatal  shock  to  the  system.  In  all  cases,  therefore,  this  danger  has 
to  be  weighed  against  the  prospect  of  success  in  the  removal  of  a 
growth,  or  the  urgency  of  symptoms  that  may  be  relieved  for  a  time, 
even  when  the  tumour  is  beyond  reach.  It  is  only  a  small  proportion 
of  intra- cranial  growths  in  which  extirpation  is  practicable.  A  care- 
ful study  of  the  details  of  299  cases,  by  Allen  Starr,  has  led  him  to 
the  conclusion  that,  while  18  per  cent,  were  accessible,  not  more  than 
6  per  cent,  could  have  been  successfully  removed.  Earlier  diagnosis 
probably  renders  this  estimate  too  small,  but  it  is  certain  that  the 
majority  of  growths  are  beyond  reach.  The  cases  suitable  for  an 
operation  are  those  in  which  the  tumour  is  in  or  just  beneath  the 
cortex  of  the  brain,  and  in  such  a  locality  that  its  position  can 
be  inferred  with  confidence,  especially  at  the  motor  region,  and 
probably  also  in  the  occipital  or  upper  temporal  lobes.  Those  that 
spring  from  the  membranes  and  compress  the  brain  offer  the  least 
difficulty.  On  the  other  hand,  growths  in  the  central  ganglia,  crura, 
pons,  or  base  cannot  be  successfully  removed,  and  they  consti- 
tute 34  per  cent,  of  the  whole  number.  The  frequency  with  which 
there  is  more  than  one  tumour  is  another  source  of  failure.  A  growth 
in  one  hemisphere  of  the  cerebellum  would  no  doubt  be  accessible,  but 
such  tumours  seldom  cause  distinctive  symptoms  until  they  are  of 
large  size ;  even  then  it  is  scarcely  possible  to  ascertain  their  exact 
situation,  and  attempts  to  remove  a  cerebellar  tumour  have  hitherto 
been  fatal.  The  middle  lobe  of  the  cerebellum  is  so  inaccessible  and 
so  close  to  important  structures  that  it  is  not  likely  that  the  removal 
of  a  tumour  could  be  survived. 

Very  striking  is  the  effect  of  the  operation  in  some  cases  in  which 
the  tumour  has  rendered  the  patient  unconscious,  and  has  brought 
him  apparently  near  the  end  of  life.  Immediate  improvement  his 
been  followed  by  steady  recovery,  and  in  no  malady  has  life  been  more 
distinctly  saved.  But  such  cases  are  unfortunately  few,  and  we 
have  to  put  on  the  other  side  the  fact  that  the  removal  of  an  infil- 
trating tumour,  even  when  perfectly  accessible,  involves  also  that  of 
nerve-elements  which  still  retain  functional  power,  and  therefore  the 
operation  is  followed  by  increased  palsy,  which  may  be,  in  some  degree, 
of  permanent  character.  This  is  a  minor  consideration  when  life  is 
threatened,  but,  in  many  cerebral  tumours,  the  danger  to  life  is  not 
certain  or  near;  the  question  of  an  operation  is  one  of  peculiar 
difficulty  in  many  cases  of  the  kind,  especially  when  the  tumour  is 
possibly  syphilitic  or  probably  tubercular  in  nature.  Each  case  must  be 
dealt  with  according  to  its  apparent  character  and  obvious  course,  and 


528  BE  Alls. 

the  introduction  of  a  new  and  greater  danger  to  life  must  be  carefully 
avoided.  The  danger  is  not  yet  fairly  indicated  by  published  facts. 
It  must  also  be  remembered  that  convulsions  do  not  always  cease 
when  their  original  cause  is  removed  ;  although  their  recurrence,  after 
an  operation,  is  occasionally  only  for  a  time,  it  is  more  frequently 
persistent 

But  operations  that  fail  to  achieve  their  primary  object  are  not, 
therefore,  devoid  of  result.  The  removal  of  part  of  the  cranial  wall  has 
been  found,  by  experience,  to  be  followed  by  a  remarkable  diminution, 
and  even  arrest,  of  the  pain  of  a  growth  that  cannot  be  excised,  an  effect 
which  has  generally  continued  as  long  as  the  patient's  life  endured, 
which  is  seldom,  in  sucli  cases,  for  many  months.  Hence  this  operation 
has  been  advocated  by  Horsley  as  the  surest  mode  of  affording  relief, 
apart  from  the  possibility  of  excision.  Pain  is  not,  however,  the 
only  symptom  thus  relieved.  The  operation  is  usually  followed 
by  a  remarkable  subsidence  of  the  optic  neuritis,  if  this  is  present, 
probably  because  fluid  effused  outside  the  brain  is  no  longer  forced 
into  the  lymphatic  spaces  of  the  papilla,  and  no  longer  conveys  to  it 
material  capable  of  intensifying  inflammation  that  may  descend  the 
nerve.  Hence  it  is  probable  that  sight  may  sometimes  thus  be  saved, 
even  though  a  certain  amount  of  neuritis  persists.  Against  these 
advantages,  however,  must  be  placed  the  possibility  that  life  may  be 
materially  shortened,  and  the  urgency  with  which  relief  is  required 
must  be  carefully  considered.  But  the  danger  to  life  is  less  than 
from  another  procedure  which  has  also  been  advocated  for  the  same 
object,  that  of  puncture  of  the  lateral  ventricles,  any  tender  spot 
being  chosen  if  the  seat  of  the  growth  is  uncertain.*  This  has  so 
often  set  up  a  subacute  inflammation,  fatal  in  one  or  two  weeks,  that 
its  wisdom  is  doubtful,  especially  in  view  of  the  fact  that  it  seems  to 
afford  little,  if  any,  more  relief  than  the  simple  trephining.  But  if  a 
growth  can  be  influenced  by  drugs,  their  employment  is  obviously 
preferable  to  any  operation,  and,  although  the  chance  of  systemic  in- 
fection by  a  tubercular  tumour  has  been  thought  to  justify  the  removal 
of  such  formations,  the  danger  of  this  infection  seems,  in  practice,  to 
be  extremely  small. f 

*  Weir,  Horsley,  Knapp,  and  others. 

t  The  above  sketch  deals  only  with  the  more  obvious  conclusions,  suggested  to  the 
physician,  regarding  a  subject  which  has  largely  passed  into  the  province  of  surgery. 
As  such,  the  reader  will  find  it  discussed  in  greater  detail,  and  with  much  material 
for  reflection,  in  the  following  articles.  In  these,  and  in  many  others  that  have 
appeared  during  the  last  three  years,  will  he  found  a  discussion  on  fundamental 
questions  of  the  cranio-ccrebral  topography,  of  which  some  account  is  given  in  the 
early  part  of  this  volume,  but  which  abounds  with  poiuts  that  are  still  undecided. 

Horsley,  'Brit.  Med.  Journ.,'  1890.  MacEwen,  ibid.,  1888.  Knapp,  'Intra- 
cranial Growths,' Boston,  1891.  Fraser,  'A  Guide  to  Operations  on  the  Brain' 
(photographs),  London,  1891. 


ANEURISMS.  529 


INTRA-CRANIAL   ANEURISM. 

Both  the  larger  arteries  of  the  brain  and  their  branches  within  the 
cerebral  substance  are  occasionally  the  seat  of  aneurismal  dilatation. 
Within  the  brain  the  aneurisms  are  minute,  rarely  exceeding  a  pin's 
head  in  size,  and  hence  are  called  "  miliary  aneurisms."  They  are 
important  chiefly  as  causing  hemorrhage  into  the  substance  of  the 
brain,  in  connection  with  which  they  have  been  described.  Only 
the  aneurisms  of  the  larger  cerebral  arteries  will  be  considered  in 
this  section.  Such  aneurisms  are  more  common  in  the  vessels  of 
the  brain  than  in  those  of  similar  size  elsewhere,  partly  on  account 
of  the  considerable  blood-pressure  to  which  these  vessels  are  exposed, 
and  partly  because  their  walls  are  more  frequently  the  seat  of  morbid 
changes. 

■  Causes. — Males  suffer  more  frequently  than  females,  in  the  pro- 
portion of  3  to  2.  Practically  unknown  under  ten  years  of  age,* 
aneurisms  occur  in  each  decade  of  life,  from  ten  to  sixty,  with  nearly 
equal  frequency ;  after  sixty  they  become  rare,  but  are  met  with  occa- 
sionally up  to  extreme  old  age.  About  an  equal  number  occur  before 
and  after  forty,  and  about  one  sixth  in  the  second  decade  of  life. 
Thus  they  are  much  more  frequent  during  the  first  half  of  life 
than  are  aneurisms  elsewhere.  An  explanation  for  this  is  found  in 
their  immediate  causes. 

There  appears  to  be,  in  rare  cases,  a  peculiar  inherited  tendency  to 
the  formation  of  aneurism.  A  distinguished  physician  died  young 
from  the  rupture  of  an  intia-cranial  aneurism  ;  ten  years  later  his 
brother,  a  medical  student  aged  twenty,  showed  me  a  distinct  aneurism 
on  an  artery  of  his  hand. 

The  immediate  cause  is  similar  to  that  of  aneurisms  elsewhere — a 
change  in  the  structure  of  the  wall,  whereby  the  muscular  and  elastic 
elements  are  replaced  by  distensible  fibroid  tissue.  In  consequence 
of  this,  the  wall  yields  permanently  under  the  blood-pressure.  A 
bulging  results,  which  goes  on  increasing,  as  the  walls,  thinned  by 
extension,  lose  still  further  their  power  of  resistance.  The  mechanism 
by  which  this  structural  change  is  produced  varies  in  different  cases. 
It  may  be  a  primary  degeneration,  or  the  effect  of  inflammation,  caused 
by  injury  or  imperfect  embolism,  or  the  structure  may  be  changed  by 
syphilitic  disease.  The  two  latter  influences  cause  aneurism  much 
more  frequently  in  this  than  in  other  situations. 

(1)  Primary  degeneration  is  an  occasional  cause  in  the  second  half 

*  Yet  it  is  possible  that  disease  of  the  arteries  due  to  inherited  syphilis  may  cause 
aneurism  in  early  life,  since  it  may  cause  cerebral  haemorrhage.  An  instance  in  a 
boy  of  eight  is  mentioned  on  p.  389.  The  occurrence  of  aneurism  from  embolism  is 
also  possible  under  ten,  although  I  do  not  know  of  any  recorded  instance. 

vol.  ii.  34. 


530  BiiAix. 

of  life.  It  may  be  a  simple  fibroid  change  due,  apparently,  merely  to 
the  strain  to  which  the  vessels  are  exposed,  and  this  is  especially 
influential  in  arteries  which  come  off  directly  from  large  trunks. 
Thus  an  aneurism  was  seated  on  an  abnormal  artery  which  passed 
between  the  internal  carotids  beneath  the  optic  commissure  (Weir 
Mitchell).  Atheroma  seldom  leads  to  simple  dilatation,  although  the 
process  of  breaking  down  of  the  degenerated  wall  sometimes  causes  a 
dissecting  aneurism.  Tatty  degeneration  does  not  involve  a  tendency 
to  yield  before  the  blood-pressure,  as  does  simple  fibroid  change. 

(2)  Injury,  a  blow  or  fall  on  the  head,  is  an  occasional  antecedent 
(in  6  per  cent.*),  and  seems  to  act  sometimes  by  direct  damage  to 
the  wall  causing  traumatic  arteritis,  sometimes  by  a  change  in  the  wall 
of  the  artery,  produced  by  inflammation  which  spi'eads  to  it  from 
adjacent  structures.    The  internal  carotid  suffers  most  from  this  cause. 

(3)  Syphilitic  disease  affects,  as  is  well  known,  the  arteries  of 
the  brain  more  frequently  than  those  of  other  parts.  Its  charac- 
ters have  been  described  at  p.  425.  A  new  growth  infiltrates 
the  wall,  destroying  the  muscular  tissue,  and  leaving  cicatricial 
damage.  The  wall  is  often  at  last  thinner  and  more  opaque  than 
normal,  the  cavity  of  the  artery  increased,  and  the  vessel  unduly 
distensible.  An  aneurism  has  been  frequently  met  with  in  cases  of 
constitutional  syphilis  in  young  adults,  in  whom  no  other  cause  was 
discoverable.  It  is,  indeed,  surprising  that  this  consequence  is  not 
more  common,  when  we  consider  how  distinctly  the  aspect  of  the  wall 
is  altered,  even  in  cases  in  which  the  disease  has  been  removed  by 
treatment.  But  it  seems  to  be  limited  to  cases  in  which  the  morbid 
process  has  existed  for  a  long  time,  or  has  undergone  spontaneous 
cicatrisation.  It  is  possible  that  an  aneurism  only  forms  when  the 
elastic  lamina  has  been  destroyed ;  this  persists  long  after  the  mus- 
cular tissue.  The  basilar  artery  is  a  frequent  seat  of  aneurism  from 
this  cause. 

(4).  Embolism  is  probably  the  most  frequent  cause  in  the  first  half 
of  life.  There  are  few  cases  during  this  period,  without  indications 
of  syphilis  or  injury,  in  which  there  is  not  evidence  of  past  or  present 
heart  disease. f  We  know  that  the  fragments  of  lymph  which  are 
washed  from  the  valves  in  endocarditis  have  often  an  irritative 
character,  bearing  septic  material  or  organisms ;  and  these,  at  the 
place  at  which  they  are  arrested,  may  excite  inflammation  similar  to 
that  in  their  source.  If  an  artery  is  imperfectly  closed  by  such  a 
plug,  its  walls  become  inflamed,  altered,  and  yet  are  still  exj)osed  to 
the  pressure  of  the  blood,  before  which  they  yield.  The  mechanism 
has  been  traced  in  the  arteries  of  the  limbs,  but,  like  embolic  occlu- 
sion, is  far  more  frequent  in  the  arteries  of  the  brain.  Hence  also 
the  middle  cerebral  artery,  embolic  occlusion  of  which  is  the  most 

*  Eight  cases  of  131  collected  by  Killian. 

f  The  frequency  of  heart  disease  was  noted  by  Lebert  and  other  observers,  but 
the  significance  of  the  association  was  first  pointed  out  by  Church. 


ANEURISMS.  531 

frequent,  is  that  on  which  aneurisms  are  most  common,  and  may  even  be 
multiple.*  Aneurisms  due  to  this  cause  may  occur,  however,  on  any 
artery,  even  the  basilar  or  vertebrals.  Complete  closure  is  probably 
effective  if  a  pervious  branch  maintains  the  circulation  in  the  vessel 
on  the  cardiac  side  of  the  plug. 

General  Pathology. — Aneurisms  are  twice  as  common  in  the 
system  of  the  internal  carotids  as  in  that  of  the  vertebrals.  The 
middle  cerebral  branches  are  affected  more  often  than  any  other,  but 
only  a  little  more  frequently  than  the  basilar,  the  two  together 
making  up  more  than  half  the  number  of  cases.  Next  in  frequency 
is  the  internal  carotid  itself,  which  is,  however,  diseased  only  half  as 
frequently  as  the  middle  cerebral.  In  two  thirds  of  the  cases  of 
aneurism,  one  of  these  thi-ee  vessels  is  the  seat  of  the  disease.  The 
other  arteries  are  affected  in  the  following  order  of  frequency  :  ante- 
rior cerebral,  posterior  communicating,  anterior  communicating, 
vertebral,  posterior  cerebral,  inferior  cerebellar.f  Aneurisms  of  the 
arteries  of  the  central  ganglia,  within  the  substance  of  the  brain,  are 
very  rare.  A  remarkable  instance,  in  which  an  aneurism  in  the 
lenticular  nucleus  attained  the  size  of  a  small  chestnut  before  it 
caused  death  by  rupture,  has  been  recorded  by  Bastian.^  Other 
cases  are  on  record  in  which  an  aneurism,  although  not  found, 
was  probable,  because  fatal  haemorrhage  occurred  under  the  condi- 
tions in  which  aneurisms  are  produced. § 

Aneurisms  are  rather  more  common  on  the  left  side  than  on  the 
right  in  the  proportion  of  four  to  three.     In  about  a  fifth  of  the 

*  Recent  medical  literature  abounds  with  illustrations  of  the  association  of  intra- 
cranial aneurisms  and  endocarditis.  One  striking  instance  may  be  quoted.  A  boy 
twelve  years  old  suffered  from  mitral  disease  after  rheumatic  fever,  and  after  death 
there  were  found  circumscribed  deposits  on  the  mitral  valve,  with  numerous  infarcts 
in  the  spleen  and  kidneys.  At  the  origin  of  the  left  posterior  cerebral  artery  from 
the  basilar  there  was  a  small  aneurism  the  size  of  a  pea,  and  the  right  posterior 
cerebral  was  closed  by  an  embolus,  immediately  behind  which  was  another  aneurism  of 
similar  size.  The  artery  beyond  was  obliterated.  '  Here  we  have  a  demonstration 
ot  the  local  association  of  the  two  processes.  (Rauchf  uss,  *  St.  Petersburg  med. 
Wochenschrift,'  Feb.  18th,  1878,  and  'Virchow's  Jahresb.,'  1878,  vol.  ii,  p.  102.) 

f  The  following  is  the  numerical  frequency  in  154  cases,  obtained  by  combining, 
in  so  far  as  they  do  not  overlap,  the  statistics  of  Lebert  ('  Berlin,  klin.  Wochen- 
schrift/ 1866),  Durand  ('  Des  Anevrvsmes  du  Cerveau,'  Paris,  1868),  and  Bartholow 
('  Amer.  Journ.  Med.  Science,'  Oct.,  1872),  and  the  addition  of  ten  cases  recorded 
by  others : — Middle  cerebral  44  ca?es,  basilar  41,  internal  carotid  23,  anterior  cere- 
bral 14,  posterior  communicating  8,  anterior  communicating  8,  vertebral  7,  posterior 
cerebral  6,  inferior  cerebellar  3. 

X  '  Trans.  Clin.  Soc.,'  1884,  p.  18. 

§  Another  instance  is  the  case  of  haemorrhage  in  a  boy  of  eight,  with  inherited 
syphilis  and  arterial  disease,  mentioned  already.  A  very  instructive  case  of  haemor- 
rhage into  one  corpus  striatum,  bursting  into  the  ventricles,  in  a  boy  of  fifteen, 
with  slight  mitral  disease,  has  been  recorded  by  Bastian  ('  Trans.  Clin.  Soc.,'  xvii, 
1884,  p.  21).  In  each  of  these  cases  an  aneurism  of  a  cerebral  artery  was  highly 
probable. 


532  BRAIN. 

cases  there  is  more  than  one  aneurism,  generally  in  consequence  of 
embolism.  Bilateral  symmetry  is  very  rare,  as  in  the  two  middle- 
cerebrals  or  the  two  vertebrals.*  In  character  the  aneurism  is 
almost  always  a  true  sacculated  aneurism,  very  rarely  dissecting. 
Occasionally  there  is  a  general  dilatation  of  the  vessel.  The  walls 
are  usually  thin,  but  often  are  lined  by  laminated  clot,  and  some- 
times supported  by  thickened  and  adherent  membranes.  In  size 
they  commonly  vary  from  a  pea  to  a  nut,  sometimes  attaining  a 
larger  size.  They  have  been  met  with  as  large  as  a  hen's  egg  on  the 
internal  carotid,  anterior  cerebral,  basilar,  and  posterior  cerebral,  and 
as  large  as  a  pigeon's  egg  on  the  middle  cerebral  and  posterior  com- 
municating arteries.  In  shape  they  are  usually  round,  sometimes 
oval.  The  surface  is  red  and  smooth,  and  the  tumour  often  has  the 
aspect  of  a  small  round  mass  of  clot,  the  wall  being  so  thin  as  to  be 
invisible.  When  rupture  has  taken  place  the  aneurism  is  in  the 
midst  of  a  coagulum,  and  great  care  may  be  needed  to  discover  it. 
It  is  best  to  wash  away  the  clot  slowly  by  a  gentle  stream  of  water. 

An  aneurism,  except  it  be  of  very  small  size,  necessarily  obtains  room 
by  compressing  adjacent  structures.  The  cerebral  substance  may  be 
thus  damaged,  the  nerves  at  the  base  compressed,  and  even  the  bone 
eroded.     It  is  by  this  means  that  the  chief  symptoms  are  produced. 

Rupture  of  the  aneurism  occurs  in  rather  more  than  half  the  cases, 
and  in  a  still  larger  proportion  in  the  young.  Most  frequently  the 
blood  escapes  into  the  membranes  at  the  base  of  the  brain.  The  opening 
in  the  aneurism  is  usually  small,  aud  the  escape  of  blood  may  be 
gradual  and  even  inteimiittent.  It  may  be  forced  from  the  base  into 
the  fourth  ventricle  by  the  openings  through  which  liquid  escapes  out 
of  the  ventricle  ;  this  distension  of  the  fourth  ventricle  is  occa- 
sionally the  immediate  cause  of  death.  In  some  cases,  however,  in 
which  the  aneurism  is  supported  by  thickened  membranes  on  its  outer 
side,  it  gives  way  where  it  is  in  contact  with,  aud  perhaps  embedded 
in,  the  brain-substance,  and  the  haemorrhage  occurs,  not  into  the 
membranes,  but  into  the  brain.  Thus  the  blood  from  an  aneurism  of 
the  middle  cerebral  may  escape  into  the  hemisphere  until  it  reaches 
the  lateral  ventricle,  and  I  have  known  an  aneurism  of  the  commence- 
ment of  the  posterior  cerebral  to  tear  up  and  infiltrate  the  pons  before 
it  escaped  externally.  The  slowness  of  the  haemorrhage  probably 
favours  its  extension  into  the  brain,  the  blood  slowly  disintegrating 
the  tissue  before  it,  along  the  line  of  least  resistance.  In  one  case  a 
narroAv  fistulous  tract  of  blood  extended  from  an  aneurism  of  the 
middle  cerebral,  on  the  convexity,  to  the  lateral  ventricle.  An 
aneurism  of  the  internal  carotid  has  been  known  to  burst  into  the 
cavernous  sinus. 

G-eneral  Symptomatology. — A  small  aneurism,  in  any  situation, 
may  cause  no  symptoms,  and  its  existence  may  be  unsuspected  until 
*  Mott,  '  BraiD,'  18S9  ;  Hale  White. 


ANEUitlSMS.  533 

rupture  occurs.  Such  latency  is  most  common  in  aneurisms  of  the 
anterior  communicating  and  the  cerebellar  arteries,  and  it  is  not  infre- 
quent in  those  of  the  middle  cerebral  and  basilar.  When  symptoms 
occur,  these  are  partly  general,  partly  local.  Headache  is  the  most 
common,  often  pulsating  in  character ;  it  is  usually  continuous,  but 
sometimes  paroxysmal.  Its  seat  has  little  relation  to  the  position  of 
the  aueurism,  except  that  it  is  usually  occipital  when  the  basilar 
artery  is  diseased.  Giddiness  is  also  common,  whatever  be  the  seat 
of  the  aneurism.  Mental  dulness  and  irritability  have  been  caused 
by  aneurisms  in  various  situations,  but  most  frequently  when  the 
anterior  cerebral  was  diseased,  least  frequently  by  aneurism  of  the 
internal  carotid  and  middle  cerebral.  Convulsions  are  not  frequent, 
except  in  aneurism  of  the  middle  cerebral.  Large  aneurisms  in  any 
situation  may  cause  paralysis  of  limbs,  but  this  is  most  frequently 
due  to  those  of  the  middle  cerebral  and  basilar.  The  cranial  nerves 
are  often  paralysed,  as  they  are  adjacent  to  the  vessels  most  frequently 
affected  (see  Fig.  143).  Optic  neuritis  is  not  common;  it  has  been 
occasionally  met  with,  but  only  in  aneurism  of  the  internal  carotid  ; 
when  present  it  is  double.  Probably  an  ophthalmoscopic  examina- 
tion would  have  revealed  it  in  a  larger  proportion  of  cases.  A  murmur, 
the  most  common  symptom  of  aneurisms  elsewhere,  is  very  seldom 
produced  by  those  within  the  skull.  In  a  few  recorded  cases*  of 
aneurism  of  the  internal  carotid,  not  only  has  the  patient  been  con- 
scious of  a  murmur,  but  this  has  been  distinctly  audible  on 
auscultation  of  the  skull,  and  has  been  arrested  by  pressure  on  the 
carotid.  In  one  case  of  aneurism  of  the  left  vertebral  artery,  beside 
the  medulla  oblongata,  a  loud  murmur  could  be  heard  on  each  side, 
between  the  mastoid  process  and  the  spinal  column. f 

When  embolism  causes  an  aneurism  the  obstruction  is  necessarily 
partial,  and,  as  a  rule,  the  causal  process  produces  no  symptoms.  Never- 
theless it  is  possible  that  transient  symptoms  sometimes  occur  at  the 
time  of  the  embolism.  In  the  case  recorded  by  Bastian,  mentioned 
in  the  note  at  p.  531,  three  years  before  the  fatal  apoplexy,  the  boy 
was  suddenly  convulsed,  and  afterwards  screamed  for  two  or  three 
hours.  A  careful  inquiry  might  elicit  a  history  of  transient  symptoms 
in  many  of  these  cases. 

Aneurisms  of  Special  Arteries. — The  symptoms  produced  by  aneu- 
risms of  special  arteries  depend  on  the  structures  adjacent  to  these 
vessels.  Their  relations  are  imperfectly  presented  in  the  brain  after 
it  has  been  removed.  Fig.  143,  representing  the  chief  relations,  is 
from  a  dissection,  made  at  my  suggestion  by  Mr.  Shattock,  for  the 
purpose  of  showing  the  relative  positions  of  the  chief  arteries, 
nerves,  and  other  structures  at  the  base  of  the  brain.     A  reference  to 

*  Coe,  Holmes  of  Chicago,  Hutchinson,  Humble,  Jeaffreson. 
t  Moser,  '  Deut.  Arch.  f.  kl.  Med.,'  Bd.  xxxv,  p.  418. 


134 


BRAIN. 


it  will  render  clearer  many  points  in  the  special  symptomatology  of 
intra-cranial  aneurisms. 

Internal  Carotid. — An  aneurism  may  be  formed  within  the  cavernous 
sinus,  or  after  the  artery  has  emerged  from  tbis,  as  it  lies  on  the  inner 
side  of  the  anterior  clinoid  process  and  origin  of  tbe  optic  nerve,  with 
tbe  root  of  the  olfactory  nerve  in  front  of  it.  The  aneurism  may 
compress  the  adjacent  frontal  and  temporo-sphenoidal  lobes,  but  its 
chief  symptoms  are  due  to  compression  of  the  optic  nerve  on  the 
inner  side,  and  of  the  nerves  in  the  wall  of  the  cavernous  sinus  on  the 
outer  side.  The  sight  of  the  eye  on  that  side  fails.  The  third  nerve 
usually  suffers  early,  and  ptosis  may  be  the  first  symptom ;  but  all  the 
muscles  may  ultimately  become  paralysed,  and  the  eyeball  may  lose  sen- 
sibility in  consequence  of  damage  to  the  ophthalmic  branch  of  the 

Post  Cerebral  ,.v-;       \    , 

Tost.  ComXi/uar^, '-■- ■""''-      >'V^>/5^;r  :   _v^ 


v-*^     r    oc.  g.  ?  1 


Wfcft. 


Wmm&igM 


V, 


gphP 

feat  A- 


Fig.  143. — Relations  of  the  arteries  and  nerves  at  the  base  of  the  brain, 
from  an  actual  dissection  in  which  the  bones,  membranes,  and  wall  of 
the  cavernous  sinus  were  removed  from  the  left  side.  INF,  infundi- 
bulum  ;  C.  S.,  cavernous  sinus ;  Pt.  P.,  pterygoid  process ;  OC.  B.,  occi- 
pital bone.  The  cranial  nerves  are  indicated  by  Roman  numerals ;  the 
names  of  the  arteries  are  m-arked  upon  them.  (After  a  drawing,  by 
Mr.  C.  E.  Adams,  of  Mr.  Shattock's  dissection.) 

fifth.  Smell  also  may  be  impaired.  "When  the  aneurism  is  large, 
and  extends  backwards,  it  may  cause  hemiplegia  by  pressure  on  tbe 
crus.  Frequently,  the  pressure-effect  is  limited  to  the  ocular  nerves. 
Rupture  has  occurred  in  less  than  half  the  cases.  Transient  fulness 
of  the  retinal  veins  has  been  observed  to  result  from  the  compression 
of  the  cavernous  sinus  by  a  carotid  aneurism,  but  the  pressure  is 
quietly  relieved  by  the  free  communication  of  the  ophthalmic  and 
facial  veins  ;  the  enlarged  angular  vein  may  be  conspicuous  beneath 
the  skin.  Optic  neuritis,  when  it  exists,  is  apparently  due,  not  to  the 
pressure  on  the  sinus  or  the  nerve,  but  to  the  extension  of  inflam- 
mation in  the  vicinity  of  the  aneurism  (Michel). 


ANEURISMS.  535 

Anterior  Cerebral. — The  aneurism  is  usually  in  front  of  the 
origin  of  the  vessel,  sometimes  at  a  bifurcation.  The  artery  runs 
between  the  optic  and  the  olfactory  nerves,  and  an  aneurism  here 
exerts  compression  on  the  same  parts,  and  produces  nearly  the 
same  symptoms,  as  one  of  the  internal  carotid,  with  the  important 
exception  that  the  nerves  to  the  muscles  of  the  eyeball  generally 
escape.  An  aneurism  further  forwards  may  cause  no  local  symptoms, 
but  when  the  blood-supply  to  the  cortex  is  interfei'ed  with,  hemiplegia 
results,  and  aphasia,  if  the  disease  is  on  the  left  side.  The  sac  usually 
has  very  thin  walls,  and  rupture  occurs  in  more  than  half  the  cases, 
often  comparatively  early.  The  blood  has  been  known  to  find  its  way 
to  the  lateral  ventricle.* 

Anterior  Communicating. — The  tumour  exerts  pressure  only  on  the 
inner  surface  of  the  frontal  lobes.  The  aneurism  is  usually  small, 
and,  as  a  rule,  no  symptoms  are  produced.  The  wall  is  thin,  and 
here  also  rupture  occurs  early  in  most  cases. 

Posterior  Communicating. — The  aneurism  is  usually  situated  near 
the  origin  of  the  artery  from  the  internal  carotid.  It  compresses  the 
adjacent  temporo-sphenoidal  lobe,  and  the  pressure  may  even  reach 
the  corpus  striatum  and  optic  thalamus.  The  third  nerve  suffers 
most  frequently.  Affection  of  sight  is  also  common,  but  it  is  usually 
incomplete,  and  we  have  no  exact  observations  on  its  character.  Pro- 
bably there  is  hemianopia  from  pressure  on  the  optic  tract,  which  the 
artery  crosses.  Hemiplegia  is  rare,  in  spite  of  the  proximity  of  the 
vessel  to  the.crus  cerebri,  because  the  aneurism  is  thin- walled,  and 
usually  bursts  before  it  has  attained  considerable  size,  or  has  exerted 
considerable  pressure. 

Middle  Cerebral. — The  aneurism  is  sometimes  near  the  origin  of  the 
vessel,  but  more  often  within  the  fissure  of  Sylvius,  sometimes  on 
one  of  its  cortical  branches.  Occasionally  there  is  more  than  one 
dilatation.  The  chief  pressure  is  on  the  hemisphere,  and  when  the 
aneurism  is  within  the  fissure  of  Sylvius  tbe  pressure  may  reach  the 
corpus  striatum.  Paralysis  of  cranial  neiwes  is  rare ;  on  the  other 
hand,  hemiplegia  and  convulsions  are  common.  Speech  is  occasionally 
affected  when  the  disease  is  on  the  left  side.  Pupture  occurs  in  two 
thirds  of  the  cases.  Embolism  is  the  common  cause,  and  if  the 
inflammation  engendered,  involves  the  adjacent  membranes,  these 
may  be  so  thickened  as  to  resist  external  rupture.  As  mentioned, 
blood,  under  these  circumstances,  may  work  its  way,  in  the  course  ot 
a  few  days,  from  the  convexity  to  the  lateral  ventricle.  Aneurisms 
on  the  central  branches  of  the  middle  cerebral  are  small,  and  probably 
cause  no  symptoms  until  they  burst. 

Vertebral. — A  distinct  aneurism,  such  as  is  shown  in  Fig.  106,  p.  250, 
is  extremely  rare,  although  both  arteries  have  been  thus  affected  (see 
p.  425).  But  in  most  conditions  described  as  aneurism  there  has  been 
only  a  general  dilatation  of  the  vessel,  often  determined  by  an  original 

*  Mott,  '  Brain,'  1880. 


536  BRAIN. 

inequality  in  the  size  of  the  two  arteries.  Important  as  are  the  adjacent 
structures,  symptoms  have  seldom  been  observed  in  the  cases  in  which 
such  dilatation  was  found.  In  the  case  figured  (p.  250),  facial  spasm 
was  the  result  of  the  compression  of  the  trunk  of  the  facial  nerve. 

Basilar. — While  absolutely  second  in  frequency  of  affection,  if 
the  shortness  of  the  vessel  is  taken  into  consideration,  the  basilar 
exhibits  a  greater  tendency  to  suffer  than  any  other  artery ;  this  is 
chiefly  due  to  its  frequent  affection  by  syphilitic  disease.  Occasionally 
there  is  general  dilatation;  more  frequently  the  anterior  extremity  is 
enlarged  ;  sometimes  there  is  an  aneurism  on  one  side  of  the  vessel  in 
the  middle  of  its  course,  rarely  near  the  origin  from  the  vertebrals. 
The  pressure  is  differently  distributed  according  to  the  position  of  the 
aneurism.  Usually  the  pons  suffers  chiefly,  sometimes  on  one  side 
only ;  the  pi-essure  may  even  extend  to  the  middle  peduncle  of  the 
cerebellum  and  the  adjacent  cerebellar  hemisphere,  or  so  deeply  as  to 
reach  the  fourth  ventricle.  The  compressed  portion  is  often  softened. 
An  aneurism  of  the  anterior  part  may  compress  the  crus  ;  one  of  the 
postei'ior  part,  the  pyramids  and  olivary  bodies  of  the  medulla.  The 
third  nerves  rarely  suffer,  but  the  cranial  nerves,  from  the  fifth  to  the 
vagus,  are  frequently  compressed  ;  the  hypoglossal  usually  escapes. 
Internal  hydrocephalus  is  an  occasional  consequence  of  the  obstruc- 
tion to  the  passage  of  liquid  from  the  ventricles.  Rupture  occurs  in 
about  half  the  cases  ;  it  is  usually  subarachnoid,  although  the  blood 
sometimes  escapes  into  the  substance  of  the  pons.  It  is  remarkable 
that  in  about  one  third  of  the  cases  there  have  been  no  symptoms  of 
the  tumour  ;  when  present  they  have  consisted  in  occipital  headache, 
vertigo,  and  the  symptoms  common  to  basal  tumours  in  this  situation — 
paralysis  of  the  limbs,  bilateral  or  unilateral,  and  of  one  or  more 
cranial  nerves  on  the  opposite  side.  The  fifth  suffers  most  frequently, 
and  sometimes  there  is  neuro-paralytic  ophthalmia.  Difficulty  in 
articulation  and  in  swallowing  are  occasional  symptoms.  Convulsions 
are  rare.  Besides  the  terminal  apoplexy  which  results  from  rupture, 
apoplectic  attacks  occasionally  occur,  and  even  end  in  death,  without 
rupture,  in  consequence  of  softening  adjacent  to  the  aneurism,  which 
is  sometimes  due  to  the  closure  of  a  branch. 

Posterior  Cerebral. — The  aneurism  is  usually  situated  not  far  from 
the  origin  of  the  vessel,  and  may  compress  the  upper  part  of  pons, 
crus,  temporo-sphenoidal  lobe,  and  the  third  and  sixth  nerves.  Hence, 
when  symptoms  have  existed,  there  has  been  hemiplegia  with  alter- 
nate paralysis  of  these  two  nerves,  especially  of  the  third. 

Cerebellar  Arteries. — Both  the  superior  and  inferior  anterior  cere- 
bellar arteries  have  been  found  affected  with  small  aueurisms,  but 
the  pressure-effects  are  too  various,  and  usually  also  too  slight,  to  be 
of  practical  importance. 

Course — Tbe  duration  of  an  aneurism  can  only  be  inferred  from 
the  inadequate  evidence  afforded  by  the  duration  of  the  symptoms. 


ANEURISMS.  537 

It  is  certain,  however,  that  this  varies  between  wide  limits,  from,  a 
few  weeks  to  five  or  six  years.  In  some  cases  the  sac  becomes  filled 
with  clot,  and  a  spontaneous  cure  is  thus  effected.*  The  majority  of 
cases  have  ended  by  the  rupture  of  the  aneurism,  which,  is,  so  far  as 
past  experience  has  gone,  invariably  fatal.  Quickly  deepening  coma, 
and  sometimes  convulsions,  result  from  the  haemorrhage  into  the 
membranes,  and  death  often  results  in  a  few  hours,  although  some- 
times the  hemorrhage  occurs  so  slowly  that  life  is  prolonged  for 
days.  Now  and  then  one  or  more  remissions  occur,  the  cause  of 
which,  can  be  traced,  post  mortem,  to  be  the  temporary  cessation  of 
the  haemorrhage,  the  blood  having  evidently  been  effused  at  different 
dates.  Thus  one  patient  lived  for  fourteen  days  after  the  first  rupture 
of  an  aneurism  of  the  anterior  communicating  artery.  When  the 
haemorrhage  occurs  into  the  bi*ain- substance,  the  symptoms  are  similar 
to  those  in  ordinary  cerebral  haemorrhage. 

Diagnosis. — In  a  considerable  number  of  cases  the  diagnosis  of 
intra-cranial  aneurism  is  impossible,  because,  until  its  rupture,  it 
produces  no  effects  by  which  its  presence  can  be  recognised.  When 
symptoms  are  present,  they  are  commonly  those  of  a  tumour,  gene- 
rally  at  the  base  of  the  brain.  The  aneurism  is  a  tumour,  and  its 
distinction  from  a  growth  is  often  impossible,  and  is  only  quite 
certain  when  a  murmur  exists  in  it.  But  such  a  murmur  has  only 
been  heard  in  a  few  cases  of  aneurism  of  the  internal  carotid  or 
vertebral  arteries.  The  distinction  may,  however,  be  made  with 
probability  when  the  symptoms  of  a  tumour,  in  the  position  of  a 
vessel,  develop  in  connection  with,  one  of  the  causes  of  aneurism, 
especially  heart  disease.  Syphilis  and  injury  have  less  diagnostic 
significance,  because  each  (and  syphilis  especially)  is  a  cause  of 
growth  more  frequently  than  of  aneurism,  but  this  significance  varies 
according  to  the  seat  of  the  disease.  In  the  cavernous  sinus,  for 
instance,  an  aneurism  is  far  more  probable  than  a  growth.  More- 
over, in  cases  of  syphilis,  the  fact  that  treatment  fails  to  exert  an 
influence  on  the  tumour  is  often  strong  evidence  of  its  aneurismal 
nature. 

Whatever  be  the  apparent  cause,  it  is  of  great  importance  to  recog- 
nise the  correspondence  in  the  position  of  the  tumour  with  that  of 
-one  of  the  arteries  liable  to  be  thus  affected,  and  to  remember  the 
special  relation  of  some  causes  to  certain  arteries,  as  already  described, 
as  embolism  to  the  middle  cerebral  and  syphilis  to  the  basilar. 

The  evidence  of  the  existence  and  seat  of  an  aneurism  have  thus  to 
be  frequently  considered  together,  but  tbe  latter  is  not  often  unequi- 
vocal. The  seat  of  pain  is  of  significance  only  when  it  is  occipital 
(basilar  artery).  Loss  of  sight  in  one  eye,  sometimes  extending  to 
the  other — with,  or  especially  without,  optic  neuritis ;  with  or  with- 

*  A  case  in  which  this  occurred  in  an  aneurism  of  the  internal  carotid  has  been 
recorded  by  Mr.  Hutchinson  ('  Clin.  Soc.  Trans.,'  1875). 


538  BRAIN. 

out  loss  of  smell  on  the  side  first  affected, — occurs  in  aneurism  of  the 
internal  carotid  or  anterior  cerebral ;  aud  the  distinction  between  the 
two  depends  on  the  presence  or  absence  of  paralysis  of  the  other 
nerves  to  the  eyeball  first  affected,  which  occurs  especially  when 
the  aneurism  is  of  the  internal  carotid.  Paralysis  of  the  third 
nerve,  without  loss  of  sight  in  one  eye,  is  produced  by  aneurism  of 
the  posterior  communicating  artery,  and,  with  hemiplegia  on  the 
opposite  side,  by  aneurism  of  the  posterior  cerebral.  Hemianopia 
would  increase  the  probability  of  an  aneurism  in  this  part  of  the 
base.  Affection  of  the  fifth  alone  is  of  little  significance,  but  with 
bilateral  weakness  in  the  limbs,  difficulty  of  articulation  or  of 
swallowing,  it  is  produced  by  aneurism  of  the  basilar,  and  so  also  is. 
paralysis  of  the  cranial  nerves  below  the  sixth,  usually  associated 
with  weakness  of  the  limbs  on  the  opposite  side.  Hemiplegia  is  of 
little  significance  in  itself,  but  if  considerable  it  is  unlikely  that  there 
is  an  aneurism  of  either  the  anterior  cerebral  or  the  posterior  com- 
municating arteries.  General  convulsions,  epileptiform  in  character, 
are  not  common,  but  if  they  begin  locally  they  suggest  that  the 
disease  is  in  the  middle  cerebral,  and  if  they  are  opisthotonic,  that  it 
is  in  the  basilar.  These  symptoms  are  of  diagnostic  significance  only 
in  the  presence  of  a  cause  of  aneurism. 

The  occurrence  of  rupture,  with  severe  apoplectic  symptoms,  in- 
creases very  much  the  probability  of  the  diagnosis,  although  it  is. 
then  a  matter  rather  of  scientific  curiosity  than  of  practical  import- 
ance. Even  if  no  previous  symptoms  have  existed,  it  may  be 
suspected  that  sudden  apoplexy,  steadily  deepening  in  degree,  is  due 
to  the  rupture  of  an  aneurism,  if  it  occurs  in  a  young  person,  or  if, 
before  the  degenerative  period  of  life  is  reached,  there  is  a  history  of 
heart  disease  or  of  syphilis,  or  of  injui-y  to  the  head.  The  characters 
of  the  apoplexy  afford  but  limited  indications  of  the  probable  seat  of 
the  aneurism.  Those  suggestive  of  meningeal  haemorrhage  are  of  no 
localising  significance,  but  those  of  haemorrhage  into  the  pons  suggest 
an  aneurism  of  the  basilar,  or  of  the  commencement  of  the  posterior 
cerebral  artery. 

The  difficulties  of  the  diagnosis  of  aneurism  do  not  always  cease 
with  life.  The  damage  to  the  tissues  and  vessels,  caused  by  the 
haemorrhage  that  follows  rupture,  may  render  it  impossible  to  find 
the  remains  of  a  small  aneurism,  especially  of  one  with  thin  walls, 
difficult  to  discern  in  the  mass  of  clot  around  it.  But  meningeal 
haemorrhage,  under  the  conditions  that  suggest  aneurism,  is  enough 
to  justify  a  strong  suspicion  of  its  existence. 

Prognosis. — If  the  diagnosis  of  an  intra-cranial  aneurism  is  certain, 
the  prognosis  is  extremely  grave.  The  probability  that  death  will 
result  is  very  great,  and  the  duration  of  life  is  most  uncertain,  since 
it  is  impossible  to  say  how  near  or  how  distant  may  be  the  fatal 
rupture.     These  conclusions  are  not  invalidated  by  the  fact  that,  in  a- 


ANEURISMS.  539 

considerable  proportion  of  recorded  cases,  rupture  has  not  occurred. 
In  most  of  these  the  aneurisms  were  small,  and  caused  no  symptoms. 
The  question  of  prognosis  relates  only  to  aneurisms  which  have  caused 
symptoms,  and  in  most  of  these  cases  rupture  has  occurred.  But  the 
end  may  not  be  near ;  in  many  cases  the  symptoms  have  continued 
for  two,  three,  or  five  years,  and  if  stationary  the  chance  of  long 
duration  is  slightly  greater.  Nor  is  a  fatal  issue  absolutely  certain. 
A  spontaneous  cure  of  intra-cranial  aneurism  has  been  more  than  once 
observed.  In  aneurism  of  the  internal  carotid  the  prognosis  is  dis- 
tinctly better  than  in  that  of  other  arteries,  because  more  can  be  done 
by  treatment,  or  at  least  has  been  done,  than  when  other  vessels  are 
the  seat  of  the  disease. 

Treatment. — If  an  intra-cranial  aneurism  is  suspected,  it  is  impor- 
tant to  avoid  as  far  as  possible  all  influences  which  tend  to  increase 
the  arterial  pressure,  as  exertion  and  stooping,  or  which  tend  to  acce- 
lerate the  movement  of  the  blood,  as  alcohol.  To  these  ends  also  the 
bowels  should  be  kept  loose,  and  the  patient  should  sleep  with  head  and 
shoulders  well  raised.  If  there  is  reason  to  suspect  that  the  aneurism 
is  of  syphilitic  origin,  iodide  of  potassium  should  be  given  to  prevent 
increase  of  arterial  disease  elsewhere  ;  although  it  is  not  to  be  antici- 
pated that  it  can  influence  an  aneurism  already  developed,  it  may  pro- 
mote coagulation  in  it.  Ergotine  has  been  recommended,  but  the 
wall  of  an  aneurism  contains  no  tissue  on  which  the  drug  can  act. 
More  reasonable  measures  are  those  designed  to  favour  coagulation  in 
the  sac.  These  consist,  first,  in  the  "  starvation  "  treatment,  the  utility 
of  which  in  intra-cranial  aneurism  has  still  to  be  proved,  whatever 
be  the  origin  of  the  aneurism.  Secondly,  iodide  of  potassium  has  been 
given  to  promote  coagulation,  and  with  a  result  which  certainly  warrants 
its  employment.  In  one  case*  the  patient,  a  woman  aged  forty,  suffered 
from  right  frontal  headache,  photophobia,  impaired  vision  in  the  right 
eye,  and  paralysis  of  the  external  rectus ;  a  systolic  murmur  could  be 
heard,  loudest  at  the  right  temple.  Iodide  of  potassium  was  given  in 
doses  increasing  to  36  grs.  daily.  Four  months  later,  after  a  violent 
attack  of  vomiting  and  purging,  the  murmur  suddenly  ceased,  and  did 
not  recur.  In  five  weeks  the  paralysis  of  the  external  rectus  had  dis- 
appeared. There  can  be  no  doubt  that  an  aneurism  existed,  and  that 
coagulation  had  occurred  in  the  sac.  The  immediate  cause  of  the 
clotting  was  probably  the  prostration  from  the  vomiting  and  purging, 
but  it  is  at  least  possible  that  the  result  may  have  been  favoured  by 
the  iodide  of  potassium,  since  this  drug  certainly  promotes  coagulatiou 
in  aortic  aneurisms.  The  third  method  of  promoting  coagulation  in 
the  sac  is  to  ligature  the  artery  from  which  the  diseased  vessel  derives 
its  supply  of  blood.  Hitherto  this  has  only  been  adopted  in  the  case 
of  aneurism  of  the  internal  carotid,  for  which  the  common  carotid  has 
been  tied  with  success.     It  is  only  in  aneurism  of  this  artery  that  the 

*  Recorded  by  Dr.  Humble,  of  Corfe  Castle,  '  Lancet,'  1875,  ii,  pp.  490  and  874. 


540  BEAIN. 

diagnosis  has  been  sufficiently  sure  to  justify  the  surgeon's  interference. 
If  other  aneurisms  could  be  diaeuosed  with  equal  certainty,  this 
nieasui-e  "would  be  more  ofteu  justifiable.  For  basilar  aneurism,  the 
vertebrals  -would  have  to  be  tied,  but  Dr.  Alexander,  of  Liverpool,  has 
shown  that  this  operation  is  practicable,  and,  if  not  devoid  of  danger, 
is  attended  with  less  risk  than  is  the  aneurism  itself.  When  rupture 
has  occurred,  no  treatment  has  hitherto  had  auy  influence,  but  the 
onset  of  apoplexy  increases  the  indication  for  ligature,  and  likewise 
its  justification,  unless  the  end  is  obviously  too  near  to  permit  life  to 
be  saved. 


DEGENERATIONS   OF    THE  BRAIN . 


CYSTIC   DEGENERATION. 

The  shrunken  brain  of  the  old  is  occasionally  riddled  with  small 
cavities,  from  the  size  of  a  pea  downwards.  The  change  is  seen 
chiefly  in  the  white  substance,  and  is  sometimes  general,  sometimes 
limited  to  certain  parts.  The  cavities  are  the  enlarged  perivascular 
spaces,  and  the  alteration  seems  to  represent,  in  the  substance  of  the 
brain,  the  senile  atrophy  which  causes  the  surface  to  shrink,  the  sulci 
to  be  widened,  and  the  subarachnoid  fluid  in  them  to  be  increased  in 
quantity.  It  is  also  usually  associated  with  a  similar  enlargement  of 
the  ventricles.  As  Charcot  has  pointed  out,  the  most  frequent  seat 
of  this  cystic  degeneration  is  a  zone  of  the  white  substance  between 
the  region  supplied  by  the  cortical  artei'ies  and  that  of  the  central 
vessels,  in  which  the  terminal  branches  of  each  set  are  inadequate  for 
the  perfect  maintenance  of  nutrition.  It  is  not  probable  that  these 
cavities,  however  numerous,  give  rise  to  symptoms,  any  more  than 
does  the  general  shrinkage  of  the  brain,  but  the  arteries  within  them 
have  but  little  support,  and  dilatation  and  rupture  may  be  facilitated, 
especially  when  the  cavities  exist  outside  the  lenticular  nucleus,  where 
cerebral  haemorrhage  so  often  takes  place.  They  often  contain  debris 
of  nerve-tissue,  and  h39matoidin  crystals,  the  remains  of  some  small 
extravasation.  Occasionally,  especially  in  the  pons,  the  cavities  are 
met  with  at  an  earlier  age,  even  in  young  adults,  and  are  then  some- 
times thought  to  have  a  pathological  significance  which  they  do  not 
really  possess. 


CHRONIC   PROGRESSIVE   SOFTENING. 

The  old  view*  that  softening  may  occur  as  a  primary  process, 
although  wrong  as  regards  the  common  acute  softening,  seems  to  be 
justified  by  rare  cases  in  which  softening  occurs  without  demonstrable 
association  with  disease  of  the  arteries,  or  correspondence  with  their 
distribution,  and  is  so  gradual  in  its  onset,  and  slowly  progressive  in 
its  course,  as  to  make  a  dependence  on  the  vessels  very  improbable. 
Some  cases  of  this  kind  have  been  collected  by  Wernicke,*  and  a 

*  '  Lelirbuch  der  Gehirn-Krankheiten/  Bd.  ii,  p.  149. 


542  BRAIN. 

few  other  instances  are  to  be  found  in  medical  literature,  old  and 
recent.  The  affection  is  almost  always  seated  in  the  white  substance 
of  the  hemisphere,  a  feature  in  which  it  differs  from  the  acute  soften- 
ing of  actual  obstruction.  But  there  is  no  reason  to  suppose  that  the 
grey  matter  invariably  escapes.  The  change  consists  of  simple  white 
softening,  which  presents,  under  the  microscope,  chiefly  the  products 
of  degeneration.  The  affected  area  is  often  sharply  limited  from  the 
adjacent  normal  substance.  The  extent  of  the  lesion  varies  much  in 
different  cases :  subcortical  softening  has  even  extended  through  the 
whole  convexity  of  one  hemisphere.  Although  the  grey  matter  of  the 
cortex  has  not  been  primarily  affected  in  the  cases  examined,  it  may 
suffer  secondarily  when  the  softening  of  the  white  substance  is  exten- 
sive. The  diffluent  tissue  is  then  limited  externally  by  the  pia  mater, 
and  sometimes  there  is  a  thin  layer  of  cortical  grey  matter  below  this. 
Chronic  softening  may  also  affect  the  cerebellum,  but  it  there  differs 
from  the  cerebral  softening,  since  the  cortex  suffers  more  than  the 
white  substance.  I  have  seen  the  cortex  of  almost  the  whole  of  both 
hemispheres  of  the  cerebellum  uniformly  softened  and  atrophied,  while 
the  white  substance  was  unaffected.  In  this  case  there  were  also 
several  areas  of  softening  in  the  cerebral  hemispheres,  in  the  white 
substance  and  in  the  grey  matter  of  the  cerebral  ganglia. 

The  recorded  cases  are  still  too  few  to  afford  much  information  re- 
garding the  causes  of  chronic  progressive  softening.  All  that  can  be 
said  is  that  it  occurs  in  both  sexes,  and  is  a  disease  of  the  second  half 
of  life,  most  frequent  between  sixty  and  eighty.  The  chief  symptoms 
are  hemiplegia — motor  and  sensory — of  gradual  onset.  Weakness  com- 
mences in  one  part  and  gradually  spreads  to  the  whole  of  one  side,  but 
without  considerable  sensory  loss.  Slight  irritative  symptoms  occur, 
numbness,  tingling,  and  formication  in  the  limbs,  and  in  some  cases 
these  have  been  the  seat  of  paroxysmal  pain.  Rigidity  may  accom- 
pany the  commencing  paralysis,  but  ceases  when  it  is  fully  developed. 
Convulsions  are  very  rare.  There  may  be  occasional  attacks  of  giddi- 
ness, but  apoplectic  seizures  do  not  occur  in  the  chronic  form.  The 
intellect  may  be  little  affected,  or  the  patient  may  become  dull  and 
apathetic,  and,  towards  the  last,  comatose.  But  the  cerebral  sym- 
ptoms have  usually  reached  a  certain  degree  of  severity,  and  then 
remained  stationary.  Death  ultimately  occurs  from  bedsores,  pneu- 
monia, or  some  intercurrent  senile  malady,  perhaps  favoured  by  the 
nervous  state.  The  duration  of  recorded  cases  has  varied  between 
a  few  months  and  two  years,  but  the  onset  cannot  easily  be  fixed. 

Although  it  is  not  probable  that  the  condition  is  directly  related  to 
arterial  disease,  the  latter  is  present  in  most  senile  cases,  and  may 
have  an  indirect  influence  in  determining  the  lesion,  its  common  seat, 
the  white  substance,  being  nourished  partly  by  the  central,  partly  by 
the  cortical  vessels,  with  the  effect  just  mentioned  in  the  account  of 
cystic  degeneration.  Subacute  and  acute  cases  are  met  with,  which 
present  every  gradation  of  course  between  the  chronic  form,  the  less 


INSULAR    SCLEROSIS.  543 

rapid  forms  of  softening  from  arterial  occlusion,  and  focal  inflam- 
matory softening.  It  is  especially  important  to  keep  in  view  the 
cases,  in  the  old,  in  which  the  symptoms  suggest  a  focal  chronic 
inflammation  (mentioned  on  p.  469).  Pathological  facts  are  urgently 
needed  regarding  all  these  forms,  and  the  subject  is  commended  to 
the  notice  of  those  under  whose  observation,  in  workhouses  for  in- 
stance, the  diseases  of.  the  old  so  often  come. 

It  will  be  seen  that  the  chronic  symptoms  bear  a  considerable 
resemblance  to  those  of  cerebral  tumour.  A  difference  is  in  the 
fact  that  headache  is  more  often  absent  than  present,  and  very 
rarely  reaches  the  degree  of  intensity  that  is  so  characteristic  of 
tnmour.  Optic  neuritis  has  also  been  absent  in  the  cases  in  which 
the  eyes  have  been  examined.  The  greatest  diagnostic  difficulty  is 
presented  by  cases  of  very  chronic  course.  If  symptoms  develop  in 
a  subacute  manner,  reach  a  considerable  degree  of  intensity  in  six 
weeks  or  two  months,  and  then  remain  stationary,  the  distinction  from 
tumour  is  more  easy,  because  a  rapidly  growing  new  formation  rarely 
•undergoes  early  arrest.  The  age  of  the  patient  is  also  of  some  sig- 
nificance; in  the  first  half  of  life,  tumour  is  more  probable  than 
softening.  The  occurrence  of  general  convulsions  makes  softening 
unlikely,  but  cortical  fits  may  be  produced  by  softening  situated  at 
the  motor  region. 

Little  can  be  said  regarding  the  treatment  of  these  cases.  Our 
knowledge  of  them  depends  only  on  the  cases  in  which  the  nature  of 
the  disease  has  been  ascertained  by  a  post-mortem  examination,  and 
in  these  it  does  not  appear  that  any  treatment  employed  has  had  an 
appreciable  influence  on  the  course  of  the  disease.  The  most  suitable 
measures  will  probably  be  those  recommended  for  the  chronic  stage  of 
acute  softening — rest,  nutritious  food,  with  general  and  cardiac  tonics. 


DISSEMINATED   OR  INSULAR   SCLEROSIS. 

The  disease  thus  named  consists  in  the  formation  of  scattered  islets 
of  sclerosis  in  various  parts  of  the  brain  and  spinal  cord,  sometimes 
also  in  the  cranial  nerves.  Our  knowledge  of  the  affection  is  recent. 
The  lesion  was,  indeed,  long  since  figured  by  Carswell  and  Cruveilbier, 
and  it  was  described,  thirty  years  ago,  by  Frerichs,  Rindfleisch,  &c,  but 
the  malady  was  not  generally  recognised  until  re-investigated  by 
Yulpian,  and  by  Charcot  and  his  pupils,  and  described  by  Charcot  in 
his  widely  circulated  '  Lectures.'  It  is  called  by  the  French  "  Sclerose 
en  Plaques  Disseminees,"  by  the  Germans  "Multiple  Sclerosis,"  and, 
in  this  country,  the  French  designation  has  been  modified  into  "Dis- 
seminated Sclerosis ;"  but  it  is  also  called  "  Insular  Sclerosis,"  a 
convenient  term,  proposed  by  the  late  Dr.  Moxon. 


544  BRAIN. 

The  pathological  relations  of  the  morbid  process  are  still,  to  a  large 
extent,  obscure,  and  much  remains  to  be  done  in  elucidating  its  clinical 
history  and  pathological  relations.  As  regards  the  symptoms  of  the 
typical  form,  little  cau  be  added  to  the  description  given  by  Charcot, 
but  there  is  much  uncertainty  regarding  the  untypical  varieties,  which 
are  by  no  means  rare. 

Three  forms  of  the  disease  have  been  distinguished — cerebral, 
spinal,  and  cerebro- spinal,  according  to  the  situation  of  the  islets 
of  sclerosis,  and  the  corresponding  difference  in  the  symptoms  they 
produce.  The  cerebro-spinal  variety  must  be  regarded  as  the  typical 
form,  which  gives  rise  to  the  complete  series  of  symptoms ;  but  the 
disease  may  be  at  first  limited  to  one  part,  and  may  afterwards  become 
general ;  or  it  may  remain  limited,  so  far  as  symptoms  are  concerned,, 
to  the  part  first  affected.  Hence  the  nature  of  many  cases  is  mis- 
understood, and  other  diseases  have  often  been  described  as  examples 
of  this  affection  ;  its  name  having  become  familiar,  it  is  apt  to  be 
suspected  where  it  does  not  exist. 

Etiology. — Insular  sclerosis  occurs  in  both  sexes  with  nearly  the 
same  frequency.  It  is  met  with  at  almost  all  periods  of  life  between 
childhood  and  old  age,  but  especially  in  the  first  half  of  adult  life. 
The  majority  of  the  cases  commence  between  twenty  and  thirty- 
five.  In  one  verified  case  it  commenced  at  seven,  and  its  symptoms 
have  been  observed  still  earlier ;  in  another  case  it  began  as  late  as 
sixty,  but  in  old  age  it  is  extremely  rare.  Direct  heredity,  or  tbe 
affection  of  two  brothers  or  sisters,  has  been  noted  in  a  few  instances, 
but  is  quite  exceptional ;  indirect  inheritance  is  more  common, 
shown  by  a  family  history  of  insanity,  epilepsy,  or  of  some  form  of 
chronic  paralysis.  Often,  however,  no  hereditary  predisposition  can 
be  traced.  In  about  half  the  cases  the  disease  develops  without  any 
recognisable  cause,  near  or  distant.  Among  the  influences  to  which 
it  has  been  immediately  ascribed,  the  most  frequent  are  exposure  to 
cold,  mental  distress,  over-exertion,  some  acute  disease,  an  actual  lesion 
of  the  central  nervous  system  of  traumatic  or  other  nature,  or  some 
specific  febrile  disease.  But  any  single  exciting  influence  is  to  be 
traced  only  in  a  very  small  proportion  of  the  cases,  and  the  most 
noteworthy  fact  regarding  them  is  the  occurrence  of  the  disease  at  a 
time  of  life  when  general  influeuces  have,  as  a  rule,  no  late  sequelae. 
Among  the  acute  diseases  that  have  preceded  it,  typhoid  fever  and 
smallpox  are  the  most  frequent ;  it  has  also  been  known  to  follow 
diphtheria  and  erysipelas.  The  preceding  morbid  processes  in  the 
nervous  system  have  been  apparently  acute  or  subacute  inflammation 
(myelitis,  &c),  primary,  or  secondary  to  some  injury.  Their  symptoms 
have  subsided,  or  have  left  some  stationary  residual  effects;  after 
an  interval  of  a  year  or  more,  the  indications  of  insular  sclerosis  have 
slowly  developed,  I  have  known  it  to  begin  during  pregnancy,  remain 
stationary  until  the  next  pregnancy,  and  then  become  progressive. 


INSULAR  SCLEROSIS. 


545 


Preceding  syphilis  can  scarcely  ever  be  traced,  so  that  it  is  doubtful 
whether  the  very  rare  cases  in  which  symptoms  of  this  disorder  in 
syphilitic  subjects  have  been  removed  by  treatment  were  really  due  to 
sclerosis.* 

Pathological  Anatomy. — The  islets  of  sclerosis  that  characterise 
the  disease  are  always  irregular  in  situation,  scattered,  as  it  were  at 
random,  through  the  central  nervous  system,  subject  only  to  the  most 
general  laws  of  distribution,  and  corresponding  in  locality  in  no  two 
cases.  The  only  law  which  can  be  traced  is  that  they  generally  com- 
mence in  the  white  substance.  In  the  brain  they  seldom  invade  the 
grey  matter  of  the  cortex,  and  never  seem  to  begin  in  it,  however 
numerous  they  may  be  in  the  white  substance  of  the  centrum  ovale,  a 
f  avom'ite  seat.  They  are  irregular  in  shape,  and  vary  in  size  from  that 
of  a  pea  (or  less)  to  that  of  a  walnut.  In  colour  they  are  reddish  grey,  a 
little  darker  than  the  normal  grey  substance  of  the  cortex,  and  rather 
more  translucent.  Their  section  is  usually  on  the  level  of  that  of  the 
adjacent  cerebral  tissue;  occasionally  it  is  a  little  depressed,  but  on 


IK 


vi 


t 


w 


£&?    A 


Fig.  144. — Insular  sclerosis. 

A.  Centrum  ovale  of  right  hemisphere. 

B.  Pons  and  medulla. 

C.  Peri-ependymal  sclerosis  around  the  descending  cornu  of  the  lateral 
ventricle.     (A,  B,  and  C  are  from  an  original  case.) 

D.  Sections  of  the  spinal  cord  to  show  the  varying  distribution  of  the 
sclerosis  at  different  regions.     (After  Ley  den.) 

*  Some  facts  bearing  on  this  question   will   be    considered  in  the   section  on 
'■  Pathology." 
vol.  ii.  35 


5-16  BRAIN. 

the  surface  (as  in  the  crus  or  pons  or  cord)  they  are  sometimes  slightly 
prominent.  The  sclerosis  does  not,  however,  increase  perceptibly  the 
volume  of  the  part  in  which  it  occurs.  To  the  naked  eye  the  islets  are 
sharply  defined ;  the  transition  to  the  normal  tissue  is  sudden.  The 
consistence  of  the  sclerosis  is  usually  a  little  firmer  than  that  of  the 
brain -tissue,  and  they  are  sometimes  distinctly  firm  ;  occasionally,  in 
old  cases,  some  may  be  almost  cartilaginous  in  their  firmness.  Owing 
to  the  position  of  the  islets  in  the  cerebral  hemisphere  there  is  usually 
no  indication  of  their  presence  on  the  surface  of  the  brain,  even  when 
a  large  number  are  found  in  its  interior.  Although  the  cortex  is 
seldom  involved,  the  central  ganglia  are  frequently  iuvaded,  and  the 
sclerosis  is  sometimes  abundant  beneath  the  lining  membrane  of  the 
lateral  ventricle  (Fig.  144,  C)  and  in  the  corpus  callosum.  In  the 
crus  and  pons  the  islets  are  often  numerous  ;  some  may  be  conspicuous 
on  the  surface  from  their  contrast  with  the  white  fibres  which  con- 
stitute  the  superficial  layer  of  these  parts,  while  others  are  scattered 
through  the  interior  of  the  pons  or  medulla.  They  are  met  with  also 
in  the  cerebellum,  but  are  usually  few,  and  here  also  are  confined  to 
the  white  substance.  In  the  spinal  cord  the  areas  of  disease  appear 
on  the  surface  as  grey  patches ;  they  are  irregular  in  size,  but  usually 
of  greater  vertical  than  transverse  extent,  and  on  section  they  are 
seen  to  extend  for  a  variable  distance  in  the  substance  of  the  cord, 
sometimes  through  a  considerable  part  of  one  half  (Fig.  144,  D),  and, 
in  cases  of  long  duration,  the  disease  may  even  extend  through  the 
whole  thickness  of  the  cord.  Such  diffuse  sclerosis  of  the  lower  part 
of  the  cord  has  been  met  with  in  association  with  characteristic  islets 
in  the  upper  part  of  the  cord  and  brain,  from  which  it  probably  does 
not  differ  in  nature.  Very  rarely,  however,  a  slight  diffuse  sclerosis 
has  united  the  spots  of  disease  in  the  brain.  The  cranial  nerves  are 
often  involved;  for  a  certain  distance  a  nerve  may  be  grey  and 
sclerosed  either  in  its  entire  thickness  or  in  part.  The  olfactory, 
optic,  third,  fifth,  and  facial  nerves  are  those  that  have  been  most 
frequently  affected.  Less  commonly  the  roots  of  some  of  the  spinal 
nerves  are  affected. 

In  the  diseased  a.reas  there  is  an  overgrowth  of  the  neuroglia  and 
a  wasting  of  the  nerve-fibres.  The  tissue  contains  connective-tissue 
elements,  glia-cells  and  fibres,  spider-cells,  and  ultimately  a  mass  of 
fine  fibres,  denser  in  aspect  than  the  fibres  of  the  normal  neuroglia. 
Among  these  tissue-elements  there  may  be  fatty  granules  and  globules, 
the  remains  of  the  degenerated  nerve-elements.  The  nerve- tibres  that 
pass  through  are  changed  in  various  degrees.  The  chief  alteration  is 
a  narrowing  of  the  white  substance,  which  becomes  reduced  (as  seen 
in  section)  to  a  narrow,  scarcely  appreciable  ring  around  the  axis- 
cylinder,  and.  even  this  may  cease  to  be  recognisable.  The  axis- 
cylinders  persist  longest,  but  ultimately  they  may  disappear.*     The 

*  The  persistence  of  the  axis-cylinders  was  first  pointed  out  by  Charcot,  and  has 
been  since  confirmed  by  Schultze,  Dejerine,  Babinski,  and  others. 


INSULAR    SCLEROSIS.  547 

walls  of  the  vessels  become  thickened,  and  the  increase  of  the  adja- 
cent connective  tissue  may  be  very  conspicuous.  Should  the  sclerosis 
involve  the  grey  substance,  the  nerve-cells  become  atrophied,  and  the 
intervening  structures  suffer  changes  like  those  of  the  white  sub- 
stance, but,  from  its  nature,  less  readily  perceived.  Over  affected 
areas  that  reach  the  surface  there  may  be  a  slight  thickening  of  the 
pia  mater,  but  seldom  sufficient  to  be  recognised  with  the  naked  eye. 

If  an  area  of  sclerosis  occupies  part  of  a  tract  of  fibres  that  is  liable 
to  undergo  secondary  degeneration,  such  degeneration  may  or  may  not 
be  found  beyond  the  part  diseased,  but  it  is  usually  present  in  some 
degree.  "  The  difference  seems  to  depend  on  the  condition  of  the  axis- 
cylinders  ;  as  long  as  the  change  is  confined  to  the  white  substance  of 
the  nerve-fibres  there  is  no  secondary  degeneration,  but  as  soon  as 
the  axis-cylinders  suffer,  degeneration  occurs. 

When  the  optic  nerve  undergoes  general  atrophy,  the  same  ten- 
dency is  seen  for  the  axis-cylinders  to  persist  and  the  medullary 
sheath  to  suffer.  The  connective  tissue  is  much  increased  between 
the  bundles  and  in  the  inner  nerve-sheath,  and  the  nuclei  between 
the  nerve-fibres  are  multiplied  (Uhthoff).  An  islet  of  sclerosis  in 
this  or  any  nerve  presents  the  conditions  already  described. 

Symptoms. — The  wide  variations  in  the  position  of  the  islets  of 
sclerosis  entails  a  corresponding  difference  in  the  symptoms  that  are 
produced.  Loss  of  muscular  power  in  the  limbs,  variously  distri- 
buted, and  often  at  first  partial,  is  the  most  constant  manifestation  of 
the  disease.  Since  the  morbid  process  usually  involves  the  pons  and 
spinal  cord  as  well  as  the  brain,  some  islets  can  hardly  fail  to  occupy 
the  motor  tract.  .  The  deficiency  of  power  in  the  arms  is  very  variable 
in  degree,  but  the  characteristic  feature  of  the  weakness  is  its  associa- 
tion with  a  peculiar  symptom,  jerky  irregularity  of  movement,  wide 
in  range,  and  ceasing  on  rest.  It  may  exist  also  in  the  neck  muscles, 
and  in  the  legs ;  also  in  the  latter  it  is  often  masked  by  the 
general  unsteadiness  it  causes,  but  it  is  sometimes  conspicuous, 
even  .when  the  arms  are  little  affected;  ataxy  may  exist  alone, 
but  simple  spasmodic  paraplegia  is  still  more  common.  Some  of  the 
cranial  nerves  are  often  also  paralysed.  Among  other  symptoms, 
nystagmus  is  exceedingly  common,  and  so  is  a  peculiar  disturbance 
of  articulation.  These  symptoms  vary  in  occurrence  and  degree, 
in  different  cases,  to  an  extent  which  makes  it  impossible  to  give  a 
description  of  the  disease  alike  accurate  and  comprehensive,  and  also 
gives  rise  to  numerous  difficulties  in  its  diagnosis. 

The  variation  in  the  character  of  the  symptoms  extends  to  then- 
order  and  to  their  mode  of  onset.  In  some  cases  the  peculiar 
inco-ordination  in  the  hands,  or  in  one  alone,  is  the  first  indication  of 
the  disease.  In  other  and  more  frequent  cases  the  legs  first  become 
weak,  or  the  patient  is  unsteady  in  standing  or  walking.  Dull  pains 
in  the  limbs  may  trouble  the  patient  for  a  year  or  two  before  the 


548  BRAIX. 

onset,  or  a  sense  of  "numbness  "  in  the  bands  and  feet,  occasionally 
witb  actual  lessened  sensibility,  may  occur  and  pass  away,  or  even 
recur  more  tban  once.  Less  commonly  some  cranial  nerve-palsy 
occurs  at  the  onset,  or  speech  is  observed  to  be  peculiar,  but  in  the 
majority  of  cases  the  limb  symptoms  precede  the  otbers.  It  is 
important  to  remember  tbat  some  of  the  preceding  symptoms  may  be 
due  to  a  morbid  process  connected  with  the  cause  of  the  disease. 

Of  the  individual  symptoms,  the  jerky  irregtilarity  or  tremor  is  the 
most  peculiar  and  characteristic.  It  is,  as  just  observed,  manifested 
most  frequently  in  the  arms.  At  rest  the  limb  is  still,  and  presents 
no  spontaneous  tremor,  but  as  soon  as  a  movement  is  attempted,  in 
the  endeavour,  for  instance,  to  take  hold  of  some  object,  the  arm  is 
thrown  about  in  a  wildly  irregular  manner,  and  moves  in  sudden 
quick  jerks,  now  in  one  direction,  now  in  another,  until  at  last  by  a 
great  effort,  and  sometimes  with  a  sudden  dash,  the  patient  succeeds 
in  grasping  the  object.  If  he  tries  to  raise  a  glass  of  water,  the 
movements  are  so  wild  that  the  contents  of  the  glass  are  probably 
spilled.  In  an  attempt  to  write,  the  violent  movements  produce  only 
irregular  strokes  upon  the  paper  as  the  hand  dashes  to  and  fro,  and 
often  the  paper  is  pierced  or  even  the  pen  is  broken  in  the  attempt. 
In  some  instances  the  movements  are  slighter  in  range  and  more 
regular,  even  resembling  simple  tremor,  although  its  relation  to  the 
malady  may  be  proved  by  the  presence  of  the  typical  form  in  some 
other  part.  It  is  said  that  in  rare  instances  the  movements  have  been 
known  to  continue  during  rest,  but  there  is  some  doubt  as  to  the 
nature  of  such  exceptional  cases.  The  movements  are,  as  a  rule, 
increased  by  effort,  by  motion,  and  by  attention.  The  more  the 
patient  tries  to  overcome  them,  the  more  violent  they  are,  but  the 
variations  in  degree  are  not  great,  and  the  disorder  of  movement  is 
unceasing.* 

The  muscles  of  the  neck  often  share  the  disorder  of  movement,  and 
there  is  irregular  oscillation  of  the  bead,  and  sometimes  of  the  trunk, 
whenever  the  patient  sits  up.  The  derangement  may  even  be  greater 
in  the  muscles  that  support  the  head  than  elsewhere,  and  it  may  cause 
so  much  unsteadiness  that  the  head  has  to  be  kept  still  by  the  hand 
to  permit  the  patient  to  drink.  When  laid  at  rest  the  head  at  once 
becomes  still.  Although  the  affection  of  the  movement  of  the  legs 
usually  causes  unsteadiness,  which  may  render  walking  impossible 
without  assistance,  and  even  standing  difficult,  they  sometimes  present 
the  irregularity  of  movement  above  described.  It  will  be  seen  that 
the  distribution  of  this  symptom  varies  much,  and  with  it  the  general 
aspect  of  the  cases.     For  instance,  while  it  is  usually  most  marked  in 

*  Hence  they  are  called  by  the  Germans  "  Intentions-Zittern,"  a  term  which 
cannot  be  rendered  in  English  without  inaccuracy,  on  account  of  the  meaning  of 
"  intention."  "  Movement-tremor  "  embraces  all  varieties,  but  fails  to  indicate  the 
irregularity  of  the  typical  form.  Perhaps  "atactic  tremor"  would  be,  on  the 
whole,  the  best  term,  because  there  is  no  ataxy  without  voluntary  movement. 


INSULAR    SCLEROSIS.  549 

the  arms,  one  unquestionable  case  presented  in  these  only  the  fine  irre- 
gular tremor  on  sustained  movement,  great  inco-ordination  in  the  legs, 
and  extreme  jerky  disorder  in  the  muscles  supporting  the  head.  Barely 
the  limb  symptoms  exist  on  one  side,  alone  or  chiefly  ;  one  limb  is  then 
more  affected  than  the  other,  as  in  a  case  in  which  the  left  leg  was 
merely  weak,  while  the  left  arm  presented  typical  irregularity  of  move- 
ment. Such  instances  might  be  multiplied  indefinitely ;  they  are  ex- 
plained by  the  great  variety  in  the  lesions. 

Some  weakness  usually  accompanies  this  irregular  inco-ordination  ; 
it  may  be  at  first  slight,  and  indeed,  at  the  very  onset,  it  may  be 
absent.  On  the  other  hand,  weakness  may  exist  alone,  especially  in 
the  legs.     Once  established,  the  loss  of  power  gradually  increases. 

The  jerky  irregularity  has  been  ascribed  by  Charcot  to  an  irregular 
resistance  to  conduction  in  the  nerve-fibres  at  the  sclerosed  spot ;  it  is 
supposed  that  the  changes  in  the  white  substance,  or  in  the  axis- 
cylinder,  interfere  with  conduction  along  the  latter,  and  as  this  change 
is  unequal  in  degree,  even  in  adjacent  fibres,  there  is  a  vaiious  degree 
of  retardation  of  the  voluntary  influence  on  the  muscles,  and  hence  the 
irregularity  of  the  contractions.  This  hypothesis  derives  some  support 
from  the  fact  that  a  precisely  similar  symptom  is  present  in  some 
cases  of  tumour  of  the  brain,  in  which,  for  instance,  a  tubercular 
growth  compresses  the  motor  path,  as  in  the  case  of  tubercle  in  the 
crus  shown  at  Fig.  142,  p.  509.  I  have  met  with  this  symptom  also 
in  a  case  of  tubercle  of  the  pons.  To  some  (Erb,  &c.)  the  theory  has 
appeared  inadequate,  and  they  incline  to  the  alternative  exjDlanation, 
that  the  disorder  is  due  to  the  occurrence  of  islets  of  sclerosis  in  some 
particular  situation  in  which  they  derange  the  co-ordinating  function. 
The  symptom  is  said  to  coincide  with  sclerosis  of  the  pons,  and  to  be 
absent  in  cases  in  which  the  lesion  is  confined  to  the  spinal  cord. 

Simple  weakness  in  the  legs  is  common,  and  is  often  the  earliest 
symptom  of  the  disease,  and  may  present  a  paroxysmal  increase  on 
exertion,  so  that  the  patient  falls  occasionally,  and  can  only  resume 
walking  after  a  rest.  When  it  is  considerable  it  is  usually  accom- 
panied by  an  excess  of  myotatic  irritability  (increased  knee-jerk,  foot- 
clonus,  &c),  which  goes  on  to  spasm,  so  that  a  state  of  spastic  para- 
plegia is  established.  This  is  indicative,  as  in  other  cases,  of  degenera- 
tion of  the  lower  parts  of  the  pyramidal  tracts.  Such  degeneration  in 
this  disease  is  secondary,  the  consequence  of  the  development  of  areas 
of  sclerosis  somewhere  in  the  dorsal  region  of  the  cord,  involving  the 
pyramidal  tracts.  In  the  rare  cases  in  which  the  lesion  is  limited  to 
the  spinal  cord,  such  spastic  paraplegia  may  be  the  only  symptom  of 
its  presence,  and  many  cases  have  been  mistaken  for  primary  lateral 
sclerosis.  The  ataxy  of  the  legs,  present  in  other  cases,  varies  in  its 
character,  and  probably  also  in  its  mechanism.  There  may  be,  as  we 
have  seen,  jerky  inco-ordination  with  which  the  myotatic  irritability  is 
usually  increased.  In  other  cases  there  is  simple  unsteadiness,  some- 
times like  cerebellar,  sometimes  like  spinal  inco-ordination.      It  is 


550  BBA1N. 

probable  that  this  is  due  to  the  interruption  of  the  upward  paths 
from  the  muscles,  as  explained  in  vol.  i.  In  a  rare  group  of  cases 
the  state  of  the  legs  is  identical  with  that  in  true  tabes,  perhaps 
in  consequence  of  a  patch  of  sclerosis  in  the  posterior  columns  in  the 
lumbar  region ;  but  it  is  also  possible  that  the  condition  is  true  tabes, 
a  sv stem-degeneration  in  one  part  of  the  central  nervous  system  accom- 
panying the  insular  sclerosis  in  another  part.  This  association  will  be 
considered  in  the  section  on  pathology. 

The  excess  of  the  muscle-reflex  action  in  the  legs  may  increase  to 
rigidity,  the  common  variable  extensor  spasm,  or,  in  rare  cases,  flexor 
contracture,  so  that,  the  legs  are  permanently  drawn  up.  Occasionally 
a  single  group  of  muscles  may  become  rigid  and  contracted  in  the 
arms  as  well  as  in  the  legs.  Muscular  wasting  is  rare,  but  local 
irregular  atrophy  may  result  from  the  invasion  of  the  grey  matter  of 
the  cord  by  some  islet  of  sclerosis. 

Cutaneous  sensibility  is  normal  in  the  early  stage  of  the  disease, 
but  it  may  afterwards  be  impaired.  The  loss  varies  much  in  its 
distribution  according  to  the  situation  of  the  sclerosis  on  which  it 
depends.  Rarely  there  is  hemianesthesia  from  the  development  of 
an  islet  in  the  sensory  path  within  the  brain.  The  loss  is  more  often 
partial,,  involving  only  a  small  area  on  a  limb,  and  it  may  or  may  not 
correspond  to  the  motor  palsy.  When  there  is  diffuse  sclerosis  of  the 
cord  there  may  be  extensive  loss  of  sensibility  on  the  legs.  The  con- 
dition of  sensation  is  intelligible  when  we  remember  how  slowly  the 
axis-cylinders  of  the  nerve-fibres  suffer,  and  that  a  greater  amount  of 
damage  is  required  to  abolish  sensory  conduction  than  suffices  to 
cause  motor  palsy.  Irritative  symptoms  are  occasionally  present ;  a 
sense  of  vague  numbness  or  formication  in  the  hands,  sometimes  also 
in  the  feet,  may  be  a  very  early  symptom,  and  may  even  pass  away 
before  other  disturbance  is  developed,  although  it  occasionally  per- 
sists. Dull  aching  pains  in  the  limbs  are  not  uncommon,  especially 
in  the  egs,  sometimes  in  the  back,  and  may  occur  from  time  to  time 
throughout  the  course  of  the  disease.  Sharp  momentary  pains  also 
occur,  but  not  often.  A  girdle  pain  may  occur,  early  or  late,  per- 
sistent or  transient,  complete  or  partial,  but  also  is  not  frequent. 
These  sensations  are  chiefly  complained  of  when  there  is  other 
evidence  of  the  presence  of  sclerotic  islets  in  the  spinal  cord,  but  even 
then  they  may  be  absent,  and  the  comfort  of  the  patient  may  be 
undisturbed. 

Eye  symptoms  are  frequent  and  important.  The  optic  nerve  may 
suffer  in  various  ways.  There  may  be  impairment  of  sight  in  one 
eve  or  in  both,  often  with  an  irregular  contraction  in  the  field  of 
vision,  and  without  at  firsjt  any  visible  changes  in  the  optic  nerve  to 
account  for  it.  This  condition  depends  upon  the  development  of  an 
islet  of  sclerosis  in  one  or  both  optic  nerves,  or  in  the  optic  chiasma. 
It  may  progress  to  almost  complete  blindness  of  one  eye.  After  a 
time,  secondary  atrophy  supervenes,  and  can  be  seen  with  the  ophthal- 


INSULAR   SCLEROSIS.  551 

moscope.  Occasionally  the  atrophy  is  preceded  by  slight  neuritis, 
when  the  sclerosis  is  near  the  eyeball.  In  some  cases,  again,  there  is 
a  primary  atrophy  of  the  optic  nerves,  exactly  like  that  which  occurs 
in  tabes,  with  a  similar  failure  of  sight,  proportioned  to  the  visible 
alteration  in  the  nerve.  Both  eyes  usually  suffer,  but  one  is  often 
affected  earlier  and  more  than  the  other.  This  complication  is, 
according  to  my  own  experience,  rather  more  frequent  than  the  form 
first  described,  and  is  of  much  pathological  interest. 

The  internal  ocular  muscles  are  seldom  involved,  but  each  form  of 
internal  palsy  is  sometimes  met  with,  loss  of  accommodation  rather 
more  frequently  than  loss  of  the  light-reflex  alone.  The  pupils  are 
sometimes  unequal;  or  become  so  on  accommodation. 

On  the  other  hand,  the  external  muscles  often  preseut  some  abnor- 
mality. The  most  frequent  disturbance  is  nystagmus,  which  is  an 
exceedingly  common  symptom  of  the  disease,  although  we  cannot 
explain  it.  Both  forms  occur,  spontaneous  and  on  movement,  but 
the  former  is  uncommon ;  the  latter  is  that  usually  present,  and  it 
does  not  differ  in  features  from  that  which  is  met  with  in  other 
central  degenerations.  It  is  generally  on  lateral  or  upward,  seldom  on 
downward  rotation.  The  quick  displacement  of  the  globes  is,  as  a 
rule,  in  the  direction  of  the  voluntary  movement,  but  curious  varia- 
tions are  sometimes  met  with,  especially  in  association  with  loss  of 
power.  One  patient  could  only  move  the  eyes  to  the  left  balfway 
to  the  canthus  for  a  moment,  but  nystagmus  only  occurred  on  move- 
ment to  the  right.  In  another  case,  on  movement  to  the  right  there 
was  nystagmus  with  the  quick  movement  to  the  right ;  on  movement 
upwards  there  was  rotatory  nystagmus,  and  vertical  oscillation  when 
the  eyes  were  directed  to  the  left.  In  another  the  quick  motion  was 
to  the  right,  whether  the  movement  of  the  eyes  was  towards  the 
right  or  the  left  side.  These  variations  quite  baffle  our  power  of 
explanation. 

The  external  palsies  are  more  often  of  a  conjugate  movement  than 
of  a  single  nerve  or  muscle,  except  the  external  recti  '(sixth  nerves), 
which  may  be  weakened  on  one  or  both  sides  ;  one  superior  rectus 
is  occasionally  feeble.  But  convergence,  and  the  movement  of  both 
eyes  towards  one  side,  are  the  motions  most  often  impaired,  and  they 
are  occasionally  lost.  In  exceptional  cases,  however,  there  is  con- 
siderable and  increasing  palsy  of  one  of  the  ocular  nerves,  as  the  third, 
due  to  the  development  of  sclerosis  in  the  nerve-ttnank.  Transient 
diplopia  is  also  occasionally  complained  of,  even  in  the  early  stage  of 
the  disease. 

Other  cranial  nerves  may  also  become  paralysed  by  the  same 
mechanism  and  with  the  same  rarity,  especially  the  facial,  fifth,  or 
hypoglossal  nerves.  In  the  affection  of  the  first  of  these,  all  parts  of 
the  face  suffer,  and  the  degenerative  reaction  is  well  mai-ked.  Very 
rarely  there  is  clonic  spasm  in  the  face,  which  may  even  be  the  first 
symptom.     In   the   fifth   nerve,  either   one   or  both  parts   may  be 


552  BKAIN. 

involved.  The  implication  of  the  sensory  part  causes  much  less  pain 
than  is  produced  by  most  other  lesions  of  this  nerve-trunk.  The 
sclerosis  that  thus  damages  these  nerves  may  be  either  in  the  nerve 
itself,  near  the  surface  of  the  brain,  or  in  the  pons  or  medulla,  at  the 
central  course  of  the  fibres.  Difficulty  in  swallowing  may  be  present 
when  the  pons  or  medulla  is  the  seat  of  the  morbid  process. 

Another  very  frequent  symptom — so  common  as  to  be  of  diagnostic 
importance — is  a  peculiar  change  in  articulation.  Syllables  (less  fre- 
quently  words)  are  unduly  separated  and  unduly  accentuated,  in  what 
has  been  termed  "staccato,"  or  "syllabic,"  or  "scanning"  utterance, 
often  with  a  tendency  to  elide  the  ends  of  words.  Some  patients, 
indeed,  present  only  elisive  or  slurring  articulation.  The  syllabic 
form  suggests  a  difficulty  in  uttering  the  syllables,  and  there  may  be 
an  actual  consciousness  of  this  difficulty.  The  movement  of  the 
tongue  is  sometimes  jerky  and  irregular,  but  the  face  is  seldom 
involved,  and  the  peculiar  affection  of  speech  is  independent  of  any 
visible  disorder  of  the  movement  of  the  tongue.  It  has  been  met 
with  when  the  pons  and  medulla  were  free  from  sclerosis,  and  its 
source  is  thus  obscure. 

Slight  mental  change  is  common;  considerable  alteration  is  very 
rare.  There  may  be  failure  of  memory,  but  especially  frequent  is  an 
undue  complacency  and  contentment,  which,  under  the  increasing 
disability,  is  distinctly  unnatural.  There  is  not  often  any  mistaken 
idea  of  improvement,  but  the  patient  may  seize  on  and  exaggerate 
any  distinct  diminution  in  the  symptoms.  This  morbid  complacency 
is  rather  more  frequent  in  women  than  in  men,  and  in  young  adults 
than  in  later  life.  Hysterical  and  emotioual  disturbance  may  also 
occur,  even  in  men.  Yery  rarely  mental  disturbance  is  considerable 
enough  to  amount  to  chronic  insanity. 

Among  other  symptoms  that  are  frequently  met  with  are  headache 
and  giddiness  ;  both  may  occur  early  in  the  disease,  and  are  usually 
paroxysmal.  The  vertigo  is  especially  pronounced,  but  its  frequency 
has  been  over-estimated,  and  after  a  time  it  ceases  to  occur.  The 
attacks  may  be  very  severe  and  come  on  apart  from  any  apparent 
cause.  As  in  other  forms  of  severe  giddiness,  it  may  be  accompanied 
by  vomiting,  and  this  may  also  occur  in  pai'oxysms  without  vertigo, 
often  in  association  with  headache. 

Other  paroxysmal  disturbances  are  sometimes  met  with,  especially  of 
apoplectiform  character,  similar  to  those  that  occur  in  general  para- 
lysis of  the  insane.  There  may  be  attacks  of  simple  coma,  with  pyrexia 
(even  to  104°),  or  there  may  be  unilateral  convulsions,  or  the  attack 
may  be  followed  by  transient  hemiplegic  weakness  or  rigidity.  Occa- 
sionally the  patient  dies  in  such  a  coma,  and,  post  mortem  (as  in 
general  pai'alysis),  no  acute  lesion  can  be  found.  Such  paroxysmal 
disturbance,  or  some  more  trifling  functional  derangement,  may 
precede  the  definite  symptoms  of  the  disease. 

The  general  nutrition  of  the  sufferer  is  often  unimpaired,  and  some- 


INSULAR    SCLEEOSIS.  558 

times  there  is  an  actual  increase  in  the  amount  of  subcutaneous  fat. 
Trophic  disturbances  have  been  observed  in  rare  cases, — local  oedema, 
altered  secretion  of  sweat,  changes  in  the  growth  of  hair  or  nails, 
chronic  arthritis,  and  herpetic  eruptions. 

Couese  and  Duration. — In  some  cases  the  course  of  the  malady  is 
uniformly  progressive  from  the  first  to  the  last.  More  frequently 
periods  of  apparent  arrest  alternate  with  periods  of  progress,  and  its 
full  development  may  be  followed  by  arrest,  actual  or  approximate, 
for  years.  The  duration  varies  between  two  and  fifteen  years,  the 
average  being  between  three  and  six  years.  The  most  rapid  case  I 
have  known  was  fatal  a  year  and  three  quarters  from  the  onset.  The 
most  common  cause  of  early  death  is  interference  with  the  functions  of 
the  medulla  oblongata,  especially  impairment  of  deglutition  with  its 
various  consequences.  In  a  few  cases  death  occurs  from  failure  of  re- 
piration.  In  the  cases  of  longer  duration  the  patients  die  from  weak- 
ness, bedsores,  kidney  disease,  &c,  and  in  not  a  few  instances  death 
results,  not  from  any  effect  of  the  disease,  but  from  some  intercurrent 
malady. 

Pathology. — Compared  with  many  of  the  other  forms  of  sclerosis 
in  the  central  nervous  system,  this  variety  is  sharply  distinguished  by 
its  irregular  distribution.  The  islets  are,  as  it  were,  scattered  at 
random  in  seat,  and  they  thus  present  a  marked  contrast  to  the 
"  system-degenerations,"  in  which  a  tract  of  sclerosis  extends  through 
the  whole  of  a  group  of  fibres  having  a  certain  function,  and  is  sharply 
limited  to  these,  or  is  restricted  to  a  certain  area  of  grey  matter,  or  even 
to  related  groups  of  cells.  The  fact  suggests  that,  whereas  systemic 
sclerosis  certainly  commences  by  a  wasting  of  the  nerve-elements, 
to  which  the  overgrowth  of  connective  tissue  is  secondary  (see  vol.  i, 
2nd  ed.,  p.  425),  in  disseminated  sclerosis  the  primary  change  must 
be  in  the  interstitial  tissue,  and  the  damage  to  the  nerve-fibres  must  be 
secondary.  The  conclusion  is  supported  by  all  we  know  of  the  patho- 
logy of  the  disease,  by  its  aspect  and  its  histological  features,  by  the 
gradual  way  in  which  the  white  substance  of  the  fibres  wastes  before 
the  overgrowth  of  tissue  about  them,  and  by  the  absence  of  secondary 
degenerations  unless  the  local  process  has  a  certain  seat  and  a  certain 
degree.  The  immediate  local  determining  causes  of  the  overgrowth 
cauuot  yet  be  even  guessed  at.  It  has  been  conjectured  that  it 
proceeds  from  the  walls  of  the  vessels,  but  whenever  there  is  an 
overgrowth  of  interstitial  tissue  there  is  always  a  special  increase 
adjacent  to  the  vessels,  and  these  may  take  a  secondary  share  in 
the  process  even  when  there  is  no  primary  vascular  change  (see 
vol.  i,  p.  426). 

The  mystery  of  the  origin  of  insular  sclerosis,  of  the  mechanism  of 
its  causation,  and  the  uature  of  its  pathological  relations  are  in- 
creased by  the  fact  that,  different  from  system- degeneration   as  it 


554  BKA1N. 

is  in  the  main,  the  two  are  not  separated  at  all  points.  System- 
degenerations  may  be  combined  with  insular  sclerosis.  The  most 
common  instance  of  this  is  the  occurrence  of  primary  atrophy  of 
the  optic  nerves  in  disseminated  sclerosis.  This  is  a  true  system- 
degeneration  of  the  nerves,  similar  to  that  which  occurs  in  tabes.  It 
is  possible  that  in  some  cases  there  is  also  a  system-sclerosis  of  the 
posterior  columns  of  the  cord  in  the  lumbar  region,  so  that  tabes  and 
insular  sclerosis  are  combined,  while  some  of  the  combined  ocular 
palsies  point  to  the  same  conclusion,  and  so  also  does  the  occurrence 
of  the  disease  in  families  with  a  pure  neurotic  disposition,  such  as 
insanity  indicates.  Hence,  different  as  the  two  processes  are  in  their 
immediate  pathology,  they  may  possess  some  common  relations  in 
nature  or  causation,  but  our  knowledge  is  still  insufficient  to  enable 
us  to  make  any  definite  statement  on  the  subject.  "We  may,  however, 
bear  in  mind  two  very  different  sets  of  facts.  One  is  the  relation 
between  the  nutrition  of  the  interstitial  neuroglia  and  that  of  the 
nerve-fibres,  especially  of  the  medullary  sheath,  conspicuous  in  all 
processes  of  secondary  degeneration,  alike  in  general  relations  and  in 
minute  features.  It  is  a  converse  relation,  the  decay  of  the  one 
involving  the  growth  of  the  other  (see  vol.  i,  2nd  ed.,  p.  396),  but  is 
not  therefore  to  be  passed  as  without  significance.  It  seems  alike 
infhxeiitial  whichever  element  in  the  process  leads  the  way,  as  insular 
sclerosis  illustrates.  The  primary  atrophy  of  the  optic  fibres  causes 
interstitial  growth,  and  the  scattered  islets  of  the  latter  cause  the 
nerve-fibres  to  waste. 

A  second  fact  which  deserves  to  be  borne  in  mind,  although  its 
significance  is  obscure,  is  that  the  only  lesion  which  resembles  insular 
sclerosis  in  general  distribution,  and  sometimes  in  characters,  is  one 
that  is  apparently  quite  distant  from  it  in  etiology,  the  disseminated 
inflammation  in  the  central  nervous  system  produced  by  syphilis. 
This  is  always  distinguished  by  its  subacute  onset,  aud  usually  by 
the  caseation  that  it  presents ;  but  when  such  caseation  is  absent  the 
aspect  of  the  lesions  is  scarcely  distinguishable  from  that  of  sclerosis. 
The  illustration  of  the  latter  (Fig.  144)  may  be  compared  with  the 
caseating  foci  shown  in  Fig.  125.  I  have  seen  a  disseminated  myelitis, 
without  caseation,  the  aspect  of  which  could  scarcely  have  been  dis- 
tinguished from  insular  sclerosis  ;  but  it  developed  in  a  few  weeks 
(immediately  after  treatment  had  removed  a  syphilitic  tumour  of  the 
brain),  and  caused  death  in  three  months.  These  specific  inflamma- 
tions usually  resist  treatment,  and  are  therefore  probably  due  to  a 
"  toxine"  produced  by  the  organisms  rather  than  to  the  latter — a  fact 
which  brings  them  into  line  with  some  systemic  degenerations,  such 
as  tabes,  although  the  latter  begins  in,  and  the  former  outside,  tLe 
nerve-elements.  We  have  here  processes  that  bear  a  close  analogy 
to  those  of  insular  sclerosis.  But  it  is  no  more  than  an  analogy, 
because  the  general  history  of  this  disease  make  it  impossible  for  us 
to  ascribe  it  to  the  acquired  influence  of  either  organisms  or  their 


JXSULAB    SCLEkOSIS.  555 

products,  unless  in  occasional  and  exceptional  instances  (as  after  an 
acute  disease)  which  perhaps  approach,  in  nature,  such  forms  of  in- 
flammation as  that  met  with  in  the  subjects  of  syphilis.  The  common 
absence  of  distinct  causation,  the  early  adult  age  of  the  subjects,  and 
the  frequent  neuropathic  heredity,  all  point  to  some  inherent  condition, 
some  disseminated  congenital  tendency  of  the  nutrition  of  the  neu- 
roglia. The  system-degenerations  of  the  same  period  of  life  (such 
as  that  of  "  hereditary  ataxy ")  we  have  seen  (vol.  i)  must  be 
ascribed  to  an  inherent  defect  in  the  vital  endurance  of-  the  tissues, 
and  such  degenerations  may  occur  with  insular  sclerosis.  More- 
over, in  connection  with  the  apparent  scattered  tendency  to  an 
abnormal  growth  of  the  neuroglia  we  may  remember,  first,  the 
facts  already  mentioned  connecting  the  nutritional  tendency  of  it 
and  of  the  nerve- elements,  which  may  involve  similar  liabilities 
to  disease;  secondly,  the  features  of  "  gliomatosis "  of  the  cord, 
and  its  active  growth  in  early  adult  life;  and  thirdly,  the  modern 
theories  (perhaps  also  facts)  which  ascribe  tumours  of  many  kinds  to 
congenital  tissue-elements,  whose  long  quiescence  may  end  without 
perceptible  cause.  In  the  present  state  of  our  knowledge  it  seems 
impossible  to  do  more  than  offer  such  suggestions  regarding  the 
pathology  of  this  disease.  It  may  be  noted  that  they  include  its 
chief,  even  different,  features,  its  many  varieties,  and  gradation  into 
doubtful  forms,  and  do  not  exclude  the  possible  action,  in  rare 
cases,  of  acquired  influences,  such  as  those  connected  with  acute 
specific  maladies  and  general  causes.  Lastly,  we  can  thus  understand 
our  inability  to  cure,  and  too  often  even  to  arrest  the  disease. 

The  chief  general  facts  seem  to  be  that  insular  sclerosis  is  a 
neuroglial  disease,  and  that,  apart  from  secondary  degenerations, 
system-disease  of  the  nerve-elements  sometimes  forms  part  of  it.  It 
is  essentially  a  process  of  morbid  growth,  but  may  perhaps  sometimes 
commence  as  an  interstitial  inflammation.  Most  morbid  growths,  how- 
ever they  may  originate,  when  once  set  up,  have  a  vital  independence, 
and  often  a  distinctly  aggressive  character,  which  carries  them  far 
beyond  the  range  of  their  primary  cause. 

Diagnosis. — The  great  characteristic  of  the  disease  is  the  combina- 
tion of  the  jerky  inco-ordination  and  progressive  weakness  in  the 
limbs  with  nystagmus.  In  such  cases  the  diagnosis  is  easy.  The 
inco-ordination  differs  from  that  of  locomotor  ataxy  in  the  wildlv 
irregular  movements  or  tremors  which,  as  it  were,  break  out  on  any 
attempt  at  voluntary  motion.  The  only  disease  in  which  this 
symptom  exists  in  precisely  the  same  form  as  in  disseminated  sclerosis 
is  cerebral  tumour  (see  p.  510).  But  these  cases  are  distinguished  by 
other  indications  of  a  tumour  of  the  brain,  and  real  difficultv  in 
diagnosis  can  only  arise  from  ignorance  of  the  occurrence  of  the 
symptom  in  such  cases. 

The  diagnosis  from  paralysis  agitans  depends  chiefly  on  the  sym- 


556  BRAIN*. 

ptoms  which  exist  in  that  disease  in  addition  to  the  tremor,  on  the 
regularity  of  the  latter,  even  when  considerable  in  range,  and  its 
locality,  as  will  be  specially  described.  The  distinction  does  not  depend 
on  the  relation  of  slight  tremor  to  movement,  or  on  the  affection  or 
freedom  of  the  muscles  of  the  neck.  Hesitation  between  the  two 
should  be  rare. 

In  some  cases  of  general  paralysis  of  the  insane,  the  twitching 
contractions  of  the  muscles  occur  in  the  limbs  with  unusual  intensity, 
and  may  disorder  voluntary  movement  in  a  manner  very  similar  to 
that  seen  in  disseminated  sclerosis.  The  chief  difference  is  that  the 
spasm  is  most  intense  in  the  lips  and  tongue  in  general  paralysis, 
and  that  the  speech  presents  a  drawling  character,  with  hesitating 
phonatiou,  while  considerable  mental  change  is  almost  invariable.  A 
similar  difficulty,  at  least  in  aspect,  is  presented  by  some  cases  of 
infantile  brain  disease,  involving  the  motor  cortex  of  both  hemispheres. 
There  may  be  jerky  inco-ordination  of  the  arms,  identical  in  aspect 
with  that  of  sclerosis,  inco-ordination  of  the  legs,  and  even  a  staccato 
articulation.  Birth  palsy  (meningeal  haemorrhage)  or  thrombosis  in 
the  veins  and  (incomplete)  in  the  longitudinal  sinus,  are  the  probable 
causes.  The  latter  may  have  been  the  lesion  in  a  case  in  which  the 
symptom  dated  from  a  brain  illness  at  fifteen  months  and  ultimately 
resembled,  very  closely,  those  of  insular  sclerosis.  But  however  close 
the  resemblance,  the  history  of  such  cases  at  once  distinguishes  them. 
The  difficulty  of  the  diagnosis  may  seem  great  at  the  first  glance,  but 
the  onset,  or  development  and  careful  observation  of  the  several 
symptoms  always  shows  the  nature  of  the  case. 

The  spastic  paraplegia  that  results  from  insular  sclerosis  in  the 
dorsal  region  of  the  spinal  cord,  and  secondary  degeneration  below  is 
not  distinguishable  from  that  met  with  in  other  chronic  lesions  of 
the  same  part,  including  primary  lateral  sclerosis.  But  characteristic 
symptoms  elsewhere  usually  appear.  The  distinction  of  this  dis- 
seminated dorsal  myelitis,  described  in  the  section  on  Pathology, 
depends  on  the  same  considerations,  but  espe,  ially  on  the  difference 
in  the  course  of  the  two  diseases,  the  subacute  development  of  the 
paralysis  in  the  disseminated  inflammation. 

Cases  have  been  described  by  Westphal,*  Leyden,  and  Langer,f  in 
which  symptoms  closely  resembling  those  of  insular  sclei'osis  have 
existed  during  life  without  any  post-mortem  lesion  to  which  they  could 
be  ascribed.  There  is  much  doubt  as  to  the  exact  nature  of  such 
cases,  but  they  are  too  rare  to  be  of  much  practical  importance. 

Perhaps  the  greatest  real  difficulty  is  presented  by  the  cases  in 
which  there  is  only  fine  tremor  in  the  hands  with  some  weakness  in 
the  legs.  The  fact  is  certain  that  fine  tremor  may  be  combined  with 
the  other  symptoms  (see  p.  548),  and  that  which  may  co-exist  with 
more  typical  disorder  may  also  exist  alone.     A  careful  and  repeated 

*   '  Archiv  f .  Psych.,'  xiv,  pp.  87  and  767. 
t  '  Wien.  med.  JPresse/  1884,  p.  698. 


INSULAR   SCLEROSIS.  557 

search  should  be  made  for  any  unequivocal  symptoms,  and  these  will 
often  be  found  in  the  movements  of  the  eyes.  These  cases  are  most 
common  in  girls,  even  when  genuine,  and  they  furnibh  the  most 
frequent  examples  of  the  inevitable  diagnostic  problem,  the  distinction 
from  hysteria.  The  difficulty  is  occasioned  by  the  fact  that  an 
irregular  tremor,  occurring  on  movement  only,  is  sometimes  due  to 
hysteria.  While  resembling  that  of  sclerosis  in  irregularity,  it  is 
much  smaller  in  range,  and  it  is  always  accompanied  by  a  tardiness  of 
muscular  effort,  if  the  patient  is  desired  to  exert  force,  and  there  is 
the  contraction  of  antagonistic  muscles,  described  in  the  section  on 
hysteria,  which  is  of  so  much  diagnostic  importance.  The  variations 
in  the  symptoms,  and  the  other  indications  described  in  the  chapter 
on  "Hysteria,"  seldom  leave  real  room  for  a  mistake.  An  error  is 
especially  easy  when  actual  symptoms  of  hysteria  preceded  the  onset 
of  the  disease,  or  occurred  during  its  course.  But  hysterical  tremor 
may  generate  a  hopeless  prognosis,  and  distress  equally  causeless  and 
severe.  The  other  error  is  the  common  one,  and  can  only  be  avoided 
by  the  custom,  which  should  be  a  habit,  of  ignoring  any  symptoms  of 
hysteria  until  after  a  thorough  search  for  those  of  organic  nature, 
referred  to  above.  Nystagmus  may  be  safely  accepted  as  evidence 
of  more  than  hysteria,  and  this  is  one  of  the  many  maladies  in  which 
the  symptom  is  of  great  diagnostic  value.* 

Prognosis. — The  prognosis  of  insular  sclerosis  is  exceedingly  grave. 
It  depends  chiefly  on  the  observed  tendency  of  the  disease.  Tet  the 
exceptions  met  with  in  most  maladies  are  not  unknown  even  in  this 
disease,  and  should  prevent  a  prognosis  absolutely  bad.  One  patient, 
who  seemed  unlikely  to  live  many  months,  had  improved  at  the  end 
of  a  year  and  a  half  so  as  to  be  able  to  walk  several  miles.  In  cases 
in  which  there  are  periods  of  apparent  arrest,  the  duration  of  life  is 
likely  to  be  longer  than  in  those  in  which  the  progress  of  the  symptoms 
is  uniform.  In  the  latter  it  is  not  probable  that  life  will  be  pro- 
longed for  more  than  two  years  from  the  time  at  which  the  symptoms 
are  sufficiently  distinct  to  pei-mit  the  diagnosis  to  be  made  with 
confidence.  In  the  former  the- patient  may  live  for  several  years, 
but  in  all  cases  much  depends  on  the  amount  of  care  that  can  be 
given.  The  symptoms  of  greatest  gravity  are  those  of  damage  to 
the  nerves  of  the  medulla  oblongata,  especially  difficulty  in  swallowing. 
The  earlier  such  symptoms  come  on,  the  shorter  is  likely  to  be  the 
duration  of  life. 

Treatment. — Insular  sclerosis  is  a  malady  for  which,  as  its  history 
shows,  little  can  be  done.     The  primary  overgrowth  of  the  interstitial 

*  Nystagmus  has  been  said  to  occur  in  hysteria,  hut  the  assertion  is  of  very 
doubtful  truth.  In  an  extensive  investigation  into  the  distinction  between  these 
two  diseases,  Sougues  could  not  discern  it  in  any  case  of  hysteria  ('  Nouv.  Icon. 
Salpetriere,'  1892). 


558  BRAIN. 

tissue  resists  therapeutical  influences  more  than  does  the  primary 
degeneration  of  the  nerve-elements.  But  it  is  probable  that  its  causes 
vary,  and,  if  so,  some  forms  may  prove  more  amenable  than  the 
majority.  The  treatment  for  the  system-degenerations  is  that  which 
most  deserves  a  trial  in  the  insular  form,  especially  the  nervine  tonics, 
such  as  arsenic,  nitrate  of  silver,  quinine,  &c.  The  hypodermic  injec- 
tion of  arsenic  has  been  recommended  by  Eulenburg,  but  the  evidence 
that  this  method  of  administration  has  a  special  influence  is  insufficient. 
Occasionally  these  drugs  seem  to  retard  the  progress  of  the  disease, 
but  an  arrest  of  its  progress  is  seldom  lasting.  Solanine,  in  doses 
of  f-  gr.,  has  been  recommended  by  Grasset  as  lessening  the  tremor. 
Hydropathic  treatment,  and  the  use  of  electricity  in  various  forms, 
have  been  advocated  in  Germany,  but  their  influence  is  exceedingly 
doubtful.  In  the  case  of  a  peripheral  palsy,  such  as  that  of  the  face, 
due  to  sclerosis  of  the  nerve,  the  question  presents  itself  whether  the 
muscles  should  be  subjected  to  electrical  treatment.  As  a  rule  it  is 
not  worth  while  to  give  the  patient  the  pain  and  inconvenience  of  the 
applications.  The  disease  is  so  often  progressive,  that  no  recovery  of 
the  nerve  can  be  anticipated  ;  hence  electrical  treatment,  however 
prolonged,  can  have  no  influence  in  modifying  the  condition,  and 
there  is  not  the  same  reason  for  applying  it  to  the  muscles  that  exists 
in  the  case  of  lesions  from  which  the  nerve-fibres  may  recover.  It  is 
of  course  desirable  to  maintain  the  patient's  general  health  in  as  good 
condition  as  possible,  and  to  avoid  all  depressing  influences.  In  the 
case  of  women,  pregnancy  is  especially  undesirable;  the  malady  is  apt 
to  make  more  rapid  progress  during  the  later  period  of  pregnancy, 
and  sometimes  after  delivery.  When  more  is  known  of  the  causes 
and  essential  pathology  of  the  disease  in  different  cases,  more  rational 
methods  may  brighten  the  therapeutic  prospect. 

Diffuse  Sclerosis. 

If  the  connective-tissue  elements  are  increased  through  a  con- 
siderable area  in  any  part  of  the  brain,  the  sclerosis  is  said  to  be 
"  diffuse,"  iu  distinction  from  the  small  islets  of  the  disseminated  or 
insular  sclerosis  just  described.  Diffuse  induration  may  involve 
either  the  white  substance  or  the  cortex,  part  or  the  whole  of  one 
hemisphere  or  of  both,  the  cerebrum  or  the  cerebellum.  Sclerosis 
may  also  be  secondary  to  some  other  lesion,  such  as  softening,  the 
evidence  of  which  (as  a  cavity  adjacent)  is  still  conspicuous;  but  such 
forms  are  not  here  considered.  Two  varieties  must,  howrever,  be  dis- 
tinguished as  fundamentally  distinct, — those  in  which  there  is,  and 
those  in  which  there  is  not,  diminished  bulk  of  the  affected  part.  In 
the  latter,  as  a  rule,  the  change  may  involve  the  white  substance  only 
or  the  grey  matter,  or  both,  and  the  induration  is  primary  ;  in  the 
former  the  cortex  is  chiefly  affected,  sometimes  with  a  secondary 
implication  of  the  deeper   structures.     In  these  cases  the  diminu- 


DIFFUSE    SCLEKOSIS.  559 

tion  in  size  constitutes  what  is  called  "  atrophy  of  the  brain,"  general 
or  partial,  and  it  is  often  very  difficult  to  say  in  "which  class  the  lesion 
should  be  placed,  and  by  which  term  it  should  be  named,  "  sclerosis" 
or  "  atrophy."  But  it  is  certain  that,  in  most  cases  of  partial  disease, 
aud  in  many  in  which  the  affection  is  general,  unilateral  or  bilateral, 
the  influence  causing  atrophy  is  primary  and  the  induration  is 
secondary,  the  result  of  the  wasting  of  the  nerve-elements  which 
entails  the  overgrowth  of  the  interstitial  tissue.  Such  sclerosis  is 
very  common  as  a  secondary  change.  Sclerotic  induration,  for  instance, 
follows  the  damage  to  the  cortex  produced  by  the  meningeal  haemor- 
rhage that  occurs  during  birth  (see  p.  418).  It  is  a  necessary  conse 
quenceof  interstitial  inflammation,  however  produced,  aud  so  is  found 
in  the  cortex,  when  this  is  diseased  in  cases  of  acquired  infantile 
hemiplegia,  whether  the  primary  process  is  venous  thrombosis  or  acute 
inflammation.  If  any  influence  causes  a  general  arrest  of  the  growth 
and  development  of  the  cortex  of  the  brain,  it  induces  this  combina- 
tion of  atrophy  and  sclerosis,  the  cortex  being  the  part  on  which  such 
influences  seem  chiefly  to  act.  This  state  may  result  from  a  concussion 
of  the  brain  in  childhood,  from  an  actual  focal  lesion,  or  from  the 
effect  of  severe  and  repeated  epileptic  fits.  But  in  all  such  conditions 
we  must  regard  the  sclerosis  as  secondary  and  not  primary,  the  first 
effect  being  produced  on  the  nerve-elements  ;  and  the  failure  of  their 
nutrition  or  development  entails  an  ovtrgrowth  of  the  neuroglia,  which 
ultimately  becomes  firmer  than  in  some  other  conditions. 

In  the  cases  that  may  be  regarded  as  primary  sclerosis  of  the 
brain  there  is  little  or  no  diminution  in  the  size  of  the  part,  and 
no  indication  of  an  affection  of  the  nerve-elements  to  which  the 
increase  of  connective  tissue  is  secondary.  They  differ,  however,  so 
much  in  their  features,  causation,  and  symptoms,  that  it  is  difficult  to 
classify  them  into  definite  forms  until  many  more  carefully  obsei'ved 
facts  have  been  collected.  In  oue  group  of  cases,  met  with  almost 
exclusively  in  syphilitic  children,  there  is  induration  of  the  grey 
cortex,  usually  through  considerable  areas,  sometimes  confined  to  a 
single  convolution,  rarely  in  small  nodules.*  The  tint  of  the  grey 
matter  is  but  little  altered,  but  the  change  in  its  cousistence  is  very 
distinct  to  the  touch.  When  this  affection  is  of  long  duration 
there  may  be  a  trifling  diminution  in  the  bulk  of  the  part.  There 
may  be  slight  thickening  of  the  superjacent  pia  mater,  but  there  is  no 
arterial  disease  distinctly  related  to  the  affected  region.  Very  rarely 
the  central  grey  matter  has  been  the  seat  of  such  diffuse  sclerosis. 
The  microscope  shows  an  increase  in  the  neuroglia,  and  wasting  of 
the  nerve-cells.  A  similar  change  is  seen  in  the  sclerosis  that  attends 
cortical  atrophy.  The  interstitial  tissue  has  been  found  to  present 
the  aspect  of  a  finely  granular  network,  and  the  axis-cylinders  of 
the  included  nerve-fibres  have  had  a  peculiar  irregular  outline. f 

*  It  is  well  described  by  Bury  and  Barlow,  Tuke's  f  Diet.  Psych.  Med.,'  ii,  1261. 
f  Schmaus, '  Vircbow's  Archiv,'  Bd.  cxiii. 


560  BKAIX. 

The  -white  substance  is  not  often  the  seat  of  sclerosis  in  congenital 
syphilis,  except  in  very  severe  and  extensive  cases ;  and  cortical  sclerosis 
seems  to  be  equally  rare  in  the  acquired  disease  of  adults.  But  I 
have  seeu,  in  this  affection,  a  diffuse  induration  of  extensive  tracts  of 
the  centrum  ovale  of  each  hemisphere,  causing  increased  consistence, 
readily  felt,  but  with  little  change  in  aspect.  A  diffuse,  almost 
universal  sclerosis  has  been  observed  in  a  subject  of  chronic  alcohol- 
ism, associated  with  induration  of  the  kidneys  and  other  paris.* 
Lastly,  areas  of  diffuse  sclerosis  have  been  found,  in  rare  cases, 
between  and  connecting  the  islets  of  the  disseminated  form,  f  a  con- 
dition that  is  perfectly  consistent  with  the  pathological  suggestions 
made  on  a  preceding  page  regarding  this  variety. 

The  symptoms  of  diffuse  sclerosis  have  varied  much  in  different 
cases,  so  much  indeed  that  its  existence  can  ouly  be  guessed  at — except, 
perhaps,  in  some  cases  of  congenital  syphilis.  In  all  cases  of  cortical 
sclerosis  in  childhood,  mental  defect  exists  in  proportion  to  the  extent 
and,  when  limited,  to  the  seat,  of  the  lesion.  Every  grade  of  defect, 
down  to  profound  idiocy,  is  observed.  When  the  central  region  is 
affected,  motor  symptoms  become  conspicuous,  loss  of  power  on  one 
side  or  on  both,  convulsions,  and  especially  contractures  of  the  limbs 
and  spontaneous  movements.  In  adults,  the  symptoms  have  been,  on 
the  whole,  similar,  but  have  presented  great  variations.  Hemiplegia, 
contracture,  attacks  of  clonic  spasm  or  tremor,  headache,  giddiness, 
vomiting,  paroxysmal  loss  of  consciousness,  and  slowness  of  speech, 
have  been  met  with,  some  frequently.  Among  the  latter,  the  attacks  of 
spontaneous  movement  have  heen  thought  to  be  the  most  characteristic 
(Strumpell). 

Much  more  must  be  ascertained  regarding  the  affection  before  any 
prognostic  data  can  be  obtained,  or  rules  for  treatment  laid  down, 
beyond  those  indicated  by  its  apparent  causes,  and  such  as  are  suited 
for  any  chronic  cerebral  affection. 


Miliary  Sclerosis. 

The  term  "  miliary  sclerosis"  was  first  applied  by  Drs.  Batty  Tuke 
and  Rutherford  to  a  lesion  found  by  them  in  the  white  substance  of 
an  ati-opkied  cerebellar  hemisphere  in  an  insane  patient.  The  lesion 
was  chiefly  microscopic,  and  was  only  discovered  after  the  bx*ain  had 
been  hardened.  It  consisted  of  minute  spots  of  degeneration,  in  which 
there  was  little  evidence  of  a  process  deserving  to  be  called  "  sclei-osis." 
The  term  has  been  since  used  by  others  to  designate  another  micro- 
scopic lesion,  which  was  at  first  thought  to  be  really  pathological, 
but  has  since  been  abundantly  proved  to  be  of  artificial  origin — an 

*  Strumpell,  'Arch.  f.  Psych.,'  1  79. 

t  See  Westphal,  'Arch.  f.  Psych.,'  viii;  and  Kelp,  '  Deut.  Arch.  f.  kl.  Med.,'  x, 
1872.     Cases  have  also  been  recorded  by  Schule,  Jolly,  and  F.  Schulze. 


jtflLIAEY    SCLEKOSIS.  561 

"artefact,"  as' such  changes  have  been  termed.  The  most  common 
appearance  is  that  in  minute  areas  the  tissue  remains  unstained  by 
reagents,  and  presents  a  striking  contrast  to  the  well-stained  vicinity. 
On  close  inspection,  however,  the  tissue-elements  can  be  traced  in  the 
unstained  area;  and  it  is  evident  that  the  diffei'ence  between  these 
spots  and  the  adjacent  tissue  is  due  to  the  absence  of  staining.  This 
appearance  is  chiefly  seen  when  spirit  has  been  employed  in  hardening. 
The  central  organs  ought  never  to  be  placed  in  spirit,  at  any  rate, 
after  the  first  twenty-four  hours.  This  is  only  one  of  many  artificial 
changes  produced  by  spirit,  which  are  often  very  puzzling  to  the 
observer. 

It  is  questionable  whether  the  term  "  miliary  "  ought  to  be  applied 
to  a  purely  microscopic  lesion  ;  it  is  more  accurately  used  to  designate 
changes  resembling  in  size  "  miliary  "  tubercle.  But  that  there  is  a 
form  of  sclerosis  of  the  brain  which  is  truly  "  miliary  "  is  evident 
from  one  well-marked  example  that  has  come  under  my  notice.  In 
this  case,  throughout  both  hemispheres  of  the  brain,  and  in  all  parts 
of  them,  the  cortex  contained  minute  reddish-grey  spots  at  the  junction 
of  the  grey  and  white  substance.  In  tint  they  were  a  little  darker 
than  the  darkest  grey  substance,  and  their  aspect  was  exactly  like 
that  of  the  morbid  tissue  in  insular  sclerosis,  and  equally  distinct  in 
the  recent  state.  In  size  they  varied  from  that  of  a  mustard  seed,  or 
a  little  larger,  to  the  smallest  point  visible ;  large  areas,  one  eighth  of 
an  inch  in  length,  were  formed  here  and  there  by  the  coalescence  of 
the  smaller  spots.  Their  size  and  distribution  ai-e  shown  in  Fig.  145,  a. 
None  could  be  seen  in  the  white  substance  of  the  hemisphere,  but  they 
were  found  in  the  central  ganglia,  especially  in  the  outer  part  of  the 
lenticular  nucleus  (b)  and  in  the  claustrum  (c).  None  were  found 
elsewhere  in  the  brain,  except  two  beneath  the  corpora  quadrigemina. 
Under  the  microscope  the  centre  of  the  large  areas  consisted  of  a 
delicate  fibrous  tissue  with  abundant  spider-cells  and  small  round 
nucleated  cells.  In  the  fibrous  tissue  were  small  cavities,  especially 
at  the  periphery  of  the  larger  spots  and  throughout  the  smaller  ones, 
so  that  the  tissue  had  a  somewhat  sponge-like  aspect.  No  connection 
could  be  traced  between  most  of  these  areas  and  vessels,  but  in  places 
a  similar  change,  of  spongy  aspect,  could  be  seen  along  the  side  of  a 
vessel,  sometimes  extending  for  a  considerable  distance.  Thus  there 
was  a  wasting  of  the  nerve- elements,  and  an  increase  in  the  connective 
tissue  in  the  affected  areas. 

I  have  not  met  with  the  record  of  any  quite  similar  case,  but  an 
analogous  lesion  has  been  observed  in  a  few  cases  of  general  paralysis 
of  the  insane,  invisible,  however,  in  the  recent  condition.* 

In  my  case  there  was  no  mental  derangement.  The  patient  was  a 
man  aged  fifty,  and  the  first  symptom  was  general  weakness  of  the 
limbs,  accompanied  with  some  rigidity  and  a  few  left-sided  convulsive 

*  See  Grieff,  '  Archiv  f.  Psych.,'  xiv,  p.  287 ;  and  Simon,  ib.,  Bd.  ii. 
VOL.   II.  36 


562 


BRAIN. 


attacks,  beginning  in  the  muscles  of  the  shoulder.  Then  the  speech 
became  "  mumbling "  and  unintelligible  ;  coma  set  in,  and  after  a 
few  days  of  unconsciousness  he  died.      He  had  also  some  cardiac 


Fig.  145. — Miliary  sclerosis  of  the  brain.  Sections,  A,  of  the  cortex,  B,  of  the 
left,  and  c,  of  the  right  lenticular  nucleus  aud  claustrum.  The  black  dots 
represent  the  size  and  distribution  of  the  minute  foci  of  sclerosis. 

weakness,  enlargement  of  the  liver  and  spleen,  and  general  anasarca 
without  albuminuria.  The  duration  of  the  nervous  symptoms  was 
about  ten  weeks.  No  cause  for  the  disease  could  be  traced,  but  he 
had  had  constitutional  syphilis  many  years  before.* 


ASSOCIATED  PALSY  OF  THE  BULBAE  NERVES. 

It  has  been  mentioned  that,  among  the  cranial  nerves,  we  mav 
recognise  two  special  groups,  subserving  associated  functions  and 
liable  to  associated  disease.  Each  group  is  motor :  one  comprehends 
the  nerves  of  the  eyeball  muscles,  the  associated  palsy  of  which  has 
been  described  at  p.  194 ;  the  other  includes  the  nerves  to  the  complex 
series  of  muscles  of  the  upper  part  and  orifice  of  the  respiratory  and 
alimentary  passages — the  mouth,  fauces,  pharynx,  and  larynx.  These 
arise  from  tracts  of  grey  matter  in  the  lowest  part  of  the  "  middle 
brain  "  and  the  junction  of  this  with  the  spinal  cord,  the  "  medulla 
oblongata,"  or  "  bulb."  The  associated  palsy  of  these  "  bulbar " 
nerves  has  now  to  be  considered.  The  most  common  form  is  due  to 
a  degenerative  process  similar  to  that  which  occurs  in  the  spinal  cord. 
But,  as  we  have  already  seen,  a  similar  paralysis  may  result  from  a 
sudden  lesion  in  the  same  part — sudden  or  "apoplectiform"  bulbar 
paralysis.     It  is  sometimes  termed  the  "  acute  "  form,  but  there  is 

*  Fuller  details  of  this  case  will  be  found  in  the  '  Lancet,'  18SG,  January  23rd, 
p.  145. 


BULBAR    PARALYSIS.  563 

also  a  rare  variety  due  to  acute  inflammation  of  these  structures,  for 
which  the  epithet  "  acute  "  is  needed.  On  account  of  the  general 
resemblance  of  the  symptoms  it  will  be  convenient  to  mention  the 
symptoms  of  the  acute  and  sudden  forms  in  connection  with  the 
common,  chronic  variety.  As  we  shall  see,  disease  of  the  nerves  may 
cause  a  like  effect,  and  so  also  (although  by  a  very  different  mechan- 
ism) may  disease  of  the  two  cerebral  hemispheres.  These  forms 
(especially  the  latter),  from  their  superficial  likeness  to  bulbar  disease, 
but  essential  difference  from  it,  have  been  called  "  pseudo-bulbar 
paralysis." 

The  nerves,  in  the  distribution  of  which  the  symptoms  occur,  are 
the  fibres  of  the  facial  for  the  lower  part  of  the  face,  especially  for  the 
orbicularis  oris,  the  hypoglossal  for  the  tongue,  the  spinal  accessory 
for  the  larynx,  and  probably  also  for  the  palate,  and  the  glosso- 
pharyngeal or  vagus  for  the  pharynx.  It  deserves  note  that  the 
facial  nerve  occupies,  as  it  were,  an  intermediate  position  between 
the  two  nerve-groups  above  mentioned  as  liable  to  associated  disease ; 
it  supplies,  on  the  one  hand,  the  muscle  that  closes  the  eyelids,  and 
on  the  other,  that  which  closes  the  mouth.  But  the  orbicularis 
palpebrarum  does  not  seem  to  be  very  closely  associated  with  the 
eyeball  muscles,  for  it  does  not  suffer  with  them  in  disease  of  their 
nuclei.  Its  functional  association  with  the  eyeball  muscles  is  unim- 
portant ;  it  is  only  a  small  part  of  these  relations,  and  does  not  appa- 
rently include  its  action  in  protecting  the  eyeball.  But  the  orbicularis 
oris  and  the  transverse  muscles  of  the  front  of  the  tongue  have  a 
functional  association  closer,  perhaps,  than  any  other  two  muscles  in 
the  body  equally  distinct.  Neither  can  be  put  in  action  without  the 
other  (see  p.  50,  note).  The  orbicularis  is  always  involved  in  degene- 
rative disease  of  the  hypoglossal  nucleus,  and  escapes  in  disease  of 
the  chief  nucleus  of  the  facial,  as  in  a  case  of  acute  atrophic 
("infantile")  paralysis  in  which  the  face  was  involved  (see  pp.  231 
and  240). 

The  central  connection  of  the  chief  parts  that  are  affected  in  the 
disease  is  well  illusti'ated  by  the  combination  of  paralysis  of  the 
tongue,  palate,  and  vocal  cord  that  results  from  disease  of  the  nerve- 
roots  on  one  side  of  the  medulla  (p.  307).  In  central  disease  of  the 
medulla  the  paralysis  has  the  same  distribution  as  in  a  lesion  of  the 
nerve-roots,  but  it  is  almost  always  bilateral,  and,  in  addition,  the 
pharynx  is  often,  and  the  lips  are  always,  paralysed.  These  escape  in 
disease  of  the  roots,  because  the  labial  nerve-fibres,  although  they 
seem  to  arise  from  cells  in  the  medulla,  ascend  to  the  lower  part  of 
the  pons,  which  they  leave  by  the  facial  trunk.  The  most  charac- 
teristic and  complete  distribution  is  seen  in  the  cases  of  chronic 
degeneration  in  which  the  nerve-cells  suffer  according  to  their  func- 
tional nature.  The  chief  centres  concerned  lie,  however,  so  near 
together  in  the  medulla,  that  random  processes,  such  as  softening  or 
haemorrhage,  may  damage  them  on  both  sides,  and  cause  palsy  of  the 


564  BKAIN. 

same  distribution  as  that  which  results  from  primary  degeneration. 
Hence  all  forms  are  included,  under  the  term  "  bulbar  paralysis,''  but 
only  the  chronic  cases  and  the  inflammatory  form  can  be  regarded  as 
constituting  distinct  maladies. 

Chronic  Bulbar  Paralysis. 

The  chronic  bulbar  paralysis,  the  "  labio-glosso-pharyngeal "  (or 
"laryngeal")  paralysis,  was  first  described  in  1859  by  Du  Mesnil, 
and  systematically  by  Duchenne  in  1860,  while  this,  like  so  many  of 
Duchenne's  investigations,  became  widely  known  chiefly  through  the 
lectures  of  Trousseau.  The  awkwardness  of  the  descriptive  name 
given  by  him,  led  Wachsmuth,  in  1864,  to  propose  to  call  the  disease 
"  progressive  bulbar  paralysis,"  a  designation  that  has  come  into 
general  use.  The  dependence  of  the  symptoms  on  degeneration  of 
the  nuclei  of  the  medulla  was  established  especially  by  the  labours  of 
Charcot's  pupils  and  of  Leyden. 

Causes. — The  disease  occurs  chiefly  in  the  second  half  of  life, 
although  it  is  sometimes  met  with  in  middle  life,  and  in  a  few 
anomalous  instances  has  developed  in  childhood,  at  seven,  eight, 
and  ten,  and  occasionally  in  several  children  of  the  same  family.* 
But  most  of  the  sufferers  have  been  between  fifty  and  seventy 
when  the  disease  commenced.  Males  are  rather  more  liable  than 
females.  Direct  inheritance  is  practically  limited  to  rare  cases  in 
which  the  affection  forms  part  of  progressive  muscular  atrophy, f 
but  indirect  inheritance,  shown  by  other  related  neuroses,  may 
often  be  traced.  Moreover,  a  strange  family  disposition  has  been 
observed  in  cases  occurring  in  early  life.  It  does  not  seem  to  be  a 
consequence  of  syphilis.  Immediate  causes  can  be  traced  in  only  a 
minority  of  the  cases ;  the  most  frequent  are  mental  depression 
and  anxiety  (sometimes  combined  with  physical  exhaustion,  as  in 
nursing  a  relation  through  a  grave  and  fatal  illness),  exposure  to  cold^ 
debilitating  influences,  such  as  insufficient  food,  and  injury,  such  as  a 
blow  upon  the  back  of  the  neck.  Over-use  of  the  muscles  has  been 
supposed  to  be  a  rare  cause  ;  the  symptoms  developed  rapidly  in  a 
man  after  playing  on  the  clarionet  for  two  whole  nights,  but  the  patient 
at  the  same  time  had  been  exposed  to  cold  (Stein).  In  a  consider- 
able proportion  of  the  cases,  no  cause,  immediate  or  remote,  can  be 
traced.  It  is  not  unlikely  that  many  of  these  will  ultimately  be 
found  to  depend  on  some  toxsemic  influence.  I  have  known  the 
characteristic  form  to  follow  lead-poisoning  in  advanced  life,  and 

*  At  seven  and  eight,  two  sisters  and  a  brother,  the  offspring  of  intemperate  cousins, 
Moty,  'Gaz.  des  Hop./  1889 ;  at  eight,  Remak,  '  Berl.  Ges.  de  Psych..'  1890;  at  eleven, 
Hoffmann,  '  Cent,  f .  Nervenkr.,'  1889  ;  at  twelve,  Blumenthal,  '  Inaug.  Diss.,'  Dorpat, 
1884.     Many  supposed  cases  in  early  or  middle  life  have  been  due  to  tumours. 

t  As  in  three  cases  in  one  family  described  by  Bernhardt,  an  instance  observed  by 
Berger,  and  one  in  old  age  (mother  and  daughter)  by  myself. 


UHR0N1C    BULBAR    PARALYSIS.  565 

also  partial  bulbar  paralysis  to  be  associated  with  partial  nuclear 
ophthalmoplegia  in  early  adult  life  as  a  late  sequel  to  diphtheria.* 

The  relation  to  progressive  muscular  atrophy  has  been  already 
mentioned.  The  bulbar  disease  is  indeed  part  of  the  spinal  affection, 
the  grey  matter  of  the  medulla  undergoing  the  same  degenerative 
change  as  that  of  the  spinal  cord.  Lastly,  a  limited  acute  nuclear 
inflammation  may  be  followed  by  slow  degenerative  extension. f 

Symptoms. — The  distribution  of  the  symptoms,  indicated  by  the 
name  given  to  the  disease  by  Ducheune,  has  been  already  mentioned. 
The  lips,  tongue,  throat,  and  often  the  larynx,  are  paralysed  on  both 
sides.  The  symptoms  are,  so  to  speak,  grouped  about  the  tongue  as 
a  centre,  and  it  is  in  this  organ  that  the  earliest  weakness  is  usually 
manifested.  In  a  few  cases  the  distinct  paralytic  symptoms  have 
been  preceded  by  some  discomfort  or  pain  at  the  back  of  the  head. 
The  onset  of  definite  symptoms  is  gradual ;  the  cases  in  which  there 
is  a  sudden  or  even  acute  onset  are  not  examples  of  this  form.  The 
first  symptom  is  generally  a  trifling  indistinctness  of  speech,  due  to 
imperfect  articulation  of  those  sounds  in  which  the  tongue  is  chiefly 
concerned,  the  lingual  consonants  I,  r,  n,  and  t,  and  afterwards  s.  The 
commencing  change  in  articulation  is  noticed  only  when  the  parts  are 
fatigued  by  use,  and  the  patient  may  be  conscious  that  fatigue  is 
produced  with  undue  readiness.  The  early  difficulty  in  articu- 
lation is  often  ascribed  to  some  dental  imperfection,  or  to  dentists' 
procedures  undertaken  to  lessen  the  imperfection.  The  tongue 
at  first  can  still  be  protruded,  although  sometimes  not  so  far  as 
normal,  and  there  may  be  a  difficulty  in  bringing  its  tip  firmly 
against  the  roof  of  the  mouth  for  the  articulation  of  the  linguo-pala- 
tine  consonants,  as  t  and  d,  while  the  continuous  sibilant  s  can  be 
perfectly  articulated.  The  lips  become  weak  with  or  soon  after  the 
tongue,  and  some  difficulty  in  swallowing  is  often  added ;  the  latter 
may,  indeed,  be  the  earliest  symptom,  or  it  may  Only  come  on  after  arti- 
culation has  become  much  impaired.  In  consequence  of  the  weakness 
of  the  lips  the  power  of  whistling  is  lost,  and  there  develops  a 
difficulty  in  the  pronunciation  of  the  sounds  in  which  the  lips  are 
chiefly  concerned,  o,  u,  p,  b,  and  m.  The  lips  are  not  brought  together 
so  perfectly,  or  separated  so  promptly,  as  is  necessary  for  the  pro- 
nunciation of  the  labial  explosives,  and  hence  b  and  p  become  m  and  v. 
The  power  habitually  exerted  is  generally  less  than  the  patient  can 
exert  if  he  tries.  A  word  can  often  be  articulated  perfectly  by  a  de- 
liberate effort  when  the  habitual  articulation  is  very  imperfect.     The 

*  In  a  case  described  by  Stadthagen,  diphtheria  at  four  was  followed  by  the 
common  paralysis  of  the  palate,  and  this  by  wider  symptoms  of  bulbar  palsy.  When 
the  patient  came  under  observation,  some  years  later,  there  still  was  paralysis  of  the 
lips  and  palate,  accompanied  by  weakness  and  contracture  in  the  limbg  ('  Archiv  f. 
Kinderheilk.,'  Bd.  v). 

f  Reinholdt,  '  Arch.  f.  klin.  Med.,'  1889. 


566  BRAIN. 

difficulty  in  speech  is  soon  increased  by  the  weakness  of  the  palate; 
which  ceases  to  shut  off  the  nasal  cavity.  Swallowing  gradually 
becomes  difficult ;  the  weakening  of  the  tongue  impairs  the  first  pan 
of  the  act  of  deglutition,  that  in  which  the  food  is  rolled  back  into 
the  pharynx  by  the  application  of  the  tongue  to  the  roof  of  the  mouth  ; 
the  paralysis  of  the  palate  permits  the  regurgitation  of  liquids  into 
the  nose,  and  the  weakening  of  the  pharyngeal  muscles  further 
interferes  with  the  movement  of  the  food. 

As  the  paralysis  increases,  closure  of  the  mouth  becomes  impossible, 
the  lower  lip  droops,  and  the  muscles  of  the  chin  often  become  feeble. 
The  elevator  of  the  upper  lip  and  zygomatics  either  escape,  or  are  so 
much  less  affected  than  their  labial  opponents,  that  the  zygomatic 
muscles  undergo  contracture,  and*  a  very  pronounced  naso-labial 
furrow  becomes  a  characteristic  feature  of  the  disease.  Saliva  dribbles 
out  of  the  open  mouth,  and  the  patient  has  to  keep  a  handkerchief 
constantly  in  his  hand.*  The  tongue  can  no  longer  be  protruded ; 
only  the  tip  can  be  projected  over  the  lower  teeth.  Mastication  is 
difficult,  because  the  tongue  can  no  longer  guide  and  keep  the  food 
between  the  teeth.  The  palate  may  hang  motionless,  or  it  may  still 
be  raised  a  little  by  the  will.  Articulate  speech  at  last  becomes  im- 
possible, and  the  only  expression  remaining  to  the  patient  is  laryngeal 
phonation,  slightly  modulated,  and  broken  into  the  rhythm  of  form- 
less syllables,  the  meaning  of  which  can  be  hardly  more  than 
guessed  at.  Swallowing  becomes  more  and  more  difficult.  Semi-solids 
are  usually  swallowed  better  than  liquids,  because  there  is  less  risk 
of  their  escape  into  the  nose  or  larynx,  and  better  than  solids,  particles 
of  which  are  more  apt  to  enter  the  larynx  from  the  increasing  weak- 
ness of  the  epiglottidean  muscles,  which  fail  to  reflect  the  epiglottis 
during  the  act  of  deglutition.  The  muscles  of  the  vocal  cords  gene- 
rally suffer  now,  if  not  before  ;  the  voice  is  low-pitched  from  the  de- 
fective approximation  of  the  cords,  and  the  cough  is  imperfect  from 
the  feebleness  of  closure.  At  first  the  glottis  may  be  closed  only  in 
one  of  several  attempts  to  cough.  The  laryngeal  palsy  rarely  become* 
complete,  and  it  is  still  rarer  for  the  power  of  abduction  to  be  specially 
lost,  common  as  abductor  palsy  is  in  some  other  forms  of  central  de- 
generation. I  have,  however,  seen  abdtictiou  completely  lost  on  one 
side  when  it  was  preserved  on  the  other.  Thus  in  some  cases  the 
pharynx  suffers,  in  others  the  larynx,  but  both  are  usually  involved 
in  the  later  stage.  The  difference  seems  to  correspond  to  a  difference 
in  the  localisation  of  the  affection,  according  to  the  functional  relation 
of  the  parts  ;  in  some  cases  those  for  articulation  and  iu  others  those 
for  deglutition  being  apparently  primarily  involved.     Since  all  the 

*  It  is  often  thought  that  there  is  an  iu  crease  in  the  secretion  of  saliva,  and 
"  salivation  "  is  said  to  exist,  but  it  is  doubtful  whether  the  amount  is  larger  than 
the  normal.  A  pathological  increase  has  been  asserted  very  strongly  by  some 
authors ;  Schulz  supposed  that,  in  one  case  under  his  care,  the  secretion  was  in- 
creased to  six  times  the  normal  quantity. 


CHEONIG    BULBAR    PARALYSIS.  567 

muscles  concerned  and  the  structures  related  to  them  are  in  great 
part  the  same  in  the  two  sets  of  cases,  there  is  considerable  general 
correspondence  in  the  symptoms  and  lesion. 

There  is  no  loss  of  sensibility  in  any  of  the  affected  parts,  and  taste 
is  unimpaired,  but  the  reflex  action  in  the  throat,  so  active  in  health, 
ultimately  fails  from  the  motor  changes.  The  palate  or  fauces,  and 
even  the  larynx,  can  be  touched  or  tickled  without  exciting  the  spasm 
that  is  normally  produced.  Sometimes  this  loss  of  reflex  action 
precedes  the  other  symptoms  of  the  disease  (Krishaber).  It  increases 
very  much  the  risk  of  the  entrance  of  food  into  tbe  larynx.  But  reflex 
action  is  not  invariably  lost ;  Erb  twice  found  it  preserved  in  the 
palate  and  pharynx  to  a  late  stage  of  the  disease. 

Alterations  of  nutrition  are  chiefly  visible  in  the  tongue,  and  its 
condition  varies  much  in  different  cases.  In  some  the  organ  is  large 
and  broad  throughout,  although  soft  and  flabby  to  the  touch.  In 
other  cases  it  is  conspicuously  wasted,  and  the  surface  is  deeply 
furrowed  and  wrinkled  from  the  loss 
of  the  muscular  substance  (Fig.  146). 
In  some  cases  the  lips  retain  their 
normal  size ;  in  others  they  are  con- 
spicuously thin.  Electric  irritability 
is  seldom  much  changed  ;  the  muscles, 
even  when  greatly  wasted,  may  still 
react  to  faradism  with  readiness. 
Rarely,  in  rapid  cases,  there  is  loss 
of  faradic  and  preservation  of  voltaic 
irritability,  and  Erb  has  observed  the  Fig.  146.— Wasting  of  the  tongue, 
increased  and  altered  reaction  to  vol-       and  maximum  protrusion,  in  a  case 

,    ■  i  ,i       n         ■]•  •,    ■.  .,.,      .  of  chronic  bulbar  paralysis. 

taisrn,  when  the  faradic  excitability  is  ■      J 

normal,  of  the  mixed  (or  "middle")  form  of  reaction  (see  vol.  i,  p. 
26).  Symptoms  of  motor  irritation,  such  as  convulsion  or  spasm, 
are  absent,  but  choreiform  twitchings  may  occur  on  an  attempt  to 
speak,  chiefly  due  apparently  to  the  influence  of  emotion. 

Thus  there  appear  to  be  two  forms,  one  with  wasting  and  loss  of 
the  reflex  action,  the  other  with  no  wasting  and  sometimes  with 
distinct  evidence  of  excess  of  muscle  reflex  action,  at  least  so  far  as 
the  muscles  of  mastication  are  concerned.  The  occurrence  of  the 
latter  form  cannot  be  doubted  even  when  allowance  is  made  for 
the  concealment  of  atrophy  by  fat.  It  is  apparently  analogous  to  the 
spastic  paralysis  met  with  in  the  limbs.  Not  only  may  the  "  jaw-jerk" 
be  increased  in  this  form,  but  I  have  once  seen  a  distinct  clonus  in  the 
muscles  of  mastication,  obtained  by  depressing  the  jaw. 

The  intellectual  faculties,  as  a  rule,  are  unimpaired.  The  only 
alteration  that  is  common  is  a  curious  emotional  mobility ;  laughter 
or  tears  are  evoked  by  trifling  causes,  and  the  immobile  face  and  un- 
modulated tone  may  render  the  laughter  strangely  grotesque.  But 
the  unhappy  sufferer   is  painfully  conscious  of  his  state;  and   his 


568  BRAIN. 

distress  is  increased  by  the  inability  to  express  it,  except  by  the 
laryngeal  gestures  to  which  speech  is  reduced.  His  consciousness  of 
inability  often  renders  him  indisposed  to  make  even  an  attempt  to 
express  himself. 

Progressive  bulbar  paralysis,  as  already  mentioned,  is  often  associated 
with  progressive  muscular  atrophy  in  the  limbs  and  trunk,  accom- 
panied, it  may  be,  with  the  symptoms  of  lateral  sclerosis  of  the  cord. 
Either  the  bulbar  or  spinal  symptoms  may  lead  the  way,  and  dominate 
the  aspect  of  the  case.  Towards  the  close  of  a  general  progressive 
atrophy  the  mouth  and  throat  muscles  may  suffer,  or  when  these  are 
first  and  considerably  affected,  wasting  may  show  itself  in  the  muscles 
of  the  limbs.  Less  commonly,  bulbar  paralysis  is  associated  with 
spastic  paralysis  of  the  limbs  and  slight  wasting  ;  lateral  sclerosis  is 
then  found  after  death,  with  only  slight  changes  in  the  anterior  horns. 
Even  in  cases  not  accompanied  by  general  atrophy,  the  paralysis  may 
spread  beyond  the  muscles  of  the  lips,  tongue,  and  throat.  The  rare 
implication  of  the  muscles  of  the  upper  part  of  the  face  and  of  the 
eyeballs  has  been  mentioned.*  Excessive  frequency  of  the  pulse  (150 
— 160)  is  sometimes  observed  towards  the  close,  and  attacks  of  dys- 
pnoea have  been  met  with  from  the  extension  of  the  degeneration  to 
the  respiratory  centre,  which  also,  towards  the  close,  seems  to  produce 
oedema  of  the  lungs,  and  to  facilitate  the  low  pneumonia  produced  by 
the  entrance  of  particles  of  food.  It  is  noteworthy  that  glycosuria 
seems  never  to  result  from  the  degenerative  changes  beneath  the  floor 
of  the  fourth  ventricle  that  constitute  this  disease.  This  may  be 
another  instance  of  the  way  in  which  functional  relation  determines 
the  distribution  of  the  morbid  process.  Occasionally  the  muscles  of 
mastication  become  weak,  and  the  pterygoids,  which  move  the  jaAv 
laterally,  are  said  to  suffer  first,  and  often  only  (Duchenne).  Optic 
nerve  atrophy  has  been  noted  in  very  rai-e  cases. f 

Among  the  indirect  effects  of  the  disease  are  the  weakness  and 
emaciation  that  result  from  the  imperfect  supply  of  nourishment  con- 
sequent on  the  difficulty  of  swallowing,  and  the  bronchitis  that  is  apt 
to  be  set  up  by  the  passage  of  particles  of  food  into  the  air-passages. 
The  Course  of  the  disease  is  progressive,  although  not  uniformly 
so.  Erom  time  to  time  its  progress  is  retarded,  and  it  may  seem 
for  weeks,  or  even  for  months  (seldom  for  a  year  or  so),  to  be  at 
a  standstill.  The  hopes  thus  excited  are  usually  baseless,  for  the 
disease  again  increases,  often  at  a  more  rapid  rate..  An  intercurrent 
malady,  which  lessens  the  patient's  strength,  accelerates  the  progress 
of  the  disease.  But  the  cases  which  occur  in  the  first  half  of  life 
occasionally  become  arrested  before  reaching  an  extreme  and  danger- 
ous degree,  and  the  duration  of  this  later  stage  may  be  indefinite. 
The  Causes  of  Death  are  gradual  weakness  from  inanition  ;  broncho- 

*  Attention  has  lately  been  especially  directed  to  it  by  Guinon  and  Parnientier, 
Nouv.  Icon,  de  la  Salpet.,'  1890  and  1801. 
■J-  Ritchie, '  Glasgow  Med.  Jouvn.,'  1888;    Robin;   Galezowski  (quoted  by  Ritchie). 


CHRONIC   BULBAR    PARALTSIS.  569 

pneumonia,  from  the  entrance  of  food  into  the  air-passages ;  failure 
of  respiratory  power  from  associated  atrophy  of  the  muscles  of  the 
trunk,  or  the  effects  on  luugs  and  heart  irom  the  extension  of  the 
degeneration  to  the  pneumogastric  centres. 

Pathology. — In  the  affected  muscles  there  are  changes  similar  to 
those  seen  in  progressive  muscular  atrophy  of  the  limbs.  The  fibres 
may  present  extensive  granular  and  fatty  degeneration,  or  may  be 
•simply  narrowed.  Usually  some  fibres  are  much  affected,  and  others 
but  little,  so  that  empty  sarcolemma  sheaths  and  normally  striated 
fibres  may  lie  side  by  side.  There  is  an  increase  of  the  nuclei  of  the 
sheaths  and  of  the  interstitial  tissue,  and  the  latter  may  present  an 
abnormal  accumulation  of  fat.  Masses  of  reddish  pigment,  the  pro- 
duct of  the  degeneration  of  the  fibres,  lie  between  them.  The  nerve- 
endings  in  the  muscle  are  also  degenerated.  The  motor  nerve-trunks 
are  grey  and  soft,  and  the  microscope  shows  degeneration  of  the  nerve- 
fibres  and  increase  of  the  interstitial  tissue. 

The  medulla  oblongata  itself  generally  appears  normal  to  the  naked 
eye ;  rarely  there  is  slight  diminution  in  bulk.  The  important  morbid 
appearances  are  revealed  only  by  microscopical  examination.  There 
may  be  distinct  atrophy  of  the  fibres  of  the  hypoglossal  and  other 
nerves  within  the  medulla.  In  the  motor  nuclei,  changes  are  found 
similar  to  those  presented  by  the  grey  matter  of  the  cord  in  progres- 
sive muscular  atrophy.  There  is  wasting  of  the  nerve-cells,  many 
ef  which  lose  their  processes  and  shrink.  The  interstitial  tissue  is 
altered  in  various  degree,  and  contains  granule-corpuscles  and  other 
products  of  the  degeneration  of  the  nerve-elements  in  early  cases  ;  in 
some  instances  there  is  a  conspicuous  increase  in  the  connective- 
tissue  elements  ;  the  vessels  may  be  increased  in  number  and  their 
walls  thickened.  But  cases  vary  remarkably  in  this  respect:  in 
some,  only  a  wasting  of  the  nerve-cells  can  be  discerned;  while  in 
others  the  aspect  is  that  of  an  actual  interstitial  inflammation,  even 
involving  minute  extravasations  in  the  early  stage,*  and  yet  limited 
to  the  motor  nuclei.  The  variations  suggest  that  there  are  parenchy- 
matous and  interstitial  forms. f  This  difference  may  explain  some 
facts  of  limitation  or  irregularity  of  the  symptoms. 

Degeneration  is  often  found  in  the  anterior  pyramids,  just  as  the 
pyramidal  tracts  are  commonly  degenerated  in  the  corresponding 
affection  of  the  anterior  cornua  of  the  spinal  cord,  which  so  often  co- 
exists with  the  bulbar  degeneration.  In  such  combined  cases  the 
sclerosis  of  the  pyramidal  fibres  may  be  traced  through  the  pons  and 
cerebral  peduncles.  When,  as  is  commonly  the  case,  there  is  mus- 
cular atrophy  elsewhere,  the  spinal  cord  presents  corresponding 
alterations  in  the  grey  and  white  substance.  It  is  probable  that,  in 
some  cases  of  bulbar  paralysis,  the  disease  is  confined  to  the  jDyramidal 

*  Eisenlohr,  *  Arch.  f.  Psych./  1879,  p.  34. 
f  Compare  "  Acute  Polio-myelitis,"  vol.  i. 


570  '      BRAIN. 

fibres,  as  in  cases  of  lateral  sclerosis  of  the  spinal  corcl  causing  spastic 
paralysis. 

The  degeneration  in  the  bulbar  nuclei  is  constant  and  most  consider- 
able in  the  hypoglossal  nucleus,  next  in  the  adjacent  part  of  the  nucleus 
of  the  spinal  accessory  nerve,  and  it  is  usually  found  in  less  degree 
in  the  nuclei  of  the  vagus,  seldom  in  the  nucleus  ambiguus  or  glosso- 
pharyngeal, or  in  the  motor  nucleus  of  the  fifth  nerve,  or  in  the 
chief  facial  nucleus  (fig.  36,  p.  48).  The  collections  of  small  cells  in 
front  of  and  behind  the  hypoglossal,  nucleus*  usually  escape.  De- 
generation of  some  of  the  fibres  of  the  raphe  has  been  occasionally 
noted  at  the  level  of  the  hypoglossal  nucleus.  Considerable  degene- 
ration has  been  found  in  the  fibres  of  the  "  loop  "  of  the  facial  nerve, 
even  when  the  cells  of  the  chief  facial  nucleus  were  but  little  affected 
— a  mysterious  fact.  The  posterior  longitudinal  fibres  may  be  normal 
or  partly  degeneratedf  (in  proportion,  it  is  said,  to  the  affection  of  the 
hypoglossal  nucleus)  ;  especially  the  longitudinal  fibres  suffer  in  the 
inner  part  of  the  reticular  formation  which  are  supposed  to  continue 
the  anterior  ground  fibres  of  the  cord.  The  degeneration  is  always 
bilateral. 

The  grouping  of  the  symptoms  according  to  function  makes  it 
practically  certain  that  the  incidence  of  the  lesion  is  determined 
by  function,  that  it  begins,  as  a  rule,  in  the  nerve-elements,  and 
follows  their  functional  relations  in  its  extension.  The  exact  degene- 
ration on  which  the  paralysis  of  the  orbicularis  depends  is  the  most 
obscure  point.  Lockhart  Clarke  believed  that  the  small  cells  above 
the  hypoglossal  were  connected  with  the  facial  nerve,  and  that  it  was 
their  disease  that  causes  the  paralysis  of  the  lips.  Later  researches 
have  failed  to  confirm  this,  but  it  is  highly  probable  that  the  orbicu- 
lar fibres  do  descend  to  the  neighbourhood  of  the  hypoglossal  nucleus, 
and  may  even  arise  from  its  cells  (see  p.  50) ;  although  it  is  impos- 
sible to  trace  them  among  the  many  horizontal  fibres  of  the  reti- 
cular formation,  in  which  they  probably  pass  downwards,  perhaps 
reaching  it  by  the  raphe ;  into  this  many  fibres  of  the.  facial  nerve 
may  readily  be  traced  at  the  upper  part  of  the  "  loop."|  The  fibres 
of  the  anterior  pyramids  and  pyramidal  tracts  in  the  pons  and  crura 
have  been  found  degenerated,  chiefly  in  the  cases  in  which  there  has 
also  been  atrophy  or  palsy  of  the  limbs  ;  the  degeneration  of  the 
pyramids  is  then  the  rule  (see  vol.  i,  p.  490). 

The  probability  has  been  already  mentioned  that,  as  Duchenne 
originally  maintained,  there  are  two  varieties,  the  atrophic  and  the 
paralytic  ;  and  that,  as  already  mentioned,  in  some  of  the  cases  without 
obvious  wasting,  the  primary  disease  is  not  in  the  motor  cells,  but 
in  the  fibres  that  connect  these  with  the  cerebral  hemispheres,  or  in 

*  The  former  is  often  termed  "  Roller's  nucleus." 
+  See  Muratoff,  '  Cent.  f.  Nervenk.,'  1891,  p.  514. 

X  The  tongue  and  lips  have  been  paralysed  together  and  alone  on  one  side,  with 
the  reaction  of  degeneration  (Grugia  and  Mattencei,  '  Arch.  Ital.  Mai.  Nerv.,  1887). 


CHRONIC    BULBAR    PARALYSIS.  571 

the  lower  extremities  of  these  fibres  -within  the  nuclei.  We  have  seen 
that  the  pyramidal  fibres  may  be  degenerated,  and  these  fibres  are 
homologous  with  those  that  constitute  the  upward  path  from  the 
nuclei  to  the  corcex.  In  cases  in  which  these  fibres,  and  not  the 
nuclei,  are  diseased,  there  should  be  no  loss  of  reflex  action,  and  we 
have  seen  that,  in  some  cases,  the  reflex  action  is  preserved.  More- 
over, in  some  of  these  cases  there  is  marked  excess  of  myotatic  irri- 
tability in  the  muscles  of  mastication,  even,  as  we  have  also  seen,  so 
great  as  to  peimit  a  jaw-clonus  to  be  obtained — distinct  evidence  of 
the  degeneration  of  the  fibres  of  the  upper  segment  of  the  motor 
tract  for  these  muscles  (see  vol.  i,  p.  201).  The  other  parts  specially 
paralysed  do  not  permit  this  muscle  reflex  action  to  be  tested.  Thus 
these  cases  will  constitute  the  bulbar  homologue  of  primary  lateral 
sclerosis  of  the  cord. 

Atrophic  bulbar  paralysis  must  be  regarded  as  an  affection  prac- 
tically identical  with  the  progressive  muscular  atrophy  that  is  so 
often  associated  with  it.  The  difference  between  them  depends  only 
on  the  seat  of  the  morbid  process,  and  not  at  all  on  its  nature.*  The 
disease  is  a  degeneration  of  the  lower  segment  of  the  motor  path  for 
the  muscles  affected,  and  in  some  cases  it  may  be  a  degeneration  of 
the  whole  path,  upper  and  lower  segments,  or  of  the  upper  segment 
alone,  when  there  is  no  wasting.  Although  an  affection  of  the  cortical 
cells  has  not  yet  been  found,  it  is  highly  probable,  from  the  analogy 
of  progressive  muscular  atrophy.  In  other  cases,  again,  there  may  be 
a  combination  of  the  two  conditions  analogous'  to  those  in  which 
atonic  atrophy  in  the  hands  is  associated  with  tonic  palsy  in  the 
upper  arms  (see  vol.  i,  p.  480). 

The  relation  of  the  degenerative  changes  to  the  function  of  the 
affected  cells,  so  conspicuous  in  the  distribution  of  the  symptoms, 
mer'ely,  of  course,  means  that  a  certain  common  function  is  associated 
with  a  common  special  susceptibility,  on  the  part  of  the  cells,  to  suffer 
from  a  defect  in  nutrition,  which  is  progressive  in  character,  and 
teuds  to  increase  to  destructive  degeneration.  It  is  essentially  a 
defective  vitality,  and,  as  such,  is  associated  with  an  exuberance  of 
growth  in  the  interstitial  elements,  analogous  to  that  which  is  seen 
in  the  elements  surrounding  a  degenerating  nerve-fibre.  The  real 
pathology  of  the  disease  is  the  cause  which  induces  the  nutritional 
changes,  and  of  that  we  know  almost  nothing.  The  possible  influence 
of  toxic  conditions  should  always  be  remembered. 

Diagnosis. — The  distribution  of  the  palsy,  its.  bilateral  character, 
its  gradual  onset  and  progressive  course,  separate  the  disease  with 
sufficient  sharpness  from  most  other  maladies.  The  slow  onset  dis- 
tinguishes it  from  acute  lesions  of  the  medulla,  which  may  cause 
the  symptoms  of  similar  character  and  distribution  described  in  the 

*  The  essential  identity  of  the  two  diseases  was  first  urged  by  Kussmaul  ( Volk- 
mann's  'Clin.  Lect.,'  No.  54, 1873). 


572  BRAIN. 

next  section.  The  chief  difficulty  is  presented  by  organic  diseases 
of  the  medulla,  which  may  also  cause  "  bulbar  palsy  "  of  slow  onset. 
The  most  frequent  of  these  is  a  tumour  in  or  outside  the  medulla,  or  a 
narrowing  of  the  foramen  magnum  by  thickening  of  the  bone  or 
enlargement  of  the  odontoid  process,  damaging  the  bulb  by  invasion 
or  compression,  or  compressing  the  nerve-roots ;  but  the  symptoms 
thus  produced  seldom  present  the  perfect  bilateral  symmetry  that 
characterises  the  degenerative  affection.  One  side  is  affected  first  or 
most,  the  difficulty  of  swallowing  preponderates  over  the  other  sym- 
ptoms, and  the  lips  usually  escape  altogether.  Moreover,  headache  is 
usual,  and  convulsions  are  occasionally  met  with. 

Tumours  within  the  medulla  sometimes  give  rise  to  greater  diffi- 
culty, but  the  cases  in  which  a  growth  acts  on  both  sides  in  such  an 
equal  manner  as  to  cause  perfectly  symmetrical  symptoms  are  exces- 
sively rare,  and  there  are  usually  other  indications  to  help  the  dia- 
gnosis,— either  there  are  other  indications  of  a  tumour,  or  the 
patient  is  so  young  as  to  render  the  degenerative  disease  highly 
improbable.  Insular  sclerosis,  involving  the  medulla,  is  seldom  so 
symmetrical  as  to  give  rise  to  real  difficulty,  and  there  are  always  indi- 
cations, in  other  parts,  of  the  morbid  process. 

Chronic  lesions  in  both  cerebral  hemispheres  may  cause  symptoms 
resembling  those  of  bulbar  palsy,  constituting  a  chronic  form  of 
"  pseudo-bulbar  paralysis."  Although  such  an  effect  is  far  more 
rarely  produced  by  chronic  than  by  acute  lesions,  it  has  been  caused  by 
symmetrical  sclerosis  of  the  two  hemispheres  ;  *  the  chief  distinctions 
are  afforded  by  the  development  of  symptoms  first  on  one  side  and 
then  on  the  other — the  affection  of  the  limbs,  as  well  as  the  face,  in 
distinct  double  hemiplegia, — and  by  other  symptoms  indicative  of  the 
nature  of  the  morbid  process.  Keflex  action  is  preserved  in  the 
parts  paralysed,  and  these  are  never  wasted,  but  alone  these  points 
are  not  sufficient  for  the  diagnosis,  although  they  may  be  allowed 
weight  in  support  of  other  indications. 

Prognosis. — In  every  case  of  gradual  onset  the  prognosis  is  most 
grave.  The  affection  is  so  progressive  in  its  tendency,  and  the  parts 
affected  are  so  important  for  life,  that  the  disease  almost  invariably 
leads  to  death.  This  is  especially  true  of  the  senile  form,  and  of  that 
which  supervenes  on  spinal  muscular  atrophy.  When  the  affection 
begins  in  middle  life,  arrest  may  be  regarded  as  a  possible  event,  and 
it  is  not  improbable  in  the  rare  cases  that  come  on  in  late  childhood, 
or  follow  some  disease  that  has  nerve-degeneration  for  its  occasional 
sequel.  The  possible  cause,  as  well  as  the  obvious  course,  must, 
therefore,  be  considered  in  the  prognosis. 

Treatment. — Although  experience  shows  that  we  can  scarcely 
expect,  in  any  case,  that  our  treatment  will  have  an  appreciable  influ- 

*  Jolly, '  Arch.  f.  Psych.,'  iii,  1872. 


CHRONIC    BULBAR   PARALYSIS.  573 

ence  on  the  disease,  we  may  strive  at  least  to  retard  its  progress,  and 
employ  such  measures  as,  from  their  action  on  the  nervous  system,  are 
most  likely  to  produce  this  effect.  It  is  probable  that  cases  will  occa- 
sionally be  met  with  in  which  the  morbid  tendency  is  less  strong  than 
it  usually  is,  and  in  which  treatment  may  have  some  influence.  Ner- 
vine tonics,  quinine,  strychnine,  arsenic,  phosphorus,  or  nitrate  of 
silver  may  be  given,  or  hypodermic  injections  of  strychnia  (-^  gr.) 
may  be  administered,  as  recommended  for  progressive  muscular 
atrophy  (vol.  i,  p.  497).  The  latter  is  especially  indicated  in  the 
non-senile  forms.  In  advanced  cases  I  have  known  transient  im- 
provement to  follow  the  injection  of  strychnia  combined  with  minute 
stimulant  doses  of  morphia  (3^ — -^  gr.).  The  power  of  swallowing 
has  been  increased  by  this  treatment,  but  unfortunately  the  effect  has 
not  been  permanent.  To  lessen  the  flow  of  saliva,  belladonna  or 
atropine  has  been  given,  but  seldom  with  effect. 

Electricity  has  been  extensively  used.  With  the  view  of  influenc- 
ing the  morbid  process  in  the  medulla,  the  voltaic  cm*rent  has  been 
passed  from  one  mastoid  process  to  the  other.  In  order  to  maintain 
the  nutrition  of  the  muscles,  either  faradism  or  voltaism  may  be  em- 
ployed, for  they  respond  to  either  in  the  majority  of  cases.  It  may 
be  applied  to  the  tongue,  lips,  or  pharynx  ;  to  the  last  by  placing 
the  positive  pole  at  the  back  of  the  neck,  and  moving  the  other  along 
the  side  of  the  throat.  Electrisation  of  the  sympathetic  has  also 
been  used  as  a  method  of  treatment,  but  is  probably  as  destitute  of 
rational  foundation  as  it  certainly  is  of  practical  effect.  Indeed,  the 
result  of  all  electrical  treatment  is  most  unsatisfactory.  For  an 
hour  or  two  after  each  application  there  may  be  a  little  more  power, 
but  the  effect  does  not  last.  I  have  never  observed  distinct  evidence 
that  electricity  had  the  slightest  influence  on  the  course  of  the  disease 
in  any  one  of  many  cases  in  which  I  have  seen  it  used. 

In  all  cases  the  feeding  of  the  patient  demands  much  care.  Semi- 
solid pulpy  food  can  usually  be  swallowed  better  than  liquids  or  solids. 
When  deglutition  is  impossible  without  constant  risk  of  the  entrance 
of  particles  of  food  into  the  air-passages,  and  of  prostrating  and  dis- 
tressing paroxysms  of  choking,  liquid  food  may  be  given  by  an  oeso- 
phageal tube,  or  by  means  of  a  catheter  or  soft  india-rubber  tube 
passed  through  the  nose  into  the  upper  part  of  the  oesophagus.  The 
food  may  be  slowly  poured  into  the  tube  through  a  small  funnel, 
the  patient's  head  being  bent  back.  The  only  alternatives  are  the 
injection  of  food  by  the  stomach-pump,  or  the  less  effectual  method 
of  rectal  feeding  with  peptonised  food.  The  larynx  has  been  opened 
when  the  attacks  of  threatened  suffocation  were  frequent  and  severe. 

Chronic  Bulbar  Paralysis  without  Anatomical  Changes,  anomalous 
and  mysterious,  has  been  occasionally  met  with.  The  cases  have  con- 
formed, in  general  features  and  course,  to  the  common  degenerative 
variety,  but  have  deviated  from  this  in  some  minor  point.     Palsy  of 


574  BRAIN. 

lips,  masseters,  and  pharynx  was  attended,  in  one  case,*  with  only 
slight  weakness  of  the  tongue,  but  with  an  amount  of  paralysis  of 
the  intercostals  that  caused  fatal  dyspnoea.  No  changes  could  be 
discovered  in  the  nerve-nuclei,  and  the  hypothesis  of  chronic  peri- 
pheral neuritis  naturally  presents  itself  to  the  mind,  but  this  was 
excluded  by  Oppenheimf  in  a  case  in  which  the  larynx,  pharynx,  and 
tongue  were  paralysed.  Degenerative  changes  in  the  lower  part  of 
the  cerebro-nuclear  fibres  may  have  escaped  detection. J  Moreover, 
function  may  be  abolished  by  changes  in  the  nutrition  of  the  nerve- 
cells,  that  leave  their  aspect  unaltered. 

Sudden  (Apoplectiform)  Bulbar  Paralysis. 

It  has  been  already  mentioned  that  various  acute  lesions  of  the 
medulla  cause  symptoms  in  the  region  of  the  nerves  implicated  in 
the  degenerative  form,  and  that  these  lesions  generally  differ  from 
the  latter  in  the  less  regular  grouping  of  the  symptoms  produced. 
Occasionally  a  sudden  lesion  causes  symptoms  that  are  perfectly  sym- 
metrical, and  correspond  very  closely  to  those  of  degeneration  of  the 
bulbar  nuclei.  Most  of  the  sufferers  have  been  advanced  in  life, 
■ — at  the  period  in  which  arterial  degenei'ation  is  common  ;  but  this 
form  has  also  been  met  with  in  younger  persons  as  a  result  of  blows 
and  falls  on  the  head  or  neck,§  or  of  syphilis, — influences  which  may 
cause  disease  in  the  vertebral  artery,  or  lower  end  of  the  basilar,  and 
narrow  or  occlude  the  branches.  Such  disease  may  cause  successive 
sudden  attacks,  sometimes  induced  by  depression  of  the  general 
health  or  some  influence  that  retards  the  circulation  or  promotes 
thrombosis.  This  is  also  true  of  another  very  rare  mechanism,  embo- 
lism, by  which  the  vertebral  may  be  closed  (owing  to  the  narrower 
calibre  at  its  extremity),  or  its  branches  ;  the  latter  are  commonly 
saved  from  separate  occlusion  by  the  angle  at  which  they  arise, 
which  makes  the  entrance  of  a  plug  difficult,  though  not  impossible. 
This  arrangement,  while  it  indisposes  to  embolism,  promotes  throm- 
bosis. Among  the  many  causes  of  thrombosis  in  this  situation 
must  be  placed  chronic  basal  meningitis  and  its  effects  on  the 
arteries. ||  The  onset  of  the  paralysis  is  sudden  and  "  apoplectiform," 
sometimes  with  giddiness  and  vomiting,  usually  without  loss  of 
consciousness.     The  initial  symptoms  may  be  of  wider  range ;  there 

*  Dr.  L.  E.  Shaw,  '  Brain,'  1890. 

■f  '  Virchow's  Archiv,'  Bd.  cviii. 

J  Compare  vol.  i,  p.  440. 

§  As  in  the  case  of  a  boy  aged  twelve,  recorded  by  Schulz  ('  Neurol.  Centralbl.,' 
1883,  p.  99),  in  which  bulbar  paralysis  followed  immediately  a  blow  on  the  back  of 
the  neck,  and  increased  considerably  a  day  or  two  afterwards.  It  is  assumed  that 
there  was  traumatic  haemorrhage,  followed  by  secondary  inflammation.  Compare 
a  case  of  fatal  traumatic  haemorrhage  recorded  by  Bochefontaine,  '  Arch,  de  Phys.,' 
1883,  p.  160. 

||  The  possibility  that  thrombosis,  found  after  death,  may  have  been  only  a  ter- 
minal event  must  also  be  borne  in  mind. 


SUDDEN  BULBAE  PARALYSIS. 


575 


may  be  weakness  of  the  limbs  or  an  affection  of  sensibility,  usually 
in  the  form  of  subjective  sensations,  rarely  actual  anaesthesia.  Any 
of  the  symptoms  of  a  lesion  of  the  part  may  co-exist,  often  only 
for  a  time ;  the  wider  symptoms  pass  away,  and  leave  a  permanent 
condition  closely  resembling  that  of  the  degenerative  form,  but  differ- 
ing in  the  absence  of  a  progressive  tendency.  For  a  time,  indeed, 
improvement  may  be  conspicuous;  the  symptoms  lessen,  and  then 
the  condition  becomes  stationary  or  neai-ly  so,  for  a  time  which  differs 
with  the  causal  influences.  As  elsewhere,  the  symptoms  may  increase 
for  a  few  days,  owing  to  inflammatory  processes  in  the  vicinity  of  the 
most  affected  area.  Functional  disturbance  (as  spasm  in  the  masseters) 
has  been  observed  to  precede  or  attend  the  onset.  In  some  cases, 
after  a  time,  degenerative  changes  supervene  on  the  original  acute 
lesion,  and  the  case  assumes  a  progressive  character.  Not  seldom  the 
symptoms,  although  bilateral,  are  unsymnietrical ;  but  it  is  very  rare 
for  them  to  be  quite  one-sided,  as  in  a  case  recorded  by  Hirt,  in  which 
paralysis  of  one  vocal  cord  and  of  the  corresponding  side  of  the  tongue 
came  on  suddenly ;  there  was  wasting  of  the  tongue  with  the  reaction 
of  degeneration.*  Very  often  the  symptoms,  although  bilateral,  are 
more  or  less  irregular  in  distribution  and  character,  as  we  should 
expect  from  the  nature  of  their  cause.  This  feature  is  often  promi- 
nent and  important ;  there  may  be  absolute  inability  to  swallow,  with 
no  paralysis  of  the  tongue  or  face.  When  the  onset  is  by  several 
successive  attacks,  each  is  usually  slight,  although  one  may  be  more 
severe  than  the  others. 

As  an  example  of  this  sudden  form  may  be  mentioned  the  case  of 
a  man  aged  sixty-three.  At  fifty-five  he  had  a  slight  attack  of  right 
hemiplegia  of  ordinary  type,  without 
affection  of  speech  or  of  swallowing, 
from  which  he  recovered  perfectly  in 
the  course  of  a  few  months.  Five 
weeks  before  being  seen  he  suddenly 
became  unable  to  articulate,  and  had 
great  difficulty  in  swallowing.  There 
was  no  loss  of  consciousness.  No 
change  in  his  condition  had  occurred 
when  he  came  under  observation.  His 
condition  then  resembled  perfectly 
that  of  the  progressive  degenerative 
form.  His  lower  lip  hung  down; 
saliva  constantly  dribbled  from  the 
mouth.  The  tongue  was  broad,  flabby, 
and  almost  motionless,  only  the  tip 
could  be  brought  over  the  lower  teeth 
(see  Fig.  147).  The  palate  was  flaccid,  but  could  be  raised  a  little. 
Swallowing  was  very  difficult,  and  attacks  of  choking  were  frequent. 
*  Hirt,  '  Berlin,  klin.  Wochenschrift,'  1885,  No.  26. 


_iri__ 


Pig.  147. — Bulbar  paralysis  of  sud- 
den onset,  maximum  protrusion 
of  the  tongue. 


576  BRAIN. 

The  vocal  cords  could  be  brought  together,  although  with  little  force, 
so  that  no  explosive  cough  was  possible.  He  could  still  phonate, 
although  with  little  modulation.  There  was  not  the  slightest  power 
of  articulation ;  attempts  to  speak  resulted  only  in  "  ah-ah-ah." 
Expression  by  writing  was  unimpaired.  This  patient  was  seen  from 
time  to  time  for  five  years  after  the  onset,  and  his  condition  remained 
essentially  unaltered.  His  power  of  swallowing  varied ;  sometimes- 
it  became  less,  and  then  under  treatment  it  improved  again,  but  on 
the  whole  the  loss  of  articulation  and  of  swallowing,  the  paralysis  of 
lips,  tongue,  and  larynx,  were  neither  better  nor  worse  at  the  end  of 
the  five  years  than  they  were  five  weeks  from  the  onset.  There  was 
no  wasting  and  no  loss  of  faradic  irritability.  As  in  this  case,  the 
muscles  involved  are  usually  those  supplied  from  the  medulla 
oblongata  only,  but  a  curious  case  has  been  recorded  by  Dixon 
Mann  in  which  there  was  also  some  paralysis  of  the  muscles  of 
mastication.* 

The  pathology  of  these  cases  rests  at  present  on  little  exact  observa- 
tion. It  is  probable  that  they  depend  on  softening  from  vascular 
occlusion,  situated  in  or  near  the  middle  line,  and,  at  any  rate  in  the 
cases  with  muscular  wasting,  damaging  the  nuclei-  that  are  the  seat 
of  degeneration  in  the  progressive  form.  The  position  of  the  lesion 
in  cases  such  as  that  detailed  above,  in  which  there  is  no  wasting 
and  no  loss  of  electrical  irritability,  i.  e.  no  evidence  of  damage  to  the 
nuclei  themselves,  is  uncertain.  It  is  probable  that,  in  many  cases, 
the  lesion  is  just  above  the  nuclei,  so  as  to  damage  the  paths  from 
the  cerebral  hemispheres,  which,  after  descending  with  the  pyramidal 
fibres,  certainly  decussate  near  the  nuclei,  and  would  therefore  be 
liable  to  common  damage  from  a  single  lesion  in  the  middle  line. 
Thus,  in  a  case  described  by  Leyden,  there  was  an  area  of  softening 
in  the  middle  line,  at  the  level  of  the  olivary  bodies.f  "When  the  one 
vertebral  artery  is  much  smaller  than  its  fellow,  disease  of  the  latter 
may  damage  both  sides  of  the  medulla.  J  But  there  is  evidence  that 
bilateral  symptoms  sometimes  result  from  a  one-sided  lesion.  The 
functional  connection  between  the  nuclei  of  the  two  sides  is  exceed- 
ingly close ;  they  habitually  act  together  in  perfect  equality,  and 
destruction  of  those  on  one  side  may  for  a  time  interfere  with  the 
function  of  their  fellows  on  the  other  side.  In  most  cases  of  the  kind 
the  duration  of  life  has  been  short,  and  it  may  be  that  the  muscles 
of  the  other  side  would  ultimately  have  recovered.  No  opportunity 
should  be  lost  of  ascertaining  the  exact  nature  of  all  cases  of  sudden 

*  Dixon  Manu,  '  Brain,'  July,  1884,  p.  244.  It  is  very  difficult  to  explain  this 
direct  combination  of  symptoms  except  on  the  hypothesis  of  a  double  lesion.  But- 
an  association  of  indirect  nature  is  conceivable,  since  the  functions  of  chewing  and 
swallowing  are  so  constantly  united. 

t  Leyden,  '  Arch.  f.  Psych.,'  vii,  p.  44. 

t  The  basilar  may  be,  in  effect,  a  continuation  of  one  vertebral  only,  the  other 
ending  in  the  posterior  inferior  cerebellar  artery. 


SUDDEN  BULBAR  PARALYSIS.  577 

onset,  whether  a  microscopical  investigation  is  undertaken  or 
not. 

The  Diagnosis  of  these  cases  presents  little  difficulty.  The  symptoms 
are  due  to  a  sudden  lesion  of  the  medulla,  and  the  cases  in  which  they 
are  symmetrical  are  not  strictly  separable  from  the  others  just  men- 
tioned, in  which  symptoms  of  similar  character  are  of  less  regular 
and  symmetrical  arrangement.  The  distinction  from  the  degenerative 
form  rests  on  the  mode  of  onset,  sudden  in  the  one  case,  gradual  in 
the  other.  If  a  sudden  increase  of  the  paralysis  should  occur  in  the  slow 
form,  the  preceding  symptoms  distinguish  it  from  the  acute  variety. 
The  nature  of  the  lesion  is  shown  by  the  indications  that  furnish 
guidance  in  other  parts  of  the  brain.  It  is  important  to  note  that  sym- 
ptoms may  result  from  very  slight  vascular  derangement,  on  account 
of  the  proximity  of  important  parts,  and  that  slight  gradual  derange- 
ment sometimes  precedes  the  sudden  attack. 

The  chief  diagnostic  difficulty  in  connection  with  these  cases  is  due 
to  the  fact  that  the  "  pseuclo-bulbar  paralysis  "  mentioned  on  p.  320 
may  simulate  very  closely  the  symptoms  of  a  sudden  lesion  of  the- 
medulla.*  But,  as  a  rule,  the  indications  of  a  lesion  in  each  cerebral 
hemisphere  are  clear.  There  are  two  distinct  attacks,  scarcely  ever 
simultaneous,  and  it  is  the  second  attack  that  leaves  the  paralysis  of 
the  lips,  tongue,  and  pharynx  that  simulates  a  lesion  in  the  medulla. 
In  most  cases  of  the  kind  the  disease  has  been  in  the  central  ganglia, 
especially  in  the  lenticular  nuclei ;  less  commonly  it  has  been  in  the 
white  substance,  or  in  the  lower  part  of  the  motor  cortex,  or  in  this 
part  on  one  side  and  in  the  central  ganglia  on  the  other.  In  cases  of 
this  nature,  the  diagnosis  is  not  difficult  if  the  observer  is  aware  of 
the  possibility  of  bulbar  symptoms.  A  much  greater  difficulty  exists 
if  the  bulbar  symptoms  follow  a  single  apoplectiform  seizure.  In- 
some  instances,  lesions  occur  simultaneously  in  both  hemispheres;  in- 
others,  a  subsequent  post-mortem  examination  has  shown  that  only- 
one  hemisphere  of  the  brain  was  diseased,  and  the  lesion  has  some- 
times been  on  one  side,  sometimes  ou  the  other.  We  have  seen  that 
an  acute  lesion  may  completely  inhibit  the  function  of  the  corre- 
sponding centre  in  the  other  hemisphere,  even  for  days.  It  has  been 
assumed  that  the  lenticular  nucleus  has  a  special  relation  to  the- 
processes  of  articulation  and  deglutition,f  an  assumption  which  is 
scarcely  consistent  with  the  frequency  with  which  it  has  been  found 
diseased  without  the  occurrence  of  bulbar  (or  other)  symptoms.  The 
implication  of  the  internal  capsule  is  generally  possible  in  lesions  of 
this  nucleus.  Another  hypothesis  is  that  in  cases  of  one-sided  lesion 
there  is  an  exclusive  relation  of  the  affected  functions  to  one  hemi- 
sphere, owing  to  some  congenital  structural    peculiarity. J     On  the 

*  Cases  of   this  character  have  been  described  by  T.   Barlow,  Joffroy,  Lepine^ 
Berger,  Jolly,  Ross,  and  others. 
t  Ross, '  Brain,'  July,  1882. 
J  O.  Berger,  *  Breslauer  Arztl.  Zeitschr./  1884. 

VOL.  II.  37 


578  BIIAIN. 

other  liand,  it  has  been  held  that  undetected  microscopical  lesions  of 
the  medulla  are  the  real  cause  of  the  symptoms  in  these  and  many 
other  cases  of  pseudo-bulbar  paralysis.*  The  certaiu  fact  is  that  we 
have  much  still  to  learn  by  careful  observation  before  these  cases  of 
unilateral  disease  can  be  comprehended. 

Besides  the  distinction  often  afforded  by  the  mode  of  onset,  pseudo- 
bulbar paralysis  is  characterised  by  the  slighter  degree  of  the  sym- 
ptoms, and  by  the  facts  that  the  nutrition  of  the  tongue  is  unimpaired, 
reflex  action  is  undiminished,  and  there  is  no  change  in  electrical  irri- 
tability. The  larynx  is  seldom  paralysed.  These  negative  charac- 
teristics being  sometimes  present  when  the  lesion  is  in  the  medulla, 
their  diagnostic  value  is  not  absolute.  The  fact  that  a  second  lesion 
may  occur  in  the  medulla  must  also  be  borne  in  mind,  and  must 
occasionally  lessen  even  the  moderate  amount  of  confidence  Avith 
which  the  diagnosis  of  pseudo-bulbar  paralysis  can  be  made. 

Prognosis. — Sudden  apoplectiform  bulbar  paralysis  involves  much 
danger  to  life  in  the  early  stage  of  the  disease,  but  the  subsequent 
prognosis  is  less  grave  than  in  the  chronic  degenerative  form.  The 
tendency  of  the  symptoms  to  progress  is  slight  or  absent.  In  many 
cases  considerable  improvement  occurs  ;  some  recover  entirely.  In 
others,, as  in  that  described  above,  little  or  no  power  returns  in  the 
paralysed  parts.  The  only  guide  as  to  the  probable  course  of  the  sym- 
ptoms is  that  afforded  by  the  condition  of  the  patient  when  the  acute 
stage  has  passed.  If,  at  the  end  of  a  month,  there  is  no  sign  of  im- 
provement, and  there  is  still  a  considerable  degree  of  paralysis,  it  is 
improbable  that  much  improvement  will  ensue.  But  the  further 
forecast  must  depend  on  the  nature  of  the  lesion  and  on  the  indica- 
tions available,  which  have  been  considered  in  the  general  account  of 
such  lesions.  Then,  if  the  evidence  points,  as  it  often  does,  to 
atheroma  and  thrombosis,  the  danger  of  a  recurrence  will  be  less, 
according  to  the  absence  of  influences  favouring  thrombosis,  or  their 
limitation  to  such  as  may  be  obviated  by  suitable  measures.  The 
malady  is  only  a  local  instance  of  the  disease  already  considered. 

The  Treatment  of  this  form  illustrates  the  fact  just  mentioned;  it 
is  essentially  that  of  acute  softening  from  vascular  occlusion,  as 
described  in  detail  at  a  previous  page.  The  general  management  of 
the  case,  in  regard  to  feeding,  &c,  is  the  same  as  in  the  degenerative 
variety. 

Acute  Inflammatory  Bulbar  Paralysis 

(POLIO-MYELITIS    BuLBl). 

The  term  "acute  bulbar  paralysis"  is  commonly  applied  to  the 
sudden  form   described  in  the  last  section,  but  is  needed  for  a  third 
variety,  to  which  alone  it  is  strictly  applicable,  in  which  the  symptoms 
*  Oppeuheiui  and  Siemerling,  59th  '  Versain.  Deut.  Aerzt.,'  1886. 


ACUTE  BULBAR  PARALYSIS.  579 

develop,  not  suddenly,  in  a  few  minutes,  but  acutely,  in  a  few  days. 
The  mode  of  onset  is  that  which  is  characteristic  of  acute  inflammation, 
and  that  this  is  actually  the  lesion  has  been  proved  by  several  cases. 
In  one  observed  by  Etter,*  a  boy,  aged  fifteen,  was  taken  ill  with  head- 
ache and  vomiting,  discomfort  in  the  throat,  difficulty  in  swallowing, 
and  fever.  In  the  course  of  the  first  week  there  developed  bilateral 
paralysis  of  the  face,  accompanied  by  palsy  of  the  tongue,  greatest  on 
the  left  side,  paralysis  of  the  palate,  and  of  the  left  sixth  nerve. 
Death  resulted  from  pneumonia  on  the  tenth  day.  The  post-mortem 
and  microscopical  examinations  revealed  many  myelitic  foci  in  the 
medulla,  symmetrical  on  the  two  sides,  but  greater  on  the  left.  They 
involved  the  left  sixth  nucleus,  the  left  facial  nerve  within  the  pons, 
and  the  right  facial  nucleus,  the  left  hypoglossal  nucleus  and  the 
right  hypoglossal  fibres,  and  the  accessory  nucleus  on  each  side,  the 
motor  part  of  the  vagus  nucleus  on  each  side,  and  many  cells  and 
fibres  in  the  tegmental  region  of  the  lower  part  of  the  pons.  The 
foci  of  inflammation  in  the  accessory  nuclei  could  be  traced  down  the 
cord  as  far  as  the  fourth  cervical  nerves.  Such  a  lesion  is  evidently 
closely  analogous  to  that  which,  in  the  spinal  cord,  causes  acute 
atrophic  paralysis.  We  have  seen  (p.  194)  that  a  similar  inflammation 
may  involve  the  nuclei  of  the  ocular  nerves  in  the  upper  part  of  the 
pons.  The  distribution  in  this  case  is  that  which  has  been  found  in 
the  few  others  investigated,  but  the  glosso-pharyngeal  nuclei  may  also 
suffer.  The  inflammation  is  sometimes  irregular  in  its  distribution 
in  the  nuclei,  and  in  one  case  it  caused  paralysis  of  all  parts  of  the 
face.  Hence  this  affection  has  been  termed  "  acute  inferior  nuclear 
inflammation." 

Its  causes  are  as  little  known  as  are  those  of  the  similar  inflamma- 
tion of  grey  matter  in  other  parts. 

The.  character  of  the  changes  seen  with  the  microscope  depends  on 
the  acuteness  of  the  inflammation,  varying  from  destruction  of  the 
nerve-elements  and  leucocytal  aggregations  or  minute  cavities  of  dis- 
integration, to  mere  change  of  form  and  aspect  of  the  nerve-cells, 
"  cloudy  swelling,"  loss  of  the  processes,  and  ultimate  shrinkage  into 
small  angular  bodies.  The  increased  interstitial  tissue  may  present 
conspicuous  spider-cells  and  the  other  features  described  in  the 
account  of  analogous  affections. 

It  is  possible  that  similar  symptoms  are  sometimes  due  to  a  peri- 
pheral neuritis  of  the  bulbar  nerves.  Disease  elsewhere  prepares  us 
for  a  similar  susceptibility  of  the  motor  cells  and  their  nerve-endings 
to  morbid  influences,  which  may  act  generally  on  one,  occasionally  on 
the  other,  owing  to  some  slight  difference  in  nature.  But  such  acute 
peripheral  bulbar  neuritis  has  hitherto  only  been  met  with  as  part  of 
a  more  general  affection  of  the  cranial  nerves,  such  as  existed  in  a  case 
described  by  Eisenlohr,f  in  which  there  were  haemorrhages  in  nearly 

*  '  Corresp.-Bl.  f.  Schweizer  Aerzte/  1882,  No.  24. 
f  '  Arch.  f.  Psych.,'  ix. 


580  BRAIN. 

all  the  cranial  nerves.  Bulbar  palsv  was  the  predominant  symptom, 
but  included  all  parts  of  the  face ;  the  motor  fifth  was  also 
weakened. 

The  treatment  of  this  affection  must  be  that  of  other  forms  of  acute 
inflammation  of  the  brain. 


ATROPHY   OF   THE   BRAIN. 

The  whole -or  part  of  the  brain  may  be  below  the  normal  size.  In 
general  atrophy  the  texture  of  the  brain  is  normal ;  the  whole  brain 
is  small,  and  the  skull  is  also  small  (microcephaly).  Little  is  known 
of  the  causes  of  this  condition,  whether  the  small  size  of  the  brain  is 
the  cause  of  the  small  size  of  the  skull,  or  the  reverse.  The  condition 
is  generally  associated  with  a  high  degree  of  mental  defect  of  long 
duration,  but  an  unexpected  diminution  in  the  size  of  one  hemisphere 
is  sometimes  met  with  in  chronic  insanity,  probably  connected  with 
a  predisposition  to  the  mental  derangement. 

In  partial  atrophy  of  the  brain,  one  part  is  unduly  small  in  propor- 
tion to  the  rest.  The  part  so  affected  is  usually  changed  in  structure. 
It  is  firmer  than  normal — less  firm  only  in  rare  cases  of  uncertain 
nature.  It  contains  more  connective  tissue  and  fewer  nerve-elements. 
Such  sclerotic  indm-ation  involves  a  difficulty  as  to  the  classification  of 
the  lesion,  as  already  mentioned  (p.  555).  Almost  any  part  of  the  brain 
may  be  thus  smaller  than  normal — the  whole  of  one  cerebral  hemi- 
sphere, or  only  part  of  it,  seldom  both  hemispheres,  the  central 
ganglia  on  one  side,  the  pons,  or  the  cerebellum.  Atrophy  of  the 
cerebellum  may  involve  the  whole  or  only  one  hemisphere,  or  both 
hemispheres — the  middle  lobe  being  normal.  When  the  whole  of  one 
cerebral  hemisphere  is  atrophied,  one  part  is  usually  more  affected 
than  the  rest.  Several  parts  of  the  brain  are  frequently  atrophied 
together,  in  a  manner  that  shows  a  causal  relation,  depending  on  a 
structural  connection,  in  consequence  of  which  the  atrophy  of  one 
part  entails  that  of  the  other.  Thus  atrophy  of  the  whole  of  one 
cerebral  hemisphere  is  usually  associated  with  atrophy  of  the  opposite 
cerebellar  hemisphere.  The  latter  maybe  associated  with  atrophy  of 
the  opposite  corpus  striatum  without  the  rest  of  the  hemisphere,  and 
it  is  usually  associated  also  with  atrophy  of  the  opposite  olivary  body 
of  the  medulla  oblongata.  The  parts  concerned  in  vision  may  be 
thus  marked  out  by  separate  wasting  (see  p.  71).  The  arteries  may 
share  the  diminution  in  size  without  presenting  any  special  disease. 

Partial  atrophy  of  the  brain  is  probably  in  most  cases  acquired. 
This  is  clear  in  many  instances  in  which  it  is  attended  with  symptoms 
that  commenced  during  the  first  years  of  life.  In  some  of  these 
cases  the  lesion  dates  from  birth,  and  the  change  in  the  brain  is  the 


ATEOPHY    OP   TEE    BEAIN.  581 

result  of  its  compression  by  local  meningeal  haemorrhage  (see  p.  413). 
In  other  instances  the  lesion  occurs  during  infancy,  and  is  accompanied 
by  "  infantile  hemiplegia,"  in  the  account  of  which  (p.  456)  will  be 
found  some  evidence  as  to  the  nature  of  the  disease.  In  some  cases, 
again,  it  is  probable  that  an  attack  of  meningitis  was  the  cause.  Both 
hemispheres  may  suffer  from  this  cause,  and  also  in  the  cases  of  menin- 
geal haemorrhage  during  birth.  In  all  varieties,  the  local  atrophy  is 
often  accompanied  by  a  general  diminution  in  size  of  the  hemisphere, 
no  doubt  due  to  the  connection  that  exists  between  all  parts,  and  to 
the  effect  of  considerable  damage  to  one  part  of  the  growing  brain 
on  the  development  of  the  rest.  With  only  local  atrophy  of  the 
superior  parietal  lobule,  one  hemisphere  of  an  adult  has  been  found 
one  and  a  half  inches  shorter  than  the  other.* 

Partial  atrophy  of  the  brain  may  also  develop  during  intra-uterine 
life.  It  may  be  found  present  at  the  time  of  birth.  In  some  cases  it 
is  pei'haps  due  to  intra-uterine  disease  similar  in  character  to  that 
which,  after  birth,  has  similar  consequences.  More  frequently  the 
atrophy  is  such  that  it  can  scarcely  be  thus  explained.  Atrophy  of 
the  cerebellum  is  more  frequent  in  these  cases  than  is  atrophy  of  one 
cerebral  hemisphere.  Sometimes  both  cerebellar  hemispheres  are  very 
small,  and  the  middle  lobe  is  of  normal  size.  It  is  very  difficult  to 
explain  this  condition  on  the  supposition  of  any  intra-uterine  morbid 
process ;  it  would  seem  rather  to  be  connected  with  the  entire  absence 
of  the  cerebellum  sometimes  observed.  This  is  apparently  due  to  some 
perversion  or  defect  of  the  process  of  development ;  the  cause  of 
this  is  practically  unknown,  but  we  are  probably  safe  in  ascribing  it 
to  a  positive  germinal  defect. 

The  symptoms  that  attend  atrophy  of  the  brain  vary  much.  Mental 
defect  is  the  most  constant,  and  usually  amounts  to  idiocy.  Hemi- 
plegia and  epileptic  fits  often  accompany  atrophy  of  one  cerebral 
.hemisphere.  Bilateral  weakness,  with  athetoid  movements  and 
inco-ordination,  may  attend  bilateral  atrophy,  such  as  is  due  to  diffi- 
cult birth  and  meningeal  haemorrhage  compressing  the  cortex.  In 
many  cases,  however,  it  is  certainly  incorrect  to  regard  these  symptoms 
as  the  direct  consequences  of  the  diminished  size  of  the  convolutions  ■ 
they  are  the  result  of  the  disease  which  has  also  caused  the  atrophy, — 
the  local  atrophy  directly,  the  slighter  general  atrophy  of  the  hemi- 
sphere, which  is  often  present,  indirectly,  by  checking  its  growth. 
In  atrophy  of  the  whole  of  the  cerebellum,  unsteadiness  has  been 
observed  similar  to  that  which  results  from  disease  of  the  middle 
lobe.  When  only  the  hemispheres  have  been  affected,  there  have 
sometimes  been  no  motor  symptoms,  but  in  some  cases  there  was 
intellectual  defect.  Atrophy  of  one  hemisphere  of  the  cerebellum  has 
also  been  found  when  no  symptoms,  that  could  be  ascribed  to  it,  were 
present  during  life. 

Senile  Atrophy. — In  old  age  the  brain  wastes,  like  many  other  organs, 
*  Fraser,  '  Glasgow  Med.  Journ  '  1889. 


582  BKA1N. 

and  becomes  smaller  and  firmer.  The  amount  of  fluid  in  the  ventricles 
and  on  the  surface  is  increased  in  proportion  to  the  lessened  bulk  of 
the  brain.  This  natural  increase  of  fluid  was  formerly  regarded 
as  pathological,  and  a  mysterious  death  was  ascribed  to  "  serous 
apoplexy  " — a  purely  imaginary  lesion,  not  yet  quite  forgotten.  But 
this  wasting  of  the  brain  is  commonly  attended  by  no  symptoms. 
Senile  mental  failure  is  often  ascribed  to  it,  but,  since  it  may  exist 
in  considerable  degree  without  the  slightest  mental  defect,  caution 
should  be  observed  in  attributing  to  it  any  mental  change  that  may 
co-exist. 


HYPERTROPHY  OF  THE  BRAIN. 

Under  the  name  "  hypertrophy  of  the  brain  "  a  condition  has  been 
described  in  which  the  brain  is  of  abnormal  size.  Sometimes  it  has 
been  found  also  to  be  of  distinctly  abnormal  weight,  but  the  wide 
variations  in  the  weight  of  the  brain  under  normal  conditions  render 
this  criterion  decisive  only  in  extreme  cases.*  The  size  of  the  brain 
in  relation  to  the  size  of  the  skull  is  the  feature  that  has  attracted 
most  attention.  If  the  condition  develops  before  the  bones  have 
united,  the  skull  is  said  to  undergo  enlargement  similar  to  that  of 
hydrocephalus.  If  the  sutures  have  been  closed,  the  convolutions  are 
compressed  and  pale  ;  and  when  the  brain  has  been  removed,  it  cannot 
be  replaced  in  the  cranial  cavity — a  feature  which,  since  the  days  of 
Morgagni,  has  attracted  attention,  perhaps  more  than  it  deserves.  In 
all  cases  the  ventricles  are  empty  ;  their  walls  are  pressed  together,  and 
the  vessels  of  the  brain  contain  little  blood. 

Decisive  examples  of  this  state  are  extremely  rare ;  there  are  few 
satisfactory  observations  on  the  minute  structure  of  the  enlarged 
organ,  and  we  do  not  therefore  know  whether  this  is  the  same  in  all 
cases.  In  some,  an  increase  in  the  neuroglia  has  been  found,  and  has 
been  regarded  as  the  cause  of  the  enlargement  (Virchow ;  Tuke,  in 
an  unusual  case  in  which  the  enlargement  was  confined  to  one  hemi- 
sphere). In  other  cases  no  increase  in  the  connective  tissue  could 
be  found. 

Such  enlargement  of  the  brain  Las  been  met  with  chiefly  under 
three  conditions.  (1)  In  very  youug  children  soon  after  birth.  It  is 
in  these  that  the  hydrocephaloid  enlargement  of  the  head  has  been 

*  The  weight  and  size  of  the  brain  differ  according  to  age  and  stature,  but  even 
thus  tested  the  variations  are  great.  Proportion  to  absolute  body-weight  lias  also 
been  taken  as  a  guide,  but  it  is  not  to  be  relied  on,  since  the  body-weight  varies  in 
each  direction,  that  of  obesity  and  emaciation,  irrespective  of  stature.  If  the  body- 
weight  is  taken  as  a  term  of  comparison  it  should  be  the  average  for  each  age  and 
stature 


HYPERTROPHY   OP   THE   BRAIN.  583 

described.  (2)  Towards  the  end  of  the  first  year  of  life,  in  associa- 
tion with  rickets.  It  may  be  that,  the  closure  of  the  skull  being 
retarded,  the  brain  attains  an  abnormal  size  in  consequence  of  the 
deficiency  of  the  mechanical  restraint  that  should  be  furnished  by  the 
skull  when  its  bones  unite.  It  has  been  thought  that  the  enlargement 
of  the  brain  increases  the  size  of  the  skull,  but  the  shape  of  this  is 
that  characteristic  of  rickets,  and  the  size  may  be  due  to  the  double 
influence  of  abnormal  ossification,  and  the  enlargement  of  the  brain. 
(3)  An  increase  in  size  has  been  occasionally  observed  in  older  children 
and  even  in  adults,  but  of  its  nature  very  little  is  known. 

Of  the  causes  of  this  condition  only  two  facts  can  be  regarded  as 
established  :  first,  that  it  has  been  occasionally  observed  in  families ; 
secondly,  the  relation  to  rickets  already  described. 

The  symptoms  that  it  produces  are  very  uncertain.  The  form  that 
occurs  soon  after  birth  and  causes  enlargement  of  the  head  is  said  to 
be  attended  by  nervous  symptoms  almost  identical  with  those  of 
chronic  hydrocephalus,  so  that  the  distinction  of  the  two  is  practically 
impossible.  It  is  doubtful  whether  the  rickety  enlargement  causes 
any  symptoms.  We  are  not  justified  in  referring  to  it  the  laryngeal 
spasm  or  general  convulsions  or  mental  backwardness  of  rickety 
children,  since  these  may  be  present  when  there  is  no  enlargement  of 
the  brain. 

Even  more  doubt  exists  as  to  the  symptoms  of  the  form  that  has 
been  met  with  at  a  later  age.  In  some  cases  it  has  apparently  caused 
none.  In  others,  acute  cerebral  symptoms,  resembling  meningitis, 
have  occurred,  and  have  run  a  rapid  course,  ending  in  death.  The 
evidence  of  a  connection  between  the  enlargement  of  the  brain,  which 
was  regarded  as  chronic,  and  the  acute  symptoms  is  not  satisfactory, 
and  no  explanation  of  the  supposed  connection  has  been  attempted. 
The  condition  seems  never  to  have  been  recognised  during  life,  and 
nothing  is  known  of  its  treatment. 

The  so-called  hypertrophy  of  a  small  part  of  the  brain,  as  of  certain 
convolutions,  or  of  the  pons  Varolii,  has  probably  been  always  due  to 
an  infiltrating  growth  (see  p.  495). 

Prom  what  has  been  said,  it  is  clear  that  the  pathology  of  enlarge- 
ment of  the  brain  needs  fresh  study  in  the  light  of  future  investi- 
gation. Moreover,  the  common  tendency  to  speak  of  the  enlargement 
caused  by  overgrowth  of  connective  tissue  as  "  hypertrophy  "  of  an 
organ,  is  an  inexact  use  of  the  word,  which,  when  applied  to  an  organ 
without  qualification,  should  designate  only  an  enlargement  chiefly 
due  to  an  overgrowth  of  the  elements  on  which  the  function  of  the 
organ  depends. 


-584  BttAlN. 


HYDEOCEPHALUS. 

Hydrocephalus,  or  dropsy  of  the  brain,  consists  in  an  accumulation 
of  fluid  within  the  skull,  either  in  the  subdural  space  (external  hydro- 
cephalus) or  within  the  ventricles  (internal  hydrocephalus).  It  may 
be  acute  or  chronic,  the  result  of  other  morbid  processes  that  are  con- 
spicuous ("  secondary  form  "),  or  the  consequeuce  of  a  process  that  is 
ohiefly  manifested  by  this  effect  (so-called  "  primary  form  "). 


Acute  Hydrocephalus. 

The  only  known  cause  of  actually  acute  hydrocephalus  is  menin- 
gitis. This,  in  all  forms,  may  be  attended  by  effusion  of  fluid  in  the 
subdural  space  or  into  the  ventricles.  The  latter,  for  instance,  occurs 
in  four  fifths  of  the  cases  of  tubercular  meningitis.  Hence  the  term 
"  acute  hydrocephalus  "  was  for  a  long  time  the  common  designation 
for  meningitis.  The  external  effusion  is  the  direct  result  of  the  inflam- 
mation of  the  pia  mater,  and  the  internal  effusion  is  probably  also  the 
result  of  inflammation  of  the  choroid  plexuses  and  velum  interpositum, 
perhaps  also  of  the  lining  membrane  of  the  ventricle. 

In  some  cases,  however,  the  effusion  into  the  ventricles  is  the  only 
pathological  change  in  an  affection  of  acute  and  febrile  course.  The 
external  meninges  are  healthy ;  the  choroid  plexuses  may  be  the  seat 
of  distinct  inflammatory  changes,  and  the  lining  membrane  of  the 
veutricles  may  be  finely  granular ;  the  adjacent  brain  tissue  is  softened, 
and  the  brain-substance  and  convolutions  are  compressed.  There  is 
no  indication  of  auy  processes  of  which  the  effusion  could  be  a 
mechanical  consequence,  such  as  is  an  occasional  cause  of  chronic 
hydrocephalus.  The  symptoms  during  life  are  those  of  an  acute 
inflammatory  disease,  and  resemble  very  closely  those  of  tubercular 
meningitis.  Hence  it  is  commonly  assumed  that  they  are  due  to  a 
ventricular  meningitis,  affecting  chiefly  the  choroid  plexuses,  and 
causing  an  abundant  effusiou  of  serum.  Although  the  pathology  of 
the  cases  is  obscure,  no  better  explanation  has  yet  been  given. 


Chronic  Hydrocephalus. 

External  Chronic  Hydrocephalus. — "Whenever  there  is  wasting 
of  the  brain,  there  is  increase  of  the  subarachnoid  fluid  to  occupy  the 
space  left.  This  is  a  common  senile  condition.  Of  the  same  character 
is  the  accumulation  of  fluid  met  with  in  some  cases  of  arrested  deve- 
lopment, in  which  the  brain  is  small  and  does  not  fill  the  cranial 
cavity. 


HYDROCEPHALUS.  585 

In  other  cases,  without  the  brain  being  smaller  than  normal,  there 
is  a  congenital  excess  in  the  amount  of  fluid  in  the  subdural  space, 
and  this  expands  the  skull.  The  expansion  may  be  so  great  as  to 
prevent  the  child  being  born  alive.  If  birth  is  survived,  the  head 
rapidly  increases  in  size,  and  is  of  the  same  shape  as  in  the  internal 
hydrocephalus,  to  be  immediately  described.  Post  mortem,  the  excess 
of  fluid  is  the  Only  morbid  condition.  There  is  no  change  in  the 
membranes,  and  the  origin  of  the  condition  is  not  known.  It  is  usually 
attended  by  synrptoms  similar  to  those  of  internal  effusion,  having  a 
similar  course.  Caries  of  the  bone  of  the  skull,  in  such  cases,  has 
occasionally  permitted  the  escape  of  the  effusion. 

External  hydrocephalus  is  sometimes  "  sacculated,"  i.  e.  limited 
to  a  certain  region  by  adhesions  between  the  dura  and  pia  mater. 
This  condition  is,  in  effect,  a  meningeal  cyst.  Its  position  may  be 
over  part  of  one  cerebral  hemisphere  or  beneath  the  tentorium.  If 
there  is  enlargement  of  the  skull,  this  is  correspondingly  unsymme- 
trical.  The  brain  may  be  compressed  opposite  the  seat  of  the  effusion, 
and  corresponding  local  symptoms  may  result.  These  cases  doubtless 
arise  from  inflammation,  and  their  course  may  be  varied  by  inter- 
current attacks  of  a  meningitic  character. 

Chronic  Internal  Hydrocephalus  may  be  either  congenital  or 
acquired. 

Congenital  Internal  Hydrocephalus  develops  in  utero,  and  may  cause 
such  enlargement  of  the  head  as  to  prevent  birth  until  the  fluid  is  let 
out ;  or  it  may  be  moderate  at  the  time  of  birth,  and  afterwards 
rapidly  increase.  The  causes  and  pathological  mechanism  are  prac- 
tically unknown.  It  has  been  ascribed  to  maternal  grief  or  other 
emotion,  but  on  no  reasonable  grounds,  and  also  to  injury  of  the 
foetus  by  falls,  &c, — an  influence  which  is  at  least  intelligible.  A 
connection  has  been  supposed  to  exist  between  uterine  disease  and 
hydrocephalus,  and  has  been  explained  hypothetically,  but  it  has  yet 
to  be  proved.  There  is,  however,  no  doubt  that  a  tendency  to  the 
occurrence  of  fcetal  hydrocephalus  sometimes  runs  in  families,  and  that 
more  than  one  child  may  be  affected  in  succession. 

Sometimes  all  the  ventricles  are  distended  ;  more  often  the  fourth 
ventricle  suffers  little,  even  when  there  is  no  obstruction  in  the 
aqueduct  of  Sylvius.  In  such  a  case  the  aqueduct  may  be  funnel- 
shaped,  dilated  towards  the  enlarged  third  ventricle.  If  the  disten- 
sion is  confined  to  one  or  both  lateral  ventricles,  there  is  some  obstruc- 
tion at  the  foramen  of  Monro  (see  further,  under  "  Acquired  Hydro- 
cephalus ").  The  fluid  is  usually  clear,  of  low  specific  gravity,  1001 
— 1009,  and  contains  a  small  and  variable  amount  of 'albumen,  some 
chloride  of  sodium,  and  sometimes  urea,  cholesterin,  and  other  sub- 
stances in  small  quantity.  The  amount  of  liquid  varies  according  to 
the  degree  of  the  disease,  and  has  been  as  much  as  twenty-seven 
pounds.     In  proportion  to  its  quantity,  the  substance  of  the  cerebral 


586  BRAIN. 

hemispheres  is  compressed,  and  thinned  by  extension  and  wasting,' 
especially  the  white  substance,  and,  it  is  said,  the  callosal  fibres.* 
The  corpus  callosum  is  displaced  upwards,  and  if  the  cranium 
is  enlarged,  the  hemisphere  extends  further  forwards,  backwards, 
upwards,  and  outwards  than  normal.  The  cerebral  substance  may  be 
reduced  to  a  layer  only  a  few  millimetres  thick,  constituting  the  thin 
wall  of  a  vast  cavity.  In  such  a  case,  all  traces  of  the  convolutions  and 
sulci  may  have  disappeared,  and  even  the  basal  ganglia  may  be  almost 
unrecognisable.  More  often  indications  of  the  sulci  can  be  traced,  and 
the  compressed  basal  ganglia  lie  at  the  bottom  of  the  sac.  The  cranium 
is  enlarged  in  proportion  to  the  amount  of  effusion,  and  the  bones  of 
the  skull  are  thin.  The  falx  is  necessai-ily  stretched,  and  its  edge 
forms  a  larger  curve  than  normal  ;  the  extension  of  its  edge  raises 
the  anterior  part  of  the  tentorium.  Hence  the  subtentorial  space  is 
increased  in  size,  and  is  not  completely  filled  by  the  cerebellum,  the 
interval  being  occcupied  by  liquid,  and  sometimes  by  loose  connective 
tissue.  Otherwise  the  membranes  are  normal.  The  choroid  plexus 
may  be  thickened,  as  if  from  old  inflammation.  The  lining  membrane 
of  the  ventricles  is  often  finely  granular  on  the  surface,  and  is  some- 
times thickened. 

The  external  enlargement  of  the  skull  is  very  conspicuous  and 
characteristic,  and  rapidly  increases  after  birth.  The  fontanelles  be- 
come very  large,  and  bulge  ;  at  the  sutures,  the  bones  are  widely  sepa- 
rated. The  cranium  has  a  rounded  shape,  and  becomes  dispropor- 
tionately large  in  comparison  with  the  face.  The  disparity  is  increased 
by  the  projection  of  the  frontal  portion  of  the  skull.  The  orbital 
plates  have  an  oblique  direction,  and  the  eyes  are  directed  downwai'ds 
and  partially  covered  by  the  lower  eyelids.  If  the  child  lives,  the  head 
may  attain  an  enormous  size ;  in  one  case,  at  sixteen  months  old, 
the  circumference  was  107*6  cm.  (Klein).  The  symptoms  vary  much. 
There  is  usually  considerable  mental  defect,  often  amounting  to 
idiocy.  The  limbs  are  weak  ;  convulsions  and  various  contractures 
are  frequent ;  occasionally  febrile  attacks  occur,  attended  by  vomiting. 
The  head  is  supported  with  difficulty,  on  account  both  of  its  weight 
and  of  the  muscular  weakness.  The  eyeballs  are  often  rolled  from 
side  to  side,  and  their  axes  may  not  correspond.  The  skin  of  the  head 
is  thin,  and  the  hair  scanty.  In  extreme  cases,  blindness  occurs,  and 
the  ophthalmoscope  shows  optic  nerve  atrophy,  produced  by  the 
stretching  of  the  nerve,  or  by  the  compression  of  the  chiasma.  In  con- 
genital cases,  the  rapid  increase  of  the  disease  usually  causes  death  in 
the  second  or  third  month  of  life,  by  marasmus,  convulsions,  or  coma. 
Occasionally  the  morbid  process  becomes  arrested,  and  the  patient  may 
live  on  to  adult  life  and  even  to  old  age.  It  is  said  that  the  fluid  is 
sometimes  gradually  absorbed.  Ossification  of  the  bones  may  pro- 
gress, and  is  usually  completed  by  the  development  of  "  Wormian 
bones  "  within  the  sutures.  If  the  disease  is  considerable  in  degree,. 
*  Anton, '  Wien.  med.  Jahrb.,'  1888. 


HYDROCEPHALUS.  587 

the  mental  and  motor  symptoms  usually  continue  in  some  degree 
through  life — mental  weakness,  often  with  irritability  of  temper,  epi- 
leptic fits,  muscular  weakness,  and  contractures. 

Acquired  Chronic  Internal  Hydrocephalus  may  be  (1)  secondary  to 
a  lesion  that  produces  the  effusion  mechanically  ;  (2)  consecutive  to 
an  attack  of  meningitis  ;   (3)  of  apparently  primary  origin. 

Secondary  Mechanical  Form,.  —  Why  tt  pointed  out  in  the  last  century 
that  any  obstruction  of  the  veins  of  Galen,  hindering  the  return 
of  blood  from  the  intra-ventricular  vessels,  causes  effusion  into  the 
ventricles,  which  may  reach  a,n  extreme  degree.  The  most  common 
cause  is  an  adjacent  tumour.  But  an  obstruction  to  the  passage  of 
fluid  out  of  the  ventricles  is  another  mechanical  cause,  commonly  co- 
existing with  the  pressure  on  the  veins,  and  more  certainly  effective 
when  it  acts  alone.  The  fluid  normally  escapes  by  the  openings  in 
the  membrane  closing  the  fourth  ventricle,  the  foramen  of  Magendie 
in  the  middle  line,  and  the  openings,  one  on  each  side,  behind  the 
roots  of  the  glosso-pharyngeal  nerve,  first  described  by  Mierzejewski. 
These  may  be  occluded  by  meningitis,  and  then  all  the  ventricles 
become  distended  ;  the  passage  from  the  third  to  the  fourth  ventricles 
is  closed,  only  the  ventricles  above  are  distended,  and  from  obstruc- 
tion at  the  foramen  of  Monro  the  effusion  is  confined  to  the  lateral 
ventricles.  Progressive  effusion  is  probably  in  most  cases  the  result 
of  one  of  the  two  mechanical  processes  just  mentioned,  chiefly  of  the 
hindered  exit  (see  Hilton  on  "  Rest  and  Pain  ").  A  moderate  amount 
of  effusion  may  be  associated  with  diseases  (as  abscess  or  tumour) 
which  do  not  involve  any  distinct  mechanical  influence.  Its  mechanism 
is  obscure. 

Primary  Hydrocephalus. — Internal  effusion  sometimes  occurs  with- 
out any  of  the  above  causes  being  traceable.  In  children  with  yielding 
skulls,  it  is  supposed  that  the  mechanical  congestion  of  frequent  cough, 
or  the  tendency  to  transudation  present  in  anaemia,  may  lead  to  some 
effusion,  but  it  is  not  probable  that  the  amount  from  these  causes  is 
ever  considerable.  At  any  age,  the  condition  has  been  known  to  de- 
velop and  attain  a  considerable  degree,  without,  it  is  said,  any  other 
pathological  condition  being  discoverable  than  the  slight  traces  of 
ventricular  inflammation  that  are  met  with  in  the  congenital  cases. 
Dean  Swift  died  from  this  disease  at  seventy-eight,  after  it  had  existed 
for  three  years.     These  cases  are  probably  due  to  obstruction. 

The  symptoms  in  the  acquired  form  are,  on  the  whole,  similar  to 
those  in  the  congenital  variety,  due  allowance  being  made  for  differ- 
ences of  age.  These  are  mental  weakness,  somnolence,  coma,  muscu- 
lar weakness,  con vtilsion,  contractures,  and  loss  of  sight  from  pressure 
of  the  distended  third  ventricle  on  the  optic  chiasma.  Temporal 
hemianopia  may,  therefore,  precede  the  complete  blindness.  In  young 
children,  with  incomplete  closure  of  the  sutures,  the  head  readily 
enlarges,  although  rarely  to  the  same  extent  as  in  the  congenital  form. 
In  the  adult,  enlargement  of  the  head  is  less  common,  although  it 


588  BRAIN. 

lias  been  known  to  occur,  and  the  sutures  may,  as  I  have  seen,  become 
separated,  usually  after  the  gradual  thinning  of  the  cranial  bones 
described  in  the  section  on  tumours  of  the  brain  (p.  503).-  It  might 
be  supposed  that  the  intra-ocular  circulation  would  show  the  effects  of 
the  increased  pressure  within  the  skull,  but  this  is  seldom  the  case,  on 
account  of  the  anastomoses  of  the  ophthalmic  vein.  Even  during  the 
process  of  separation  of  the  sutures,  I  have  been  unable  to  observe  any 
marked  increase  in  the  size  of  the  retinal  veins.  The  course  of  the 
acquired  form  varies  much.  Death  usually  occurs  at  the  end  of  a  few 
months  or  years.  The  progress  sometimes  ceases,  and  if  the  affection 
is  moderate  in  degree,  recovery  may  occur.  It  is  only  in  children,  in 
whom  the  ready  enlargement  of  the  head  enables  a  certain  diagnosis 
to  be  made  when  the  disease  is  still  in  an  early  stage,  that  recovery 
<jan  be  proved.  The  sac  has  been  known,  in  very  rare  instances,  to 
rupture  into  the  subdural  space. 

Diagnosis. — As  just  intimated,  hydrocephalus  can  only  be  dia- 
gnosed with  certainty  when  there  is  distinct  progressive  enlargement  of 
the  head.  When  the  bones  are  united,  internal  effusion  may  be  sus- 
pected if  its  indications  slowly  follow  an  attack  of  meningitic  character, 
•or  accompany  the  symptoms  of  a  tumour  of  the  cerebellum.  But 
primary  hydrocephalus  causes  only  symptoms  that  are  not  distinctive, 
-and  are  much  more  frequently  produced  by  other  morbid  processes. 
Hence,  as  a  matter  of  fact,  the  existence  of  the  disease,  when  it  leads 
to  no  enlargement  of  the  head,  and  when  the  causal  indications  just 
mentioned  are  absent,  cannot  be  recognised. 

In  slight  degree  the  enlargement  of  the  head  may  be  confounded 
with  that  produced  by  two  other  causes,  rickets  and  thickening  of  the 
bone.  In  the  former  the  head  has  a  somewhat  square  form,  and  not 
the  globular  shape  characteristic  of  hydrocephalus.  Although  the 
fontanelle  may  be  large,  it  is  not  bulged.  The  other  signs  of  rickets 
are  present  in  high  degree.  Thickening  of  the  cranial  bones  may 
simulate  hydrocephalus  at  almost  any  age.  I  have  seen  it  in  a  boy  of 
ten,  the  subject  of  inherited  syphilis,  and  iu  a  man  of  fifty.  In  the 
latter,  a  slow  progressive  enlargement  of  the  head  during  several  years 
led  to  a  diagnosis  of  hydrocephalus,  but  at  the  post-mortem  examina- 
tion the  cranial  bones  were  found  to  be  three  quarters  of  an  inch  in 
thickness,  and  the  cavity  was  of  normal  size.  It  is  doubtful  whether 
the  nature  of  these  rare  cases  can  be  ascertained  during  life.  A  dis- 
tinction of  internal  from  external  hydrocephalus  can  only  be  made 
by  paracentesis,  and  not  always  with  certainty  even  by  this  means, 
since  a  thin-walled  sac  may  be  readily  opened  by  a  comparatively 
superficial  puncture. 

The  Peognosis  of  hydrocephalus  of  any  form  is  usually  grave  and 
always  uncertain,  unless  the  occurrence  of  arrest  can  be  distinctly 
recognised. 


HYDROCEPHALUS.  589 

Treatment. — Whatever  lessens  the  volume  of  the  blood  diminishes 
for  a  time  the  amount  of  the  effusion.  Thus  an  attack  of  diarrhoea 
lessens  the  prominence  of  the  fontanelle.  But  purgatives  are  inadmis- 
sible ;  to  be  effective  they  must  be  more  vigorous  than  a  hydrocephalic 
child  can  bear.  Diuresis  constitutes  a  safer,  but  unfortunately  less 
effective,  mode  of  attaining  the  same  end.  In  no  case  in  which  these 
measures  have  been  used  has  a  permanent  effect  been  produced. 
Agents  tbat  are  supposed  to  promote  absorption,  as  iodide  of  potas- 
sium and  mercury,  have  been  extensively  tried,  but  are  as  a  rule 
powerless,  and  are  sometimes  harmful.  The  most  direct  treatment, 
which  is  unfortunately  the  most  dangerous,  is  evacuation  by  puncture 
with  a  trocar  or  aspirator,  a  small  quantity  being  let  out  each  time, 
and  compression  of  the  skull  by  elastic  bandages  kept  up  during  and 
after  the  operation.  This  procedure  is  of  course  most  suitable  to 
external  hydrocephalus,  but  it  has  been  employed  in  ventricular  effu- 
sion, occasionally  without  ill  effects,  but  with  absolute  success  only  in 
rare  instances.  The  place  for  puncture  was  formerly  at  the  outer 
angle  of  the  anterior  fontanelle,  butantiseptic  measures  have  permitted 
trephining  and  puncture  in  a  locality  at  which  the  lateral  ventricle  is 
most  accessible.  Continuous  drainage  has  even  been  employed,  but. 
the  result  has  seldom  been  satisfactory,  whatever  the  nature  of  the 
case.*  The  first  puncture  has  generally  been  well  borne,  and  has 
relieved  urgent  symptoms  of  cerebral  compression,  but  the  second 
or  third  has  usually  had  little  effect,  and  has  sometimes  been  fatal — 
in  some  instances  apparently  because  too  little  time  was  allowed  to 
elapse  between  the  operations.  Puncture  of  the  spinal  membranes  below 
the  cord  has  also  been  resorted  to.  It  can,  of  course,  relieve  internal 
hydrocephalus  only  when  there  is  no  obstruction  to  the  passage  of 
the  fluid  from  the  ventricles,  and  this  the  operation  only  may  decide. 
It  has  relieved  urgent  symptoms  for  a  time,  and  has  been  thought 
capable  of  starting  absorption  in  chronic  cases,  but  its  demonstrated 
service  is  limited  to  relief.  On  the  other  hand,  it  seems  to  do  no 
harm.f 

Good  has  been  observed  to  follow  simple  compression  of  the  skull, 
a  mode  of  treatment  first  advocated  and  energetically  employed  fifty 
years  ago  by  Barnard,  of  Bath.  Trousseau  employed  strips  of 
diachylon  plaster,  a  third  of  an  inch  broad,  in  the  following  manner  :J 
— (1)  From  each  mastoid  process  to  the  outer  part  of  the  orbit  on  the 
opposite  side  ;  (2)  from  the  hair  at  the  back  of  the  neck,  along  the 
sagittal  suture,  to  the  root  of  the  nose ;  (3)  over  the  whole  head  in 
such  a  manner  that  the  different  strips  shall  cross  each  other  at  the 

*  See  Keen,  '  Phil.  Med.  News,'  1889,  and  '  Trans.  Tenth  Int.  Med.  Congress ;' 
Robson,  '  Brit.  Med.  Journ.,'  1890. 

f  See  Quincke,  '  Berlin,  klin.  Wochenschrift,'  1891,  for  the  details  of  ten  cases, 
five  of  whom  were  adults;  also  Wynter,  '  Lancet,'  1891,  i. 

X  '  Journal  de  Medecine,'  April,  1843,  quoted  hy  West,  '  Dis.  of  Infancy  and 
Childhood,'  7th  ed„  1884,  p.  136. 


590  BRAIN. 

vertex  ;  (4)  a  long  strip  around  the  head  three  times,  taken  first 
above  the  ears  and  eyebrows,  and  a  little  below  the  occipital  protu- 
berance, so  that  the  ends  of  all  the  other  strips  shall  project  below 
the  circular  strip  ;  these  ends  are  next  to  be  doubled  up  on  the  circular 
strip,  and  its  remaining  two  turns  passed  over  them  in  the  same  direc- 
tion as  the  first  turn.  It  is  necessary  to  watch  the  effect,  and  loosen 
the  strips  if  there  are  any  symptoms  of  compression.  Dr.  West 
advises  a  broad  elastic  band  as  safer  and  more  manageable  than  the 
plasters.  His  experience  of  pressure  in  severe  cases  has  not  been 
encouraging,  since  it  has  not  hindered  the  accumulation  of  fluid,  and 
has  increased  the  symptoms  of  compression  of  the  brain. 


PART  V. 

GENERAL   AND   FUNCTIONAL   DISEASES    OF 
THE   NERVOUS   SYSTEM. 


The  diseases  that  remain  for  consideration  are  those  in  which  there 
are  no  constant  changes  to  he  seen  with  the  naked  eye.  It  was 
formerly  the  custom  to  include  them  all  under  the  term  "  functional 
diseases,"  but  microscopical  changes  have  been  discovered  in  some  of 
them  with  sufficient  frequency  to  make  it  certain  that  there  is  far 
more  than  a  mere  disturbance  of  function,  and  it  cannot  be  doubted 
that  most  of  these  maladies  depend  upon  alterations  in  the  nutrition 
of  the  nerve-elements,  although  these  may  not  yet  have  been  found, 
and  perhaps  cannot  be  detected  without  more  means  of  investigation 
than  we  at  present  possess.  The  diseases  themselves  are  so  different 
in  character  and  so  various  in  seat,  that  their  classification  into  groups 
is  alike  difficult  and  useless.  Anything  like  a  scientific  classification, 
based  upon  our  present  knowledge,  would  result  in  little  more  than 
enumeration,  and  is  therefore  not  attempted.  The  order  in  which 
they  are  described  is  based  only  on  convenience. 


CHOREA. 

Chorea  is  a  disease  that  occurs  chiefly  in  young  persons,  is  usually 
of  limited  duration,  and  is  characterised  by  irregular  spasmodic  move- 
ments, by  inco-ordination  of  voluntary  movement,  and  often  by  mus- 
cular and  mental  weakness.  The  proportion  of  these  elements  varies 
in  different  cases. 

The  term  "  Chorea  Sancti  Viti"  {^opeia  =  dancing),  or  St.  Vitus's 
dance,  was  first  applied  at  Strasburg  to  the  epidemic  dancing  mania 
prevalent  in  the  fourteenth  and  fifteenth  centuries,  when  the  sufferers 
were  taken,  by  order  of  the  Strasburg  magistrate,  to  the  chapel  of  St. 
Vitus,  to  be  cured  by  the  influence  of  the  saint.     The  term  became 


592  CHOREA. 

restricted,  chiefly  through  the  influence  of  Sydenham,  to  the  disease 
now  known  by  the  name,  but  it  is  even  now  used  more  widely  in 
Germany,  and  the  affection  here  described  is  distinguished,  as  chorea 
minor,  from  chorea  major,  a  form  of  hysterical  disorder  distinct  from 
ordinary  chorea,  and  more  closely  allied  to  the  epidemic  malady  of  the 
Middle  Ages. 


Etiology. — The  relation  of  chorea  to  race  is  a  subject  that  has 
been  but  little  studied.  According  to  Weir  Mitchell,  in  the  United 
States  the  disease  is  less  frequent  among  the  negro  than  among  the 
white  population,  and  in  some  places  in  which  there  is  a  mixed  popula- 
tion (e.  g.  in  the  island  of  Cuba),  where  chorea  is  not  uncommon 
among  the  white  children,  it  is  unknown  among  the  coloured  children. 
Urban  residence  is  said  by  the  same  writer  to  favour  the  occurrence 
of  the  disease,  and  it  is  probable  that  the  influence  could  be  traced 
also  in  this  country. 

Hereditary  influences  can  be  found  in  many  cases  of  chorea,  and. 
a  double  relation  of  the  disease  can  often  be  traced  in  these  influ- 
ences ;  its  relation  to  acute  rheumatism  on  the  one  hand,  and  to  other 
nervous  diseases  on  the  other.  These  relations  may  be  separate  or 
may  be  combined.  Rheumatism  is  so  common  that  it  is  only  signi- 
ficant when  the  family  tendency  is  strong  or  close,  unless,  as  is  fre- 
quently the  case,  the  patient  has  also  suffered  from  rheumatism  ; 
it  is,  however,  sometimes  very  pronounced,  and  some  family  tendency 
can  be  traced  in  45  per  cent.*  A  neuropathic  heredity  has  been 
found  in  one  sixth  of  the  cases — epilepsy,  insanity,  or  chorea  itself. 
This  proportion  is  not  great,  but  the  actual  facts,  in  the  case  of 
neuroses,  always  exceed  those  that  can  be  ascertained,  and  often  much 
exceed  them.  Moreover  they  are  emphasised  by  the  strong  character 
of  many  instances.  For  example,  three  sisters  suffered  from  true 
chorea ;  a  sister  also  suffered  from  chorea,  and  the  mother  from 
epilepsy ;  the  mother  of  one  patient  was  insane,  and  her  sister's  child, 
also  had  chorea ;  the  father  of  another  had  suffered  from  chorea  in 
early  life,  and  so  had  two  children  of  his  brother ;  five  relations  of 
another  had  been  insane.  Many  other  similar  facts  have  been  met 
with  in  the  investigation  of  the  clinical  history  of  epilepsy.  For 
instance,  a  man  was  epileptic,  his  sister  insane;  and  two  of  her  children 
had  chorea.  Two  sisters  of  an  epileptic  girl  had  had  chorea.  Two 
children  suffered  from  chorea,  their  mother's  sister  being  epileptic 
and  insane.f 

*  Brit.  Med.  Association's  Collection  (see  note  on  next  page). 

t  Many  illustrations  of  a  double  family  tendency  are  mentioned  by  Money  in 
his  analysis  of  236  cases  of  chorea  contained  in  the  case-books  of  University  College 
Hospital  and  of  the  Hospital  for  Sick  Children  ('  Brain/  1882,  vol.  v,  p.  513).  In 
two  cases  the  patient's  father  had  suffered  from  rheumatic  fever  and  chorea  j  in 
another  both  the  father  and  the  mother  had  had  rheumatic  fever,  and  a  brother 


ETIOLOGY.  593 

Age. — Chorea  is  essentially  a  disease  of  the  later  period  of  childhood. 
Nine  tenths  of  the  cases  occur  between  5  and  20,  and  four  fifths 
between  5  and  15.  A  larger  number  of  first  attacks  (nearly  half  the 
total)  occur  between  5  and  10  than  between  10  and  15  ;  but  according 
to  my  own  observations,  if  relapses  are  included,  more  cases  occur 
between  10  and  15,  aud  the  thirteenth  year  of  life  is  that  which  presents 
the  largest  number  of  attacks.*  Under  5  the  disease  is  extremely 
rare  ;  a  few  cases  have  been  recorded  at  4,  and  one  recorded  case  (with 
endocarditis)  in  a  girl  commenced  at  the  age  of  2  years  11  months. f 
Not  more  than  5  per  cent,  of  the  total  number  of  attacks  occur  over 
20.  The  disease  is,  however,  occasionally  met  with  in  later  life, 
even  up  to  extreme  old  age.  Between  30  and  40  the  disease  is 
scarcely  ever  met  with.  Many  cases  of  senile  chorea  probably  depend 
on  a  morbid  process  different  in  nature  from  that  which  causes  the 
juvenile  form  of  the  disease,  although  similar  in  effect. 

Sex. — Chorea  affects  girls  nearly,  but  not  quite,  three  times  as  fre- 
quently as  boys.  A  combination  of  recorded  statistics  yields  365  boys 
to  1000  girls. X  The  preponderance  of  girls  is  least  in  childhood,  and 
increases  after  puberty.  The  disease  is  rare  in  lads  over  16.  Between 
20  and  30  it  is  practically  confined  to  females.  During  the  second  half 
of  life,  however,  the  rare  cases  of  chorea  occur  in  both  sexes,  and  seem 
a  distinct  variety. 

Climate  has  little  influence.  Chorea  occurs  in  warm  as  well  as  in 
temperate  countries.  The  question  of  its  relation  to  season  has 
recently  attracted  attention,  especially  in  America.  At  Philadelphia, 
Morris  Lewis  found  an  apparently  distinct  relation  to  time  of  year, 

chorea ;  in  another  the  mother  had  had  rheumatic  fever,  and  mother,  father,  and 
brother  had  had  chorea.  Great  variations  exist  in  the  proportions  of  both  rheumatic 
and  neurotic  heredity  sjiven  in  the  collection  of  cases  made  by  different  observers. 
That  of  th-e  former  has  been  thought  to  be  due  to  locality,  but  both  are  probably 
chiefly  the  result  of  the  narrowness  or  width  of  the  conceptions  applied  to  the  facts 
ascertained. 

The  special  form  of  "  hereditary  chorea "  (affecting  many  generations)  is 
separately  described  on  a  later  page. 

*  The  439  cases  tabulated  by  Dr.  S.  Mackenzie  for  the  Brit.  Med.  Assoc.  Collec- 
tive Investigation  Committee  ('  Brit.  Med.  Journal/  February  26th,  1887)  give  34 
per  cent,  (one  third)  between  five  and  ten,  43  per  cent,  between  ten  and  fifteen,  and 
16  per  cent,  between  fifteen  and  twenty;  but  unfortunately  it  is  not  stated  how 
many  were  first  attacks.  In  this  list  are  cases  at  forty,  sixty-three,  sixty-eight, 
seventy-three,  seventy-eight,  and  eighty-six.  The  facts  there  stated  agree  closely 
with  those  in  the  text,  which  have  been  furnished  by  an  extensive  and  unselected 
series  of  cases  that  have  come  under  my  own  observation. 

t  Sturges,  '  Lancet,'  1888. 

%  The  statement  in  the  text  is  based  on  the  cases  collected  by  Hughes,  See,  Pye- 
Smith,  Rufz,  Steiuer,  Wilkinson,  Sturges,  and  on  100  original  cases.  Correct  facts 
regarding  the  influence  of  age  can  only  be  ascertained  by  combining  statistics,  since 
they  are  not  fairly  represented  either  by  the  figures  obtained  from  Children's 
Hospitals,  or  by  those  from  General  Hospitals  in  towns  in  which  Children's  Hos- 
pitals exist. 

vol.  ii.  38 


594  CHOREA. 

most  cases  occurring  in  the  spring  months  ;  *  in  Boston,  however, 
Putnam  failed  to  trace  such  an  influence,  and  in  this  country  the  effect 
of  season  does  not  seem  to  be  great,  the  numbers  (of  100  attacks) 
commencing  iu  each  quarter  being— 1st,  thirty -three;  2nd,  twenty-five; 
3rd,  twenty ;  4th,  twenty-seven.  The  minimum  was  in  July  and  August. 
A  more  distinct  relation  to  season  is,  however,  occasionally  to  be  traced 
in  the  recurrences  of  the  disease  (see  p.  608).  An  occasional  special 
frequency  of  the  malady  is  often  to  be  observed,  perhaps  connected 
with  the  influence  of  weather,  but  definite  proof  of  this  is  wanting. 
In  its  study,  ihe  cases  with  neurotic  and  with  rheumatic  heredity 
should  be  separated  ;  this  influence  may  be  true  of  the  latter  only, 
and  obscured  if  all  are  taken  together,  f 

The  only  immediate  cause  of  chorea  that  can  be  traced  with  any 
frequency  is  emotion,  usually  fright,  rarely  mental  distress.  The 
proportion  of  cases  in  which  mental  emotion  can  be  traced  has  varied 
in  different  collections,  between  a  fifth  and  a  fourth.  I  have  found 
the  frequency  to  be  nearly  the  same  in  each  sex,  but  it  is  relatively 
more  common  in  boys  under  twelve,  and  is  rare  in  boys  over  fourteen, 
whereas  it  is  a  not  uncommon  excitant  of  chorea  in  girl*  up  to  twenty. 
The  interval  between  the  fright  and  the  first  symptoms  of  the  chorea 
rarely  exceeds  a  week  ;  J  it  is  about  as  frequent  for  it  to  be  one  week  as 
to  be  less  than  a  week  (three  or  five  days).  Very  rarely  the  interval 
is  only  one  day,  and  still  more  rarely  there  is  no  interval, — the  chorea 
immediately  succeeds  the  fright.  This  was  the  case  in  a  lad  in  whom 
the  movements  commenced  immediately  after  a  pistol  had  been  unex- 
pectedly discharged  close  to  his  ear.  Another  boy  was  discovered  in 
an  apple  tree,  and  fell  in  his  hasty  descent ;  he  immediately  began  to 
shake  ;  the  tremor  of  alai  m  assumed  a  choreic  character,  and  persisted 
as  chorea. 

Occasionally  the  fright,  which  was  the  cause  of  the  chorea  in  girls, 
occurred  at  the  menstrual  period,  but  such  instances  are  too  rare  for 

*  The  percentage  varied  from  4*1  per  cent,  in  October,  and  4*3  per  cent,  in 
November,  to  8"2  per  cent,  in  January,  15'3  in  March,  8'6  in  April,  10'7  in  May, 
and  10-5  in  July,  and  then  fell  gradually  to  its  lowest  point  in  October. 

f  Dr.  Morris  Lewis  instituted  an  elaborate  inquiry  with  the  object  of  ascer- 
taining whether  there  is  any  relation  between  temperature,  humidity,  or  baro- 
metric variations  and  the  occurrence  of  chorea  (compared  over  a  period  of  ten 
years),  but  he  could  find  none.  He  found,  however,  that  there  is  a  slight  corre- 
spondence with  the  average  number  of  cloudy  days  per  month,  and  also  with  the 
actual  number  of  rainy  days,  and  a  still  closer  connection  with  the  number  of  storm 
centres  passing  over  Philadelphia;  and  that  the  correspondence  became  closer  the 
wider  the  range  of  country  included  in  the  meteorological  observations,  till  an  area 
of  a  radius  of  400  miles  was  reached,  and  then  the  correspondence  between  the 
storm  curve  and  the  chorea  curve  became  still  more  close.  Comparing  the  average 
number  of  attacks  per  month  of  chorea  and  rheumatism,  the  curious  fact  was 
ascertained  that  the  variations  in  the  occurrence  of  rheumatism  corresponded  with 
those  of  chorea,  but  were  uniformly  a  month  later.     (The  '  Polyclinic,'  Jan.,  1887.) 

X  In  the  cases  in  which  many  weeks  elapse  between  the  fright  and  the  first  sym- 
ptoms, a  causal  relation  is  extremely  doubtful. 


ETIOLOGi7.  595 

any  special  significance  to  be  attached  to  the  coincidence.  Nor  is  any 
disorder  of  menstruation  to  be  recognised  with  sufficient  frequency  to 
justify  the  assumption  of  a  causal  influence.  Imitation  is  often  said 
to  be  an  occasional  cause  of  chorea  ;  the  hysterical  variety  often  arises 
thus,  but  it  is  doubtful  whether  true  ordinary  chorea  is  so  produced. 
It  should  be  noted,  however,  that  the  connection  between  some  cases 
of  apparently  hysterical  chorea  and  the  common  form  is  exceedingly 
close.  In  the  epidemics  of  chorea  that  are  occasionally  met  with 
among  children  at  the  same'  school,  for  instance,  most  cases  are  dis- 
tinctly of  the  hysterical  variety,  but  in  a  few  the  movements  may 
resemble  those  of  the  common  form. 

Chorea  sometimes  results  from  traumatic  influences,  but  it  is  pro- 
bable that  their  efficiency  depends  on  coincident  emotion.  Thus 
ohorea  has  resulted  from  a  fall  or  a  blow  on  the  head  and  from  the 
extraction  of  a  tooth,  but  it  has  also  followed  an  attempt  at  tooth- 
extraction  which  was  unsuccessful. 

Intestinal  worms  are  occasionally  present  in  choreic  patients,  and 
have  been  supposed  to  cause  the  disease.  In  extremely  rare  cases 
chorea  has  been  ascribed  to  the  irritation  of  a  peripheral  spinal  nerve. 
The  influence  of  these  reflex  causes  is  doubtful,  since  they  are  so 
seldom  met  with,  but  it  can  scarcely  be  denied. 

Chorea  is  so  rare  in  association  with  acute  specific  diseases, 
that  such  a  coincidence  is  probably  accidental ;  or,  at  most,  the 
general  disease  only  serves  to  excite  the  chorea  in  an  indirect  way. 
A  girl  sixteen  years  old  had  a  well-marked  attack  of  chorea  during 
the  course  of  typhoid,  but  she  had  suffered  from  acute  articular 
rheumatism  a  year  before.*  Toxic  influences  may  perhaps  some- 
times cause  it.  An  attack  and  relapse  seemed  clearly  the  result  of 
the  absorption  of  iodine  in  one  case ;  in  another,  severe  coincident 
multiple  neuritis  suggested  a  blood-state  of  peculiar  character. f 

Three  important  etiological  influences  remain  for*  discussion,  two 
of  which  have  given  rise  to  much  controversy, — acute  rheumatism, 
organic  heart  disease,  and  pregnancy. 

Acute  Rheumatism. — The  fact  that  a  considerable  number  of  patients 
with  chorea  have  had  acute  rheumatism  has  been  recognised  by  all 
observers  since  it  was  first  pointed  out  by  Hughes  and  by  G-.  See, 
although  the  extent  and  significance  of  the  association  have  been 
variously  estimated.  The  largest  recorded  proportion  of  cases  with  pre- 
ceding rheumatism  is  one  half.  J  In  my  own  cases  the  proportion  was 
about  one  fourth,  but  varied  at  different  ages  ;  in  only  one  case, 

*  Peiper,  '  Deut.  med.  Wochenschrift,'  1885,  No.  8. 

f  Fry,  '  Journ.  Nerv.  and  Ment.  Dis.,'  1890. 

%  Tylden,  '  St.  Bart.  Hosp.  Rep.,'  found  some  rheumatic  history,  family  or 
personal,  in  72  per  cent.  About  a  fourth  is  the  proportion  found  by  Hughes, 
two  fifths  by  See,  and  a  fourth  by  the  '  B.  M.  A.  Coll.  Invest.  Rep.'  (loc.  cit., 
p.  428).  In  the  latter  the  percentage  was  26,  and  about  the  same  in  each  sex; 
but  when  to  these  cases  are  added  those  in  which  acute  rheumatism  occurred 
during  or  after  the  chorea,  the  percentage  rises  to  32,  or  one  third,  and  another 


596  CHOREA. 

under  nine,  was  there  a  history  of  rheumatism,  while  of  53  cases 
which  occurred  between  ten  and  fifteen  years,  16,  considerably  more 
than  one  fourth,  had  suffered  from  rheumatic  fever.  This  fact  shows 
clearly  that  the  influence  of  rheumatism  will  be  under- represented 
in  statistics  collected  at  hospitals  for  children.  The  proportion,  in  later 
childhood  at  least,  is  too  large  to  be  ascribed  to  accidental  coincidence, 
and  the  close  relationship  between  the  two  diseases  is  shown  in  an 
emphatic  manner,  by  the  facts  that  not  very  rarely  chorea  immediately 
follows  acute  rheumatism,  that  the  latter  occasionally  comes  on  in  the 
course  of  chorea,  and  also  by  the  mysterious  but  unquestionable  rela- 
tion next  to  be  mentioned  between  chorea  and  disease  of  the  cardiac 
valves. 

Heart  disease  maybe  developed  during  the  course  of  chorea,  or  may 
precede  it.  The  latter  only  concerns  us  now.  Published  statistics 
afford  no  information  on  this  point,  for  no  attempt  has  been  made  to 
discriminate  between  the  two  forms.*  When  the  cardiac  disease  is 
considerable  in  amount,  and  the  chorea  of  short  duration,  and  espe 
•  •ially  if  the  walls  of  the  heart  present  evidence  of  consecutive  changes, 
we  are  justified  in  assuming  that  the  heart  disease  preceded  the  chorea, 
and  this  assumption  is  rendered  the  more  probable  if  there  has  been 
a  preceding  attack  of  rheumatic  fever.  Of  forty  cases  in  which  I 
found  evidence  of  organic  heart  disease  there  was  strong  reason  to 
believe  that  this  preceded  the  chorea  in  eighteen.  From  the  nature 
of  the  investigation,  this  proportion  is  probably  below  the  actual  facts 
(because  only  conclusive  evidence  was  admitted),  and  it  is  therefore 
probable  that  in  about  one  half  of  the  cases  in  which  organic  disease 
of  the  heart  exists,  this  preceded  the  attack  of  chorea  in  which  it  was 
evident. 

Regarding  the  combinations  of  the  three  conditions,  rheumatism, 
organic  heart  disease,  and  fright,  I  have  found  that  cardiac  disease 
was  present  (either  before  or  during  the  chorea)  in  three  quarters  of 
the  cases  in  which  there  was  a  history  of  rheumatic  fever,  while  in 
those  without  such  history  there  was  heart  disease  in  only  a  third. 
Fright  was  the  apparent  cause  of  the  chorea  in  a  rather  larger  pro- 
portion of  the  patients  who  had  had  rheumatic  fever,  or  preceding 
heart  disease,  than  of  those  who  had  not. 

Pregnancy . — Chorea  may  occur  as  a  complication  and  consequence 
of  pregnancy.  The  hysterical  form,  to  be  presently  described,  is 
sometimes  met  with,  but  as  a  rule  the  malady  corresponds  with  the 
form  met  with  in  early  life.  Some  of  the  patients  who  thus  suffer 
have  had  chorea  or  rheumatic  fever  in  childhood  or  youth,f  or  an 

14  per  cent,  had  suffered  from  vagne  rheumatic  pains.  For  other  statistics  see 
Herringham,  '  Med.-Chir.  Trans.,'  vol.  Ixxii,  and  Syers,  '  Lancet,'  1889. 

*  To  this  statement,  however,  the  '  B.  M.  A.  Collect.  Inv.  Report '  constitutes  au 
exception. 

t  Of  course  the  converse  must  not  be  assumed  ;  very  few  of  those  who  have  chorea 
in  childhood  suffer  from  it  during  pregnancy. 


ETIOLOGY.  597 

attack  of  rheumatic  fever  immediately  precedes  the  chorea.  One 
patient  had  no  chorea  during  the  first  pregnancy ;  in  the  interval 
between  the  first  and  the  second  she  had  an  attack  of  rheumatic 
fever,  and  during  the  second  she  suffered  from  chorea  (Mosler). 
But  in  the  majority  there  is  no  predisposing  influence,  except  the 
pregnancy,  to  Avhich  the  disease  can  he  ascribed.  Fright,  or  some 
other  distressing  emotion,  is  the  appai-ent  exciting  cause  of  the  dis- 
ease in  about  the  same  proportion  in  gestational  chorea  as  in  the 
chorea  of  earlier  life.  If  the  disease  has  occurred  during  one  preg- 
nancy it  may  or  may  not  occur  during  one  or  more  succeeding 
pregnancies.  It  scarcely  ever  occurs  for  the  first  time  over  twenty- 
five  years  of  age.  The  number  (28)  of  cases  occurring  at  different 
ages  is  as  follows  :  17,  three  ;  18,  three  ;  19,  three  ;  20,  eight ;  21, 
two ;  22,  two  ;  23,  six ;  24,  one.* 

In  the  recorded  cases  of  distinct  chorea  occurring  during  pregnancy 
after  twenty-four  years  of  age,  the  patients  have  suffered  from  chorea 
•during  a  previous  pregnancy.  The  disease  is  most  common  during  the 
first  pregnancy,  and  is  very  rare  after  the  second  except  as  a  recurrence. 
Of  thirty-eight  recorded  attacks,  twenty-five  were  during  the  first,  and 
ten  were  during  the  second  pregnancy,  the  first  having  been  free.  In 
two  attacks  in  the  third,  and  one  during  the  fourth  pi-egnancy,  the 
patients  had  previously  suffered  from  chorea  during  a  similar  condi- 
tion. In  the  only  recorded  casef  in  which  a  patient  is  said  to  have 
suffered  for  the  first  time  during  the  fourth  pregnancy,  it  is  doubtful 
whether  the  disease  was  really  chorea,  since  the  movements  were  con- 
fined to  the  legs. 

The  chorea  may  commence  at  any  period  of  pregnancy,  from  the 
beginning  until  near  the  close,  but  it  begins  more  frequently  in  the 
third  than  in  any  other  month,  and  very  rarely  in  the  ninth  month. 
Of  thirty-six  attacks  J  the  numbers  commencing  in  each  month  were — 
1st,  four;  2nd,  three;  3rd,  nine;  4th,  five  ;  5th,  four;  6th,  four;  7th, 
three  ;  8th,  three  ;  9th,  one.  Thus  two  thirds  of  the  attacks  commence 
before  the  end  of  the  fifth  month,  and  one  quarter  of  the  total  number 
commence  in  the  third  month.  If  chorea  recurs  during  several  preg- 
nancies, there  is  no  uniformity  in  the  date  of  its  commencement;  for 
instance,  in  one  remarkable  example  of  recurrence,  the  patient  (who 
had  had  rheumatic  fever,  followed  by  chorea  at  sixteen)  became 
choreic  in  the  fourth  month  of  her  first  pregnancy  (at  twenty-two),  in 
the  third  month  of  the  second,  at  the  commencement  of  the  third,  and 
in  the  fourth  month  of  the  fourth  pregnancy  (Lawson  Tait).     The 

*  The  figures  are  based  on  an  analysis  of  recorded  and  original  cases ;  most  of.  tbe 
former  have  been  collected  by  Barnes  ('Obstetrical  Trans./  1869),  but  some  of  his 
cases  have  not  been  included,  either  because  insufficiently  reported,  or  because  their 
nature  is  open  to  question. 

t  Levick,  '  Am.  Journal  of  Med.  Science,'  1862. 

%  In  the  statement  in  the  text  those  cases  which  have  been  recorded  as  commenc- 
ing when  the  pregnancy  had  existed  for  a  certain  number  of  months  are  considered 
as  commencing  in  the  subsequent  "  month  "  of  gestation. 


598  CHOIiEA. 

cases  apparently  excited  by  fright  show  no  difference  in  the  date  of 
their  commencement,  but  a  rather  larger  proportion  do  not  exceed 
twenty  years  of  age  than  of  the  cases  in  which  no  exciting  cause  can 
be  ti'aced.  In  one  instance  albuminuria  existed,  left  (with  a  cardiac 
murmur)  by  an  attack  of  scarlet  fever  in  the  fourth  month  of  preg- 
nancy ;  the  chorea  commenced  in  the  eighth  month  (Woodman). 

In  extremely  rare  cases,  chorea  (of  ordinary  form)  has  been  observed 
to  commence  after  delivery  or  after  abortion,  and  the  subjects  of  this 
post-puerperal  chorea  have  for  the  most  part  been  beyond  the  age  to 
which  the  chorea  of  gestation  is  chiefly  limited. 

Symptoms. — The  characteristic  symptoms  of  chorea,  the  spontaneous 
movement,  inco-oidination,  and  muscular  weakness,  are  all  present  in 
severe  cases,  and  are  often  associated  with  some  mental  failure.  In 
slight  cases  the  symptoms  may  be  combined  in  various  degrees. 

The  first  thing  to  attract  attention  is  sometimes  the  spontaneous 
twitching,  sometimes  the  interference  with  voluntary  action.  The 
spontaneous  movements  are  first  noticed  in  the  hands  or  face,  rarely 
in  the  legs,  and  so  closely  resemble  those  involuntary  actions  which 
"nervous"  children  present  under  emotion  that  they  are  often 
regarded  as  such.  The  interference  with  movement  is  rarely  at  first 
a  conspicuous  inco-ordination  ;  a  sudden  purposed  movement  is  more 
considerable  than  was  intended,  or  a  persistent  action  is  suddenly 
disturbed  by  an  unwilled  movement.  The  insubordination  of  the 
motor  centres  is  seen  also  in  the  occasional  unintended  relaxation 
of  muscles,  or  in  a  delay  of  intended  i-elaxation.  Thus  objects  which 
are  being  carried  are  suddenly  dropped,  and  in  one  lad  the  first 
indication  of  the  commencing  disease  was  that  in  throwing  a  cricket 
ball  the  fingers  relaxed  their  grasp  too  late,  and  the  ball  simply  fell 
to  the  ground.  The  spontaneous  movements  may  at  first  be  recog- 
nised only  on  close  observation,  but  as  the  disease  advances  they 
become  conspicuous  enough.  They  are  quick  and  irregular,  some- 
times complex  in  character,  and  each  movement  is  brief  in  duration. 
The  mouth  is  drawn  to  one  side  with  an  associated  movement  of  the 
lips,  the  eyes  ai*e  closed  for  a  moment.  The  fingers  are  irregularly 
extended,  the  hand  is  pronated  or  supinated,  or  the  whole  arm  is 
suddenly  extended  or  rotated,  and  these  movements  are  often  com- 
bined. In  the  legs  the  movements  are  usually  more  simple,  momen- 
tary muscular  contractions ;  they  may  cause  merely  a  slight  jerk  of 
the  body,  but,  if  considerable,  walking  and  even  standing  may  be 
seriously  interfered  with. 

The  spasmodic  movements  are  always  irregular  in  time  as  well  as 
in  character  and  degree.  At  first  thpy  are  occasional  only,  but  their 
frequency  increases  with  their  severity,  until  at  last  they  may  be  so 
continuous  and  violent  that  the  limbs  are  in  constant  movement.  The 
spasm  in  the  muscles  of  the  neck  may  cause  frequent  movement  of 
the  head  to  one  side,  and  the  eyes  may  move  with  the  head.     In  many 


SYMPTOMS.  599 

cases  the  spasm  of  the  eyeball  muscles  is  not  quite  equal,  and  momen- 
tary diplopia  results.  The  muscles  of  the  trunk  may  also  be  involved. 
When  their  affection  is  slight,  the  patient  from  time  to  time  sways  to 
one  side  while  sittiug  or  standing  ;  when  considerable,  standing  or 
sitting  is  impossible,  and  the  patient  may  even  be  thrown  out  of  bed 
by  some  violent  contortion.  The  limbs  may  be  thrown  about  with 
such  force  that  serious  bruises  result  from  their  contact  with  adjacent 
objects,  and  in  one  recorded  case  the  choreic  spasm  of  the  muscles  of 
the  jaw  was  so  violent  that  several  of  the  teeth  were  broken  (Tuck- 
well).  The  movements  are  always  increased  by  excitement,  and  by 
attempts  at  voluntary  movement,  and  are  lessened  by  repose,  physical 
and  mental.  They  almost  invariably  cease  during  sleep,  natural  or 
induced,  but  their  severity  may  prevent  sleep  for  days  together. 

Voluntary  movements  are  executed  rapidly  and  in  a  spasmodic 
manner.  This  character  seems  to  be  in  part  impressed  upon  them  by 
the  tendency  to  spasm,  in  part  to  be  the  result  of  an  attempt  to  escape 
the  disturbing  influence  by  rapidity  of  movement.  Thus  the  tono-ue 
is  protruded  suddenly  and  jerked  back  again,  or  the  hand  makes  a 
dash  at  any  object  which  it  attempts  to  grasp.  Usually,  and  always 
in  severe  cases,  the  resulting  movement  is  irregular,  partly  from  dis- 
turbing spasm,  partly  from  an  inco-ordination  which  is  not  always 
related  in  degree  to  the  amount  of  spontaneous  movement.  In  some 
cases  the  latter  may  be  slight  while  inco-ordination  is  great,  and, 
conversely,  voluntary  movement  may  be  almost  steady  although  there 
is  much  spontaneous  spasm.  Sustained  muscular  action  is  often 
impossible ;  an  object  may  be  grasped  with  firmness,  but  first  one 
finger  and  then  another  relaxes  in  spite  of  the  will. 

The  muscles  of  respiration,  especially  the  diaphragm,  frequently 
share  the  irregularity  observed  in  the  action  of  the  more  strictly 
voluntary  muscles ;  the  respirations  are  unequal ;  deep  and  shallow 
breathing  alternates,  or  deep  breaths  are  separated  by  pauses  ;  thoracic 
and  abdominal  breathing  may  alternate  irregularly.  The  heart's 
action  is  sometimes  irregular,  but  this  is  almost  always  produced  by, 
and  distinctly  consequent  on,  the  inequality  of  the  respiratory  move- 
ments. 

Besides  the  interference  with  movement  occasioned  by  spasm,  and 
inco-ordination,  there  is  usually  distinct  deficiency  of  muscular  power. 
The  degree  of  loss  of  power  may  not  be  proportioned  to  the  spasm ; 
it  may  be  considerable  when  the  latter  is  barely  recognisable.  This 
is  frequently  noticeable  at  the  onset,  but  sometimes  there  is  much 
weakness  and  scarcely  any  spasm,  a  form  which  I  have  proposed  to  call 
"  paralytic  chorea."*  There  is  never,  however,  anything  like  complete 
loss  of  power,  and  often  the  loss  of  use  of  a  limb  is  out  of  proportion 
to  the  actual  muscular  weakness. 

These  motor  symptoms  may  be  from  the  first  general,  and  throush- 
out  may  involve  both   sides  equally.     The  arms  are  almost  always 
*  '  Brit.  Med.  Journal/  April  23rd,  1881. 


600  CHOREA. 

affected  earlier  and  in  greater  degree  than  the  legs,  and  the  move- 
ments in  the  arms  are  wider  in  range  and  more  irregular  in  character. 
The  difference  that  exists  between  the  physiological  movements  of  the 
upper  and  the  lower  limbs  is  thus  reproduced  in  the  spasm.  In  at 
least  half  the  cases,  however,  the  affection  of  the  two  sides  is  not 
equal.  It  may  be  throughout  limited  to  one  side  (herni chorea),  or 
it  may  affect  one  side  first,  and  afterwards  the  other.  In  the  latter 
cases  it  may  continue  on  tbe  side  first  affected  when  the  other  is 
involved,  unilateral  chorea  thus  becoming  general;  or  it  may  cease  on 
the  first,  when  it  passes  to  the  other.  The  cases  in  which  it  is  limited 
to  one  side  present  considerable  vai'iety  in  the  area  affected :  the 
movements  may  involve  the  arm  only,  the  leg  escaping  ;  they  may  affect 
the  arm  and  leg  on  the  same  side,  or  one  arm  and  both  legs,  the  other 
ai*m  remaining  free  and  the  leg  on  the  side  of  the  unaffected  arm 
being  usually  less  involved  than  the  other.  These  variations  in  the 
distribution  of  partial  chorea  correspond  closely  to  the  distribution  of 
partial  convulsive  seizures.  There  seems  to  be  no  difference  in  the 
frequency  with  which  the  right  or  the  left  side  is  the  seat  of  hemi- 
chorea,  or  is  affected  most  or  first  in  general  chorea.  No  relation  can 
be  traced  between  the  presence  of  heart  disease,  or  the  influence  of 
fright,  in  causing  the  disease,  and  the  side  affected.  Of  sixty-four 
cases  I  find  the  total  numbers  nearly  equal  for  each  side : 


One  side  only 
One  side  first 
One  side  most 


The  electric  irritability  of  the  muscles  and  nerves  can  only  be 
thoroughly  studied  in  cases  of  hemichorea  in  which  the  unaffected 
limbs  are  available  for  comparison.  Sometimes  no  alteration  of 
irritability  can  be  discovered.  But  in  other  cases  a  distinct  increase 
of  irritability  may  be  found  in  nerve  and  muscle  to  both  faradism 
and  voltaism,*  the  difference  amounting  to  one  or  two  centimetres  of 
the  secondary  coil  of  a  farad ic  apparatus,  or  two  to  four  cells  of  a 
voltaic  battery.  I  have  observed  this  iucrease  of  irritability  to  be 
absent  at  the  commencement,  to  come  on  during  the  course  of  the 
disease,  and  to  subside  with  recovery.  A  "qualitative"  change  in 
the  mode  of  response  to  voltaism  has  also  been  described,  instead  of 
the  contraction  on  closure  of  the  circuit,  occurring  at  the  negative 
pole  with  a  weaker  current  than  at  the  positive,  the  latter  may  occur 
as  readily  as  the  former  (i.  e.  instead  of  1  K.C.C.,  2  A.C.C.,  we  have 
KC.C.  =AC.C). 

Speech  is  often  impaired  in  chorea.  The  movements  of  the  muscles 
of  articulation  are  disturbed  just  as  those  of  other  voluntary  muscles. 

*  I  have  observed  this  in  several  cases,  and  it  has  also  been  noted  by  Benedikt, 
Rosenthal,  and  Schmitt. 


iglit. 

Left. 

11 

13 

10 

10 

10 

10 

31 

33  =  64. 

SYMPTOMS.  601 

Irregularity  of  movement  of  the  vocal  cords  lias  been  observed  with 
the  laryngoscope  (v.  Ziemssen),  while  the  disturbance  of  respiration 
further  deranges  utterance.  Words  are  uttered  quickly,  just  as 
voluntary  movements  are  performed  quickly  ;  speech  is  interrupted 
by  sudden,  deep  inspirations,  which  often  cut  off  the  last  syllables  of 
a  word.  Sometimes  the  words  are  jerked  out  in  separated  parts. 
Actual  stammering.is  rare,  but  I  have  met  with  one  case  in  which  it 
preceded  the  other  symptoms.  In  severe  cases  the  interference  with 
articulation  may  be  very  great ;  the  spasm  in  the  muscles  of  the  mouth 
and  tongue  on  any  attempt  at  articulation  may  render  it  impossible 
for  weeks  for  the  patient  to  utter  a  single  word.  There  is  often  a 
disinclination  to  speak  (due  to  the  conscious  difficulty,  and  partly 
perhaps  to  the  mental  state  presently  to  be  described)  in  addition  to 
the  actual  interference  with  articulation. 

Sensibility  is,  as  a  rule,  unaffected.  In  extremely  rare  cases, 
unilateral  diminution  or  increase  of  sensibility,  sometimes  involving 
the  special  senses,  has  been  observed.  Such  disturbance  is  probably 
allied  to  that  met  with  in  hysteria,  and  is  certainly  no  part  of  the 
•ordinary  symptoms  of  chorea.  Tender  points  along  the  spine  or 
along  the  course  of  the  nerves  (especially  where  these  emerge  from 
deeper  structures)  have  rarely  been  observed  (Cartier),  and  may 
have  been  due  to  a  slight  degree  of  the  multiple  neuritis  which  has 
been  met  with,  in  severe  form,  as  a  complication. 

Chorea  is,  as  a  rule,  a  painless  disease.  The  muscular  spasm  may 
cause  fatigue,  but  occasions  no  sensation  of  pain.  I  have  met  with 
only  two  cases  in  which  there  was  pain  in  the  limbs  at  tbe  onset. 
One  patient,  a  girl,  complained  of  pain  in  the  left  hand,  which 
gradually,  in  the  course  of  a  few  hours,  passed  up  the  arm  to  the 
side  of  the  head,  and  three  days  after  was  felt  in  the  leg.  The 
choreic  movements  commenced  in  each  limb  at  the  same  time  as  the 
pain.  The  disease  afterwards  became  general  without  any  pain  in 
the  other  side.  There  was  no  affection  of  the  heart.  In  the  other 
case,  also  a  girl,  intermittent  neuralgic  pains  in  face,  arm,  and  leg 
occurred  for  some  weeks  before  the  onset  of  right-sided  chorea. 
The  latter  was  accompanied  by  some  hysterical  hemiangesthesia. 

The  pupils  are  often  large,  but  it  is  doubtful  whether  this  character 
is  connected  with  the  disease.  Once  I  observed  inequality  of  the 
pupils,  the  larger  being  on  the  side  opposite  to  the  limbs  most  affected. 

The  mental  state,  in  slight  cases  of  chorea,  may  be  normal,  but  in 
severe  cases  there  is  usually  some  irritability  and  often  distinct  mental 
dulness.  The  degree  of  change  does  not  bear  any  relation  to  the 
severity  of  the  other  symptoms.  The  mental  dulness  is  usually  con- 
spicuous in  the  patient's  aspect,  and  may  amount  to  practical  dementia, 
so  that  stools  and  urine  may  be  passed  into  the  bed,  not  from  para- 
lysis of  the  sphincters,  but  from  mental  apathy.  In  other  cases  the 
irritability  may  pass  into  excitement,  the  mind  seems  to  share  the 
disturbance  so   conspicuous   in   the   muscles,  and  there   is   excited 


602  CHOREA. 

delirium,  which,  in  its  restlessness  and  delusions,  may  resemble  mania, 
and  in  some  cases  must  be  regarded  as  such.  In  some  of  these  cases 
the  physical  symptoms  are  trifling  compared  with  the  mental  dis- 
turbance. 

Symptoms  outside  the  Nervous  System,. — The  temperature  in  slight 
cases  is  normal  throughout,  but  in  severe  forms  it  may  be  raised  one 
or  two  degrees.  Even  in  these  it  rarely  reaches,  and  still  more  rarely 
exceeds,  102°  P.  I  have  once  observed  occasional  elevation  of  tempe- 
rature from  time  to  time,  during  a  prolonged  attack,  without  any 
complications  or  endocarditis  to  which  it  could  be  referred.*  Hyper- 
pyrexia occurs  in  rare  cases,  probably  as  a  rheumatic  complication  in 
most  instances,  but  in  uncomplicated  acute  chorea  a  rise  to  105°  has 
been  observed  before  death.  The  patients  are  often  previously  anaemic, 
or  they  become  pale  and  lose  weight  rapidly  during  the  course  of  the 
disease,  especially  if  this  is  so  severe  as  to  interfere  with  sleep. 

Heart. — The  cardiac  symptoms  are  of  great  importance.  The  pulse, 
as  already  stated,  may  be  irregular  in  consequence  of  the  irregularity 
of  the  breathing.  It  is  usually  increased  in  frequency.  I  have 
several  times  noted  that  the  effect  of  posture  on  the  pulse  is  less  than 
in  health  ;  the  pulse-rate  may  be  nearly  or  quite  the  same  in  the 
upright  and  the  recumbent  postures.  In  some  cases  the  sounds  and 
impulse  of  the  heart  are  normal.  More  frequently  there  is  some 
abnormality.  (1)  There  may  be  murmurs,  due  to  the  anemia,  in  the 
pulmonary  artery  and  aorta,  often  associated  with  a  venous  hum  in 
the  jugular  vein.  Sometimes  the  systolic  murmur  at  the  base  is  con- 
tinuous with  one  heard  over  both  ventricles,  having  its  maximum  at 
the  inner  end  of  the  fourth  intercostal  space,  heard  up  to  but  not 
beyond  the  left  apex,  and  probably  produced  in  the  ventricles,  in  con- 
sequence of  the  blood-state.  With  this  there  may  be  such  a  change 
in  the  character  of  the  impulse  as  indicates  slight  dilatation  of  the 
heart  consequent  on  the  anaemia.  (2)  There  may  be  a  faint  systolic 
murmur  at  the  apex  of  the  heart,  heard  with  some  beats  and  not  with 
others ;  this  is  commonly  said  to  be  due  to  irregular  contraction  of 
the  papillary  muscles,  which  sometimes  fail  to  compensate  for  the 
shortening  of  the  ventricle,  and  thus  permit  occasional  regurgitation 
— a  mechanism  that  cau  neither  be  proved  nor  disproved.  (3)  In  a 
considerable  number  of  cases  there  is  distinct  evidence  of  an  organic 
valvular  lesion.  The  frequency  of  organic  disease  is  less  in  childhood 
than  in  youth,  f  and  hence  has  been  variously  estimated  by  different 
observers,  according  to  the  class  of  cases  which  have  come  under  their 
notice. 

*  In  the  '  Collect.  Invest.'  cases,  pyrexia  was  noted  in  only  12  per  cent.,  but  it  is- 
probable  that  this  only  represents  the  frequency  of  such  considerable  and  prolonged 
pyrexia  as  would  attract  attention. 

+  This  statement  is  at  variance  with  the  opinion  of  others,  by  whom,  for  the  most 
part,  "heart  symptoms"  of  hsemic,  dynamic,  and  organic  origin  have  not  been 
properly  distinguished. 


SYMPTOxMS.  .  (J03 

In  some  cases  with  organic  disease  there  is  good  reason  to  believe 
that  the  heart  disease  preceded  the  chorea  (see  ante,  p.  595) ;  iu  other 
cases  the  true  relation  between  the  two  is  doubtful ;  in  other  cases 
again  the  organic  murmur  may  be  observed  to  develop  durino-  the 
course  of  the  disease — an  indication  of  endocarditis  which,  as  will  be 
seen,  pathology  amply  confirms  ;  in  nine  out  of  every  ten  fatal  cases 
the  cardiac  valves  are  diseased.  Hence  it  is  of  great  importance  that 
the  heart  should  be  examined  repeatedly  during  the  course  of  the 
disease,  and  also  after  its  termination,  but  it  must  be  remembered  that 
endocarditis  may  exist  when  no  murmur  can  be  heard.  Preceding- 
valvular  disease  is  most  frequently  mitral  regurgitation  ;  occasionally 
there  is  mitral  constriction  alone  or  combined  with  regurgitation.  Aortic 
disease  is  much  less  common ;  I  have  only  met  with  two  instances  of 
aortic  regurgitation  among  about  250  cases  of  chorea  that  have  come 
under  my  observation.  In  one  case  there  was  an  aortic  obstructive 
murmur,  musical  in  tone,  combined  with  mitral  regurgitation.*  In 
the  cases  in  which  the  relation  of  the  disease  to  the  chorea  is  doubtful, 
or  in  which  the  heart  is  affected  during  the  chorea,  the  lesion  is  almost 
always  mitral  regurgitation.  The  frequency  of  a  haemic  murmur  at  the 
aortic  orifice  renders  it  almost  impossible  to  recognise  the  development 
of  an  organic  obstructive  murmur  during  chorea,  but  its  occurrence 
was  probable  in  a  case  in  which  I  found,  at  a  second  attack  of  chorea, 
unquestionable  evidence  of  aortic  obstruction  which  was  absent  in  the 
first  attack,  the  patient  having  had  in  the  interval  no  rheumatic  fever. 
Post  mortem,  endocarditis  has  been  found  at  the  aortic  as  well  as  at 
the  mitral  orifice.  A  murmur  due  to  mitral  regurgitation  usually 
persists  after  the  chorea  has  ceased,  but  may  afterwards  pass  away, 
sometimes  to  be  succeeded  by  evidence  of  obstruction  as  the  altered 
orifice  contracts.  In  a  prolonged  case,  however,  I  have  known  a 
murmur,  certainly  mitral,  to  cease  before  the  movements. 

The  urine  in  chorea  contains  an  excess  of  urea  and  of  phosphates 
(Walsh e,  Haudfielcl  Jones,  and  others)  bearing  a  general  proportion 
to  the  severity  of  the  attack.  Albumen  is  present  only  from  independ- 
ent kidney  disease  or  renal  embolism.  The  peculiar  pigment  "  uro- 
hseniatoporphyrin,"  discovered  by  McMunn  in  cases  of  rheumatism, 
has  been  found  also  in  chorea  by  A.  E.  Garrod,  who  has  pointed  out 
that  it  is  additional  evidence  of  the  connection  between  the  two 
maladies,  since  it  is  absent  in  other  nervous  diseases. 

Complications. — Endocarditis  is  so  common  in  chorea  that  it  can 
scarcely  be  regarded  as  a  complication.     It  is  usual ly  of  a  benign  form, 

*  In  the  '  Brit.  Med.  Ass.  Collect.  Inv.'  there  were  116  eases  of  pure  mitral  disease 
and  only  six  of  pure  aortic  disease.  Unfortunately  the  facts  regarding  heart  disease 
and  chorea  are  given  in  so  condensed  a  form  in  the  Report  that  it  is  difficult  to 
draw  any  general  conclusion  from  them.  Distinct  organic  disease,  either  preceding 
or  secondary,  was  found  in  32  per  cent,  of  the  cases.  But  the  difficulty  of  deciding 
whether  there  is  or  is  not  organic  disease  is  often  very  great,  ami  the  large  number 
of  observers  entails  considerable  uncertainty  as  to  the  value  of  the  statistics  dn  this- 
point. 


<304  CHOREA. 

and  causes  no  subjective  symptoms,  although  it  may  lead  to  permanent 
valvular  disease.  Occasionally  its  existence  is  emphasised  by  the  occur- 
rence of  embolism.  I  have  seen  hemiplegia  from  embolic  softening  of 
the  brain  occur  during  the  course  of  chorea ;  a  similar  consequence 
of  endocarditis  distinctly  oi'iginating  during  an  attack  of  chorea  has 
been  recorded  by  others.  Embolism  of  the  central  artery  of  the 
retina  has  also  occurred  during  an  attack.*  It  is  exceedingly  rare 
for  the  endocarditis  to  assume  the  more  malignant  type  of  the 
"  ulcerative  "  form,  and  the  condition  is  met  with  only  after  child- 
hood, in  the  subjects  of  preceding  valvular  disease.  In  the  only  in- 
stance of  this  dangerous  complication  that  has  come  under  my  notice 
the  patient  was  also  suffering  from  Bright's  disease,  but  died  from 
the  septic  embolic  processes. 

Acute  articular  rheumatism  may  not  only  immediately  precede 
cborea,  but  may  come  on  during  the  course  of  the  disease  without  any 
distinct  exciting  cause.  It  is  usually  attended  with  moderate  elevation 
of  temperature,  is  trifling  in  severity,  and  brief  in  duration.  Evidence 
of  fresh  endocarditis  may  sometimes  be  detected  during  the  course  of 
the  rheumatism.  In  some  patients  there  may  be  found  the  small 
subcutaneous  nodules,  varying  in  size  from  that  of  a  pin's  head  to 
that  of  a  pea,  met  with  also  in  those  who  are  liable  to  rheumatism.f 
They  may  be  felt  not  only  beneath  the  skin,  especially  of  the  arms, 
but  also  on  the  tendons,  especially  of  the  flexors  of  the  fingers,  and 
the  peroneal  muscles  of  the  hands.  They  have  been  observed  to  come 
on  with  the  chorea  and  pass  away  with  it.  J 

In  most  cases  of  chorea  the  ophthalmoscopic  appearances  are  those 
of  health.  In  a  few  there  is  optic  neuritis,  usually  slight  in  degree, 
just  enough  to  be  unequivocal.  It  passes  away  when  the  chorea  is 
over.  In  only  one  case  have  I  seen  considerable  neuritis,  comparable  to 
that  seen  in  a  case  of  tumour  ;  the  inflammation  passed  entirely  away 
with  the  chorea.  It  is  probable  that  the  neuritis  is  related  to  the 
cause  of  the  chorea  rather  than  directly  to  the  morbid  process  in 
the  brain.  Many  of  the  patients  had  considerable  hypermetropia,  and 
it  is  known  that  this  condition  disj>oses  to  slight  neuritic  changes  in 
the  discs,  and  may  aid  other  influences  in  leading  to  the  change ;  it 
cannot  be  the  sole  cause,  because  the  discs  resume  their  normal  aspect 
without  any  ti-eatment  of  the  hypermetropia.  The  rare  ulcerative 
endocarditis  may  be  accompanied  by  the  characteristic  minute  retinal 
haemorrhages  due  to  micrococcal  embolism. 

Convulsive  attacks  of  any  form  are  more  rare  than  might  have  been 
anticipated  from  the   spasmodic   nature  of  the  affection.      In  one 

*  Syra,  '  Edin.  Med.  Journal,5  1888. 

t  They  were  fh-st  observed  by  Meynet  ('  Lyons  Medical/  1875,  No.  49).  Tbe  most 
important  articles  on  the  subject  are  by  Barlow  and  Warner,  •  Trans.  International 
Med.  Congi  ess,'  1881,  vol.  iv,  p.  116,  ami  by  Hirschsprung,  '  Jahrb.  fur  Kinderheilk.,' 
March,  1881. 

X  Sheele,  '  Deut.  med.  Wochenschrift.'  1885,  No.  41,  who  observed  that  the 
development  of  the  nodules  was  accompanied  by  transient  contracture  of  the  flexors. 


SYMPTOMS.  605 

case,  in  which  the  choreic  movements  were  most  severe,  occasional 
attacks  occurred  in  which  there  were  apparent  loss  of  consciousness 
and  peculiar  convulsions,  partly  choreic  in  form.  In  one,  for  instance, 
the  head  turned  to  the  right,  the  right  arm  and  leg  presented  violent 
choreic  movements,  while  the  left  was  stretched  out,  the  fingers 
extended,  the  thumb  inverted,  and  the  whole  limb  in  a  state  of  cata- 
leptic rigidity,  so  that  it  remained  in  whatever  position  it  was  placed. 
The  attack  lasted  two  minutes.  In  another  attack  there  was  some 
arching  of  the  back  and  tonic  flexor  spasm  in  the  arms,  followed  by 
violent  choreic  movement  in  the  right  arm.  Such,  attacks  occurred 
daily  for  three  weeks.*  Epileptiform  convulsions  are  very  rare.  In 
one  case  of  chorea  in  a  boy  of  twelve,  greater  on  the  right  side,  four 
convulsive  attacks,  limited  to  this  side,  occurred  during  the  fortnight 
after  the  cessation  of  the  chorea,  and  similar  attacks  afterwards  per- 
sisted as  chronic  epilepsy.  There  was  no  cardiac  murmur.  I  have  met 
with  a  few  other  cases  in  which  epilepsy  dated  from  an  attack  of  chorea. 

Persistent  spasm  is  also  occasionally  met  with.  In  a  young  child 
there  was  continuous  spasm  in  the  arm  during  the  attack,  which  was 
one  of  true  chorea.  The  elbow-  and  wrist-joints  were  flexed,  and  the 
aspect  of  the  limb  was  similar  to  that  seen  after  infantile  hemiplegia. 
The  choreic  movements  were  present  in  the  arm,  although  in  much 
less  degree  than  in  the  other  limbs.  As  the  child  recovered  the  per- 
sistent spasm  lessened,  and  the  movements  in  the  limb  became  greater. 
Similar  spasm  had  been  present  in  a  previous  attack.  Transient 
rigidity  of  the  neck  was  present  in  one  recorded  case,  and  in  another 
there  was,  for  a  time,  rigidity  of  the  legs,  with  foot-clonus. f 

The  cases  in  which  the  mental  disturbance  is  very  great  have  been 
termed  maniacal  chorea,  or  chorea  insaniens.  The  form  occurs  chiefly 
in  females,  at  or  soon  after  puberty,  or  during  pregnancy.  The  mental 
disturbance  may  not  come  on  until  the  disease  is  well  developed,  or  it 
may  precede  the  chorea.  Thus  either  the  mania  or  the  chorea  may  be 
primary.  In  the  latter,  the  movements  may  be  severe  or  slight ;  they 
may  even  cease  while  the  mental  disturbance  continues  in  intense 
form,  or  both  may  continue.  If  the  attack  of  chorea  is  acute  and 
severe,  there  is  often  considerable  elevation  of  temperature,  and 
much  danger  to  life.  In  less  severe  cases  there  are  often  delusions, 
and  sometimes  wild  violent  excitement,  but  rarely  the  intense  garrulity 
so  common  in  ordinary  mania.  The  excitement  usually  subsides  in 
the  course  of  a  week  or  two,  and  leaves  dulness  and  apathy,  with  a 
depressed  listless  look,  disinclination  to  speak,  and  sometimes  persist- 
ent hallucinations.  Food  has  often  to  be  administered  by  the  rectum 
or  by  force,  and  stools  and  urine  are  commonly  passed  unnoticed. 
This  condition  usually  slowly  passes  away,  but  occasionally  persists 

*  I  have  given  fuller  details  of  these  attacks  in  '  Epilepsy,  &c.,'  1881,  p.  181. 
Similar  paroxysms  of  choreiform  spasm  occurred  in  a  case  described  by  Mitchell  and 
Barr  ('  Journ.  of  Nerv.  and  Ment.  Di3./  1891). 

f  Mitchell  and  Barr. 


606  CHOEEA. - 

for  weeks  or  even  for  months  after  the  chorea  has  ceased,  and  it  may 
even  be  permanent.  In  one  case,  recorded  by  Golgi,  there  was  no 
improvement,  but  slowly  increasing  mental  failure,  until  death  ten 
years  later.  A  similar  sequel  has  been  observed  to  maniacal  chorea 
occurring  during  pregnancy. 

The  cases  in  which  loss  of  use  of  a  limb  is  the  only  conspicuous  sym- 
ptom, ''paralytic  chorea,"  occur  only  in  childhood,  and  affect  chiefly 
the  arms,  one  always  more  than  the  other.  Slight  twitchings  may 
occur  at  the  onset  and  cease,  the  weakness  remaining.  More  com- 
monly the  loss  of  power  is  the  first  symptom,  and  it  may  persist  or 
even  lessen  as  the  movements  develop.  Rarely  there  is  considerable 
weakness  of  the  legs  for  a  time. 

Duration. — Few  diseases  are  so  variable  in  duration  as  chorea. 
It  usually  lasts  from  six  weeks  to  six  months.  It  rarely  falls  short 
of  the  earlier  limit,  but  I  have  known  the  disease  in  one  or  two 
instances  to  last  only  three  weeks.  On  the  other  hand,  the  limit  of 
six  months  is  frequently  exceeded.  The  average  duration  has  been 
found  by  more  than  one  observer  to  be  ten  weeks.*  This  is,  however, 
true  only  of  cases  which  are  admitted  into  hospitals  before  they  have 
lasted  for  a  considerable  time.  At  the  National  Hospital  for  the 
Paralysed  and  Epileptic,  to  which  choreic  patients  are  often  brought 
as  a  last  resort,  I  have  met  with  no  less  than  fifteen  cases  in  which 
the  duration  exceeded  six  months,  and  seven  in  which  it  exceeded  a 
year.  Occasionally  a  slight  degree  of  chorea  persists  for  a  much 
longer  time,  and  I  have  seen  cases  in  which  it  has  continued  for  two. 
three,  four,  and  even  six  years,  without  any  comjDlete  intermission. 
In  most  of  these  cases  of  very  long  duration,  however,  thei'e  are  occa- 
sional remissions  of  the  disease,  so  that  the  prolonged  course  is  rather 
a  series  of  relapses,  with  imperfect  recovery  in  the  intervals.  In 
extremely  rare  instances  the  disease  never  ceases.  A  patient  was 
attacked  with  chorea  in  youth,  and  the  disease  continued  until  death 
at  the  age  of  sixty-six. f  A  girl  was  attacked  with  chorea  at  the  age 
of  nine,  and  the  movements  continued  and  were  still  present  at  the 
age  of  fifty. J  As  a  rule,  the  more  severe  an  attack,  the  longer  is  its 
duration,  but  the  influences  which  determine  either  severity  or  dura- 
tion are  very  obscure.  I  have  been  unable,  on  a  comparison  of  the 
details  of  cases,  to  discover  any  relatiou  between  duration  and  age, 
sex,  state  of  heart,  preceding  rheumatic  fever,  or  exciting  cause. 

*  From  the  tables  given  in  the  '  Coll.  Invest.  Report '  I  have  calculated  the  fol- 
lowing percentages  of  the  duration  of  396  cases  :— Not  exceeding  one  month,  18  per 
cent. ;  between  one  and  three  months,  57  per  cent. ;  over  three  months,  25  per  cent.; 
only  6  per  cent,  exceeded  three  months.  The  percentage  is  nearly  the  same  for 
each  sex.  (The  calculation  is  made  on  the  assumption  that  the  cases  in  which  the 
duration  is  [for  instance]  three  months  are  given  in  the  column  headed  "  under  three 
months,"  which  is  probable  from  the  way  the  table  runs,  although  inconsistent  with 
its  wording.) 

f  Meldner,  '  Wochenbl.  der  Gesellsch.  der  wiener  Aerzte/  1869,  No.  19. 

X  Macdougal, '  Lancet/  18S5,  No.  17. 


SYMPTOMS.  tf07 

Recurrence. — Chorea  is  a  disease  prone  to  recur.  In  how  many- 
cases  it  again  attacks  an  individual  can  only  be  approximately  deter- 
mined, since  the  subsequent  history  of  mauy  patients  is  unknown. 
In  the  series  of  original  cases  that  I  have  analysed,  one  third  suffered 
from  more  than  one  attack.  Fifteen  patients  had  more  than  two 
attacks,  viz.  nine,  three  attacks ;  one,  four ;  three,  five ;  one,  six .; 
and  one  no  less  than  nine  separate  attacks.  Females  are  more  liable 
to  relapse  than  males,  just  as  they  are  more  prone  to  chorea ;  the 
proportion  of  the  sexes  in  second  attacks,  however,  is  nearly  the  same 
as  in  first  attacks,  but  in  the  cases  in  which  more  than  two  occur  the 
predisposing  influence  of  sex  is  very  strong,  the  proportion  of  males 
being  much  below  the  average,  while  almost  all  patients  who  have  more 
than  three  attacks  are  of  the  female  sex.  The  disease  very  seldom 
recurs  between  eighteen  and  thirty,  except  in  connection  with  preg- 
nancy. 

Preceding  rheumatic  fever  seems  to  have  no  influence  on  recurrence. 
I  have  found  a  history  of  it  in  precisely  the  same  proportion  of  the 
cases  that  recurred  as  in  the  whole  series.  Organic  heart  disease  is 
unquestionably  more  frequently  present  in  recurrences  than  in  first 
attacks.  It  was  distinct  in  one  half  of  the  cases  in  which  the  attack 
was  the  second  or  the  third,  and  in  all  the  cases  in  which  the  number 
of  attacks  exceeded  three.  This  might,  indeed,  be  expected  from  the 
fact  that  endocarditis  often  occurs  in  chorea  without  other  discoverable 
cause  ;  the  more  attacks  of  chorea  a  patient  has  had,  the  greater  will 
be  the  probability  of  consecutive  heart  disease.  The  same  conclusion 
that  the  organic  heart  disease  is,  for  the  most  part,  the  result  of  the 
repeated  attacks,  is  also  shown  by  the  fact,  mentioned  above,  that  a 
history  of  rheumatic  fever  is  not  more  frequent  in  recurrences,  and  also 
by  the  not  infrequent  cases  in  which,  during  a  first  attack,  there  is  no 
distinct  evidence  of  valvular  disease,  but  in  which,  at  the  second 
attack,  such  disease  is  unmistakable,  although  there  has  been  no 
rheumatic  fever  in  the  interval. 

The  interval  between  the  termination  of  the  first  and  commencement 
of  the  second  attack  of  chorea  varies  from  a  few  weeks  to  two  or  three 
years.  It  is  rarely  less  than  two  months  or  more  than  two  years. 
The  average  interval  is  about  one  year.  In  only  one  third  of  my 
own  cases  was  the  interval  more  than  a  year,  and  in  only  two  did  it 
exceed  a  year  and  a  half.  If,  therefore,  a  patient  has  remained  well 
for  eighteen  months  after  the  chorea  is  over,  it  is  improbable 
that  another  attack  will  occur.  The  intervals  between  subsequent 
recurrences  present  similar  variations.  In  one  case,  however  a 
third  attack  commenced  only  two  weeks  after  the  termination  of  the 
second.  The  intervals  usually  vary  much  in  the  same  patient,  and,  as 
a  rule,  there  is  no  uniformity  in  the  time  of  year  at  which  the  recur- 
rence occurs.  Eemarkable  exceptions,  however,  are  occasionally 
met  with,  which  are  of  considerable  interest  in  connection  with  the 
relation  of  chorea  to  season.     One  girl  first  suffered  from  chorea 


608  CHOREA. 

at  nine  years  old.  The  attack  commenced  in  October,  and  lasted 
four  months.  Every  autumn,  for  the  next  six  years,  she  became 
choreic,  and  remained  so  until  the  middle  or  end  of  winter.  Her 
eighth  attack,  however,  began  in  May,  and  in  it  (at  the  age  of  seven- 
teen) she  came  under  my  care,  and  presented  the  characteristic  signs 
of  mitral  constriction,  although  she  had  never  had  rheumatism :  the 
attack  lasted  four  months.  The  following  year  a  ninth  attack  com- 
menced in  June ;  it  was  the  shortest  of  all,  lasting  only  a  month,  and 
has,  I  believe,  been  followed  by  no  recurrence.  Another  girl  was 
attacked  with  chorea  at  seven,  after  distress  at  the  death  of  her  mother, 
and  in  each  of  the  next  five  years,  chorea  came  on  in  late  spring  or 
early  summer,  and  lasted  for  three  or  four  months.  I  saw  the  sixth 
attack,  which  commenced  in  May.  There  was  a  loud  mitral  regurgi- 
tant murmur,  and  she  also  had  never  had  rheumatic  fever. 

Fright  is  to  be  traced  as  a  cause  of  recurrence  in  at  least  as  large  a 
proportion  as  of  first  attacks.  One  girl,  for  instance,  had  attacks 
at  15,  17,  17^,  and  18,  all  of  which  were  apparently  excited  by 
fright.  The  attack  at  17^  commenced  the  morning  after  she  had 
been  frightened  by  a  severe  thunderstorm ;  the  last  attack  began  a 
week  after  she  had  been  much  startled  by  the  touch  of  an  unseen 
person  when  she  thought  she  was  alone.  On  the  other  hand,  in  the 
case  in  which  there  were  nine  attacks  related  to  season,  not  one  was 
excited  by  fright.  In  the  girl  who  had  six  attacks,  the  first  five 
occurred  without  an  exciting  cause ;  the  sixth  commenced  a  few 
hours  after  a  sudden  alarm. 

The  course  of  the  affection  in  successive  recurrences,  and  the  side 
affected  first  or  chiefly,  present  no  uniformity.  In  exceptional  cases 
the  commencement  is  on  the  same  side  in  every  attack.  Thus,  in  one 
patient  four  successive  attacks  began,  and  were  more  severe,  on  the  left 
side.  In  the  patient  who  had  nine  attacks,  the  first  seven,  which  occurred 
in  winter,  affected  the  right  side  chiefly,  but  in  the  eighth  and  ninth 
attacks,  which  occurred  in  summer,  the  left  side  suffered  most.  The 
symptoms  of  the  recurrent  disease  are  similar  to  those  of  first  attacks, 
but  its  degree  is  often  slighter  and  its  duration  shorter.  In  this  respect, 
as  in  most  others,  chorea  shows  its  characteristic  variability  ;  relapses 
are  occasionally  most  severe.  A  lad  had  attacks  of  chorea  at  five  and 
seven,  each  lasting  three  months ;  and  at  ten,  without  exciting  cause,  a 
third  attack  came  on,  of  great  severity,  which  lasted,  varying  in  inten- 
sity, for  more  than  twelve  months,  in  spite  of  most  careful  treatment. 
In  this  case  there  was  no  organic  heart  disease,  but  I.have  more  than 
once  observed  distinct  signs  of  endocarditis  to  come  on  during  a  recur- 
rence, at  the  onset  of  which  the  heart  was  healthy. 

Termination  and  Sequdee. — The  vast  majority  of  the  cases  terminate 
in  recovery.  The  movements  gradually  lessen  in  severity,  until  at  last 
they  are  to  be  observed  only  in  moments  of  emotional  excitement,  and 
finally  they  disappear.  Usually  inco-ordination  ceases,  and  any  weak- 
ness passes  away,  before  the  spontaneous  spasm  has  entirely  vanished.. 


SYMPTOMS.  609 

The  final  disappearance  is  often  extremely  gradual,  and  slight  occa- 
sional movements  may  be  discerned,  if  carefully  looked  for,  long  after 
the  patient  is  practically  well. 

In  very  rare  cases  considerable  muscular  weakness,  general  or 
local,  may  succeed  chorea.  It  is  a  post-cboreic  paralysis.  The  loss 
of  power  is  sometimes  very  great.  There  is  no  change  in  muscular 
irritability,  but  there  is,  in  some  cases,  impairment  of  sensibility. 
It  is  perhaps  analogous  to  the  mental  weakness  which  sometimes 
succeeds  chorea,  and,  like  it,  always  passes  away  in  the  course  of  a 
few  weeks. 

Occasionally  the  disease  leaves  behind  it,  for  a  time,  a  liability  to 
sudden  starts  of  the  limbs,  similar  to  those  which  many  persons 
experience  on  going  to  sleep.  In  one  child  they  were  troublesome 
for  many  months.  A  sudden  start  in  the  legs  would  throw  her 
down,  and  once  the  start  was  such  as  to  make  her  jump  into  an  open 
cellar,  at  the  edge  of  which  she  was  standing.  The  fact  that  epilepsy 
is  a  rare  sequel  to  chorea  has  been  already  mentioned. 

When  the  chorea  is  attended  by  considerable  mental  disturbance, 
this  may  continue,  as  dulness  or  delusions,  for  some  weeks  after  the 
motor  phenomena  are  at  an  end.  Rarely  the  mental  derangemeut 
persists  as  a  chronic  affection  for  months  or  years,  but  it  gradually 
passes  away. 

"We  have  seen  already  that  juvenile  chorea,  in  extremely  rare 
cases,  instead  of  ceasing,  persists,  in  more  or  less  severity,  as  a 
chronic  disease,  in  spite  of  all  treatment.  In  the  case  mentioned, 
in  which  the  chorea  commenced  immediately  after  the  discharge 
of  a  pistol  near  the  ear,  the  disease  had  lasted  for  three  years  when 
the  patient  came  under  treatment,  and  it  was  still  present  when  he 
passed  from  observation  six  months  later.  Adults  are  sometimes 
seen  in  the  streets  presenting  all  tbe  characteristics  of  severe  chorea,, 
but  following  their  avocations  in  a  way  which  shows  that  the  condition 
is  one  to  which  they  have  become  habituated.  This  persistent  form, 
while  closely  resembling  ordinary  chorea,  does  not  prevent  locomo- 
tion. Most  of  the  subjects  have  been  males.  It  has  been  pointed 
out  that  the  proportion  of  males  is  unusually  large  in  cases  of 
prolonged  duration. 

The  chorea  of  childhood  rarely  terminates  in  death.  The  average 
mortality  of  a  disease  so  rarely  fatal  is  not  easy  to  ascertain,  but  it  is 
certainly  less  than  3  per  cent.,*  and  most  of  the  fatal  cases  occur  at 
the  time  of  puberty.  The  proportion  of  deaths  in  the  two  sexes  afc 
this  time  corresponds  nearly  with  their  liability  to  chorea  (Sturges), 
but  in  earlier  childhood  the  mortality,  compared  with  the  number  of 
cases,  is  relatively  lower  in  boys  than  in  girls.  The  immediate  cause 
of  death  is  sometimes  exhaustion  from  the  severity  of  the  disease  , 
and  the  loss  of  sleep,  sometimes  associated  rheumatism  or  rheumatic 

*  Nine  deaths  occurred  among  the  439  cases  of  the  B.  M.  A.  Coll.  Inv., — a  mor- 
tality of  2  per  cent. 

vol.  ii.  39 


610  CHOltEA. 

hyperpyrexia,  sometimes  intercurrent  maladies,  as  pyaemia  from  local 
injuries.  Most  of  the  fatal  cases  are  first  attacks;  death  in  recur- 
rent chorea  is  very  rare.  The  chorea  of  pregnancy  is  much  more 
fatal,  the  mortality  being  20  or  25  per  cent.  But  even  in  these  cases 
death  seldom  results  directly  from  the  chorea ;  it  has  usually  been 
due  to  the  effects  of  delivery  or  abortion,  in  the  cachectic  state  of  the 
system. 

Varieties. — Hysterical  Chorea. — Hysterical  patients  occasionally 
suffer  from  general  spasmodic  movements,  which  sometimes  resemble 
those  of  true  chorea,  but  more  often  differ  from  it  in  the  greater 
regularity  of  the  muscular  contractions.     The  mere  existence  of  sym- 
ptoms  of   hysteria  does  not  prove  that   the   chorea  is  not  of   the 
ordinary  form,  if  it  corresponds  to  this  in  its  features  ;  a  patient 
suffering  from  hysteria  may  also  suffer  from  true  chorea,  and,  in  a 
predisposed  person,  hysterical  disturbance  may  develop  during  an 
attack  of  true  chorea,  and  may  even  be  evoked  by  it.     The  only 
circumstance  that  would  justify  the  diagnosis  of  the  hysterical  uature 
of  such  an  attack  would  be  its  origin  by  imitation,  by  witnessing 
the  symptoms  of  choi'ea  in  another  patient.     In  ordinary  hysterical 
chorea  the  movements  present  certain  distinguishing  features.     They 
are  generally  more  sudden  and  shock-like,  resembling  those  of  the 
so-called  "  electrical  chorea."     This  is  a  rare  feature  of  true  chorea, 
in  which  such  sudden  contractions  of  many  muscles  are  met  with 
rather  as  a  spasmodic  sequel  than  as  part  of  the  symptoms.     The 
second  feature  of  the  hysterical  form,  more  frequent  and  of  still 
greater  significance,  is  the  rhythmical  character  of  the  spasm.     The 
movements   are   more   or   less   regular,   instead   of    presenting  the 
characteristic    irregularity   of    ordinary    chorea.      The    rhythmical 
character  is  especially  seen  in  the  movement  of  the  hands,  and  even 
of  the  fingers.     The  spasm  is  usually  moderate  in  degree,  never  so 
intense  as  in  the  severer  forms  of  the  genuine  malady ;  nevertheless 
the  hysterical  form  is  often  a  very  obstinate  malady.     It  may  last 
for  many   months ;    indeed,   its   average    duration  is   considerably 
greater  than  that  of  the  ordinary  form.     It  should  be  noted  that  the 
term  "  hysterical  chorea  "  is  sometimes  applied  to  other  foi-rns  of 
hysterical  spasm  which  bear  little  resemblance  to  true  chorea  ;  these 
are  described  in  the  chapter  on  Hysteria. 

The  relation  which  this  form  bears  to  true  chorea  is  sometimes 
uncertain,  and  the  occurrence  of  the  two  under  the  same  conditions 
of  age  may  occasionally  render  the  diagnosis  difficult.  It  is  not  so, 
however,  in  the  case  of  the  other  important  varieties  of  chorea,  the 
chronic  forms  of  middle  and  late  life,  hereditary  chorea,  and.  senile 
chorea.  In  spite  of  a  superficial  resemblance,  these  present  such 
important  differences  from  the  common  chorea  of  childhood  as  to 
make  it  convenient  to  describe  them  separately.  This  is  also  the 
case   with   the   peculiar   affection  termed  "  electrical  chorea."     The 


PATHOLOGICAL    ANATOMY.  611 

name  has  also  been  applied  to  maladies  that  have  no  real  relation  to 
chorea.  Choreoid  movements,  on  one  side,  may  be  the  result  of  an 
organic  lesion,  transient,  before  the  onset  of  hemiplegia,  pre-hemi- 
plegic  chorea,  or  persistent,  as  a  late  sequel  of  the  paralysis  and  a 
variety  of  "  athetosis,"  post-hemiplegic  chorea.  It  is  only  necessary 
here  to  mention  this  application  of  the  word.  Lastly,  it  has  been 
employed  as  a  designation  for  the  movements  that  are  better  termed 
habit-spasm  (q.  v.).  One  form  of  this,  manifested  by  a  peculiar 
rough  or  "  barking "  cough,  has  been  especially  called  "  laryngeal 
chorea;"  without,  however,  any  justification. 

Pathological  Anatomy. — As  a  rule,  the  nerve-centres  in  chorea 
present  no  abnormal  appearances  on  naked-eye  examination,  and  a 
careful  microscopical  investigation  often  yields  only  a  negative  result. 
In  some  cases,  alterations  have  been  found,  conspicuous  or  micro- 
scopical, the  significance  of  which  will  be  presently  considered.     They 
are  chiefly  of  two  classes  :  (1)  changes  in  the  vessels,  with  or  without 
secondary  effects  upon  the  brain,  the  result  either  of  a  morbid  state  of 
the  blood  or  of  local  derangement  of  function ;   (2)  alterations  in 
the  nerve-elements  themselves,  which  are  apparently  primary,  and 
the  effect  of  their  abnormal  activity.     In  severe  cases,  of  very  acute 
course,  general  hypersemia  of  the  brain  has  been  observed,  or  dilata- 
tion of  small  vessels  has  been  seen  with  the  microscope,  sometimes  in 
the  cortex,  especially  of  the  motor  region,  once  in  the  white  substance 
with  degeneration  of  the  walls  (Dana),  and  sometimes  with  a  peri- 
vascular accumulation    of    leucocytes.      Small    arteries    have    been 
found  occluded  by  a   process  of  embolism  or  thrombosis,   varying 
in   different  cases.      The    plugging   has   been  attended  by  minute 
haemorrhage  in  some  cases,  and  very  rarely  a  large  haemorrhage  has 
been  found,  connected,  no  doubt,  with  endocarditis   (see  p.    603). 
Minute  foci    of  haemorrhage  or  of  softening  are  met  with  in  very 
acute  cases,  with  endocarditis,  especially  of  the  "ulcerative"  form; 
and  iu  this  I  have  also  seen  small  round  haemorrhages  scattered  over 
the  pia  mater,  like  those  seen  in  the  retina.     Micrococcal  embolism 
of  small  arteries  is  probably  one  mechanism  by  which  these  lesions 
are  produced,  and  occasionally  endocarditis  has  caused  embolism  of 
a  larger  artery,  with  consequent  focal  softening,  corresponding  to  the 
hemiplegia  mentioned  as  an  occasional  complication.      In  one  case 
(Gray)  the  basilar,  vertebrals,  and   middle  cerebrals  were  all  thus 
closed.      The  plugs  in  minute  vessels  have   been   probably  throm- 
botic in  some   cases.     They  are  not  invariable,  for  they  have  often 
been  carefully   looked   for  without  success.      In    some  acute  cases, 
especially  with  delirium,  the  peculiar  round  hyaline  bodies,  that  are 
met  with  in  the  arterioles   and   capillaries   of   the   brain  in   acute 
infectious  diseases,  have  been  found  in  the  perivascular   sheaths.* 
Effusion  into  the  cerebral  ventricles  has  been  very  rarely  observed, 
*  Flechsig,  Wallenberg,  Jakomenko.     They  were  first  described  by  v.  Reckling- 


612  OHOKEA. 

and  it  is  only  in  cases  of  extremely  chronic  course,  which  have 
lasted  for  years,  that  any  trace  of  general  meningitis  has  been  seen, 
although  oedema  of  the  pia  mater  over  the  motor  cortex  has  been 
seen  in  an  acute  case.*  Changes  in  the  nerve-cells  have  been  found 
by  some  observers,  hyaline  swelling  and  degeneration  in  the  central 
ganglia  (Mejnert),  and  in  the  claustrum  and  island  of  Reil  (Elischer). 
The  connective  tissue  of  the  brain  has  been  found  increased  and  the 
specific  gravity  of  the  central  ganglia  lowered,  but  the  significance 
of  these  changes  is  doubtful.  No  special  importance  can  be  attached 
to  the  fatty  degeneration  of  the  perivascular  sheaths  described  by 
some  observers,  or  to  the  dilatation  of  the  spaces  around  vessels,  since 
both  these  changes  are  common  at  all  ages. 

In  the  spinal  cord,  when  changes  have  been  found,  they  are  chiefly 
such  as  result  from  functional  over-action,  and  are  met  with  in  acute  or 
very  prolonged  cases.  They  consist  in  general  hyperemia,  extravasation 
of  blood  around  minute  vessels,  leucocytal  aggregations  around  tl»3 
walls  of  the  vessels,  and  fibrinous  plugs  within  them.  The  nuclei  of 
the  interstitial  connective  tissue  have  been  increased.  The  large 
nerve-cells  were  found  by  Elischer  to  present  signs  of  degeneration 
somewhat  questionable  in  significance  (pigmentation  and  indistinct- 
ness of  nuclei).  Naked-eye  changes  (beyond  congestion)  are  seldom 
found,  but  local  softening  in  the  cervical  region  has  been  described. 
Meningitis  has  been  met  with  as  a  complication. 

In  the  peripheral  nerves  Elischer  found  an  increase  of  connective 
tissue  and  slight  changes  in  the  axis-cylinders — hyaline  swelling,. 
and  less  ready  staining  than  in  health. 

Such  of  the  above  changes  as  are  not  accidental  concomitants  of 
chorea  are  probably  the  result  of  the  excessive  and  perverted  functional 
activity  of  the  nerve-elements,  which  is  always  attended  by  vascular 
dilatation  in  the  part  affected,  and  this  may  have  its  own  consequence 
in  thrombosis,  exti-avasations,  or  leucocytal  accumulations.  Such 
changes  may  or  may  not  result,  as  is  illustrated  by  the  pathological 
anatomy  of  hydrophobia  (q.  v.),  and  also  of  chorea  in  the  dog,  an  affec- 
tion which  differs  from  the  ordinary  form  of  chorea  in  man  in  the 
shock-like  character  of  the  muscular  spasm,  which  resembles  that  of 
the  so-called  "electrical  chorea."  Of  two  typical  cases  examined  by 
Sankey  and  myself,  one  presented  only  slight  changes  (granular 
swelling)  in  the  motor  nerve-cells  of  the  spinal  cord ;  in  the  other 
these  changes  were  more  intense,  the  cells  were  extensively  vacuolated 
after  hardening,  and  the  spinal  cord,  medulla,  and  cerebellum  pre- 
sented areas  and  foci  of  intense  nuclear  (leucocytal)  infiltration  in 
various  parts  of  the  grey  or  white  substance.  These  differences  have 
been  found  by  others  ;  the  cellular  infiltration  must  be  secondary,  but 
once  produced,  developing  to  independent  excess. 

Imvsen,  and  a  full  description  of  them,  as  met  with  in  acute  diseases,  and  of  th& 
observations  by  others,  is  given  by  Manasse,  *  Virchow's  Arch./  Bd.  cxx. 
*  Powell,  '  Brit.  Med.  Journ.,'  1889. 


PATHOLOGY.  613 

Outside  the  nervous  system,  changes  are  usually  found  only  in  the 
heart.  Of  eighty  fatal  cases  collected  by  Sturges,  the  heart  was 
healthy  in  only  five.  The  most  frequent  change  is  endocarditis, 
usually  of  the  mitral  valves,  which  pi-esent  delicate  vegetations,  espe- 
cially on  the  auricular  aspect.  Similar  vegetations  are  sometimes  found 
also  on  the  aortic  valves.  Often  there  is  valvular  disease,  of  distinctly 
older  date,  in  addition  to  the  signs  of  recent  endocarditis.  In  such 
cases  there  may  even  be  "  ulcerative  endocarditis,"  with  the  character- 
istic erosions  and  extensive  vegetations,  containing  organisms,  but  this 
is  met  with  only  after  childhood.  The  signs  of  embolism  may  be  found 
also  in  other  organs.  Endocarditis,  although  very  frequent,  is  not 
invariable,  and  it  has  even  been  absent  in  a  case  in  which  the  disease 
followed  acute  rheumatism.  The  changes  met  with  in  the  chorea  of 
pregnancy  ai-e  similar;  endocarditis  is  usually  present,  but  in  rare 
cases  is  absent. 

Pathology. — The  problem  of  the  pathology  of  chorea  resolves  itself 
into  three  questions.  (1)  What  is  the  primary  seat  of  the  disease  ? 
(2)  What  is  the  nature  of  the  change  in  the  nerve-elements  ?  (3) 
What  is  the  cause  of  that  change  ? 

(1)  The  changes  that  have  been  found  after  death  in  the  common 
form  of  chorea  afford  no  clear  indication  of  the  part  primarily 
deranged.  They  have  been  found  widely  distributed,  in  the  brain, 
spinal  cord,  and  peripheral  nerves,  and  are,  moreover,  inconstant.  They 
are  certainly,  for  the  most  part,  either  merely  concomitant  or  secondary 
to  the  functional  disturbance  of  the  nerve-elements.  The  uncertain 
indications  of  pathological  anatomy  must  therefore  be  interpreted  by 
the  help  of  the  symptoms  themselves.  These  symptoms  supply  strong 
evidence  that  the  primary  seat  of  the  disease  is  in  the  brain.  The 
fact  that  the  movements  cease  during  sleep  is  opposed  to  their  origin 
in  the  spinal  cord,  the  functions  of  which  are  in  a  state  of  increased 
activity  during  sleep.  The  frequency  with  which  chorea  is  unilateral, 
or  commences  unilaterally,  suggests  that  it  depends  on  an  affection  of 
the  motor  elements,  where  those  related  to  the  various  parts  of  one  side 
have  more  in  common  than  have  those  for  the  upper  or  lower  limbs  of 
both  sides ;  i.  e.  that  it  depends  on  an  affection  of  the  cerebral  hemi- 
spheres. A  closer  study  of  the  distribution  of  unilateral  chorea  affords 
further  support  to  this  opinion,  since  the  greater  affection  of  the  arm 
than  the  leg  points  to  a  region  in  which  the  more  complex  movements 
of  the  arm  are  proportionately  represented,  and  agrees  with  the  distri- 
bution of  unilateral  paralysis  and  convulsion  of  cerebral  origin.  Since 
chorea  beginning  unilaterally  often  becomes  general,  we  are  justified 
in  believing  that  general  chorea  depends  on  an  affection,  in  both  hemi- 
spheres, of  those  structures  the  disturbance  of  which  in  one  hemisphere 
causes  hemichorea.  Choreic  movements  have  been  produced  by 
organic  disease  in  so  many  parts  of  the  brain,  that  no  conclusion  can 
be  drawn  from  such  cases  as  to  the  probable  seat  of  the  morbid  pro- 


614  OHOEEA. 

cess  that  causes  ordinary  chorea.  Such  movements  have  been  caused 
by  lesions  of  the  cortex,  central  ganglia,  and  cms  cerebx*i.* 

The  motor  impulses  that  excite  the  muscles  pass  to  the  spinal  cord 
from  the  motor  region  of  the  cortex.  It  is  here  that  movements  are 
arranged,  and  if  they  are  disarranged,  and  the  disorder  proceeds  from 
the  brain,  we  naturally  refer  it  to  a  disordered  action  of  the  cells  of 
the  motor  cortex.  Is  their  derangement  primary  ?  Is  this  the  actual 
seat  of  the  disease,  or  is  the  disorder  here  merely  secondary  to  a  mor- 
bid process  elsewhere  ?  It  is  doubtful  whether  there  are  at  present  any 
facts  to  justify  us  in  going  beyond  the  motor  cortex  in  our  search  for  the 
primary  disturbance.  At  the  same  time  we  know  very  little  of  the 
mechanisms  that  guide  the  cortex  in  arranging  movements.  It  does 
not  seem  that  there  is  any  co-ordination  of  movement  in  the  brain 
after  the  motor  impulse  leaves  the  convolutions,  and  any  co-ordination 
in  the  spinal  cord  is  subsidiary  and  involuntary.  The  influences  that 
guide  the  cortex  in  arranging  movements — the  influence  of  the  cere- 
bellum, for  instance, — however  exerted,  must  be  exerted  on  the  cortex, 
or  on  nerve-processes  anterior  in  time  to  those  in  the  cortex,  but  we 
have  no  evidence  of  their  derangement  in  chorea. 

It  was  formerly  thought  that  the  corpus  striatum  is  the  part 
primarily  diseased,  but  this  opinion  was  based  upon  the  theory  that 
the  movements  are  arranged  in  the  central  ganglia  after  the  impulses 
leave  the  cortex.  We  now  know  that  this  is  impossible,  and  there- 
fore the  ground  on  which  this  theory  was  based  has  disappeared. 
Moreover,  we  know  of  no  anatomical  arrangement  by  which  the  grey 
matter  of  the  corpus  striatum  can  influence  the  cortex.  The  optic 
thalamus,  however,  stands  on  a  different  footing.  Choreoid  movements 
have  been  caused  by  disease  of  the  thalamus,  and  it  is  connected  with 
all  parts  of  the  brain.  It  has  been  conjectured  that  it  is  a  centre 
through  which  peripheral  impressions,  which  do  not  affect  conscious- 
ness, influence  the  action  of  the  cortex.  But  of  its  relation  to  ordinary 
chorea  we  have  no  direct  evidence,  and  the  fact  that  its  disease  seems 
sometimes  to  cause  chronic  choreoid  movements  is  scarcely  relevant, 
and  altogether  isolated.  The  difference  between  the  two  conditions  is 
great,  and  it  is  possible  that  a  disorder  of  the  action  of  the  cortical 
cells  may  be  secondary  to  disease  of  the  thalamus  in  the  one  case,  and 
may  also  occur  as  a  primary  change  in  the  other.  Whether  their 
affection  is  or  is  not  the  primary  one,  we  can  hardly  resist  the  conclu- 
sion that  the  cortical  motor  cells  are  deranged  in  function  ;  and  both 
the  frequent  mental  change,  and  the  pathological  alterations  that 
cannot  be  referred  directly  to  the  blood,  suggest  that  there  is  an 
extensive  affection  of  the  cortex  in  many  cases  of  acute  character. 
It  may  well  involve  the  central  ganglia,  and  must  necessarily  extend 
to  the  white  substance,  the  spinal  cord,  and  even  the  nerves.  The 
functional  disturbance  can  only  reach  the  muscles  through  the  cord 

*  Cases  from  disease  of  the  crus  have  beeu  described  by  Magnan  (haemorrhage), 
and  by  Canfield  and  Putnam  (softening). 


PATHOLOGY.  615 

and  nerves,  and  a  proportionate  but  secondary  derangement  of  their 
function  must  occur. 

The  alteration  in  function  is  evidently  peculiar.  All  functional  dis- 
order is  attended  with  nutritional  change,  and  this  must  occur  also 
in  the  lower  structures  that  are  secondarily  affected,  whether  or  not  it 
attains  a  degree  that  can  be  recognised  by  the  microscope.  It  is  indi- 
cated in  the  increased  electric  irritability  of  the  uerve-fibres  of  the 
limbs.  But  it  seems  never  to  reach  a  destructive  degree,  or  to  involve 
true  secondary  degeneration.  Any  destruction  of  nerve-elements  is 
the  result  of  vascular  changes,  primary,  or  secondary  to  the  functional 
over-action.  Moreover  this  alteration  in  the  nutrition  and  derange- 
ment of  function  of  the  nerve- cells  tends  to  pass  away  when  their 
cause  has  ceased  to  act. 

We  have  no  evidence  regarding  the  precise  part  played  by  the 
spinal  cord  in  the  production  of  the  symptoms,  whether  it  acts 
merely  as  a  conductor,  or  whether  the  spinal  cells  attain  an  indepen- 
dent energy  under  the  prolonged  excitation,  and  intensify  the  spasm, 
or,  from  defective  power,  fail  to  transmit  the  voluntary  influence. 
Such  co-operation  of  the  spinal  elements  is,  however,  only  suggested 
by  the  rare  cases  with  bilateral  spasm  or  weakness  in  the  legs.  The 
spinal  cord  takes  an  independent  part  in  the  production  of  the  sym- 
ptoms of  canine  chorea,  but  this  malady,  as  already  stated,  is  essen- 
tially different  from  the  chorea  of  man. 

(2)  We  can  give  no  real  explanation  of  the  nature  of  the  change 
in  the  function  of  the  nerve-cells  whence  the  symptoms  arise.  We 
only  restate  in  pathological  terms  the  observed  symptoms  when  we 
say  that  these  indicate  that  there  is  a  spontaneous  action  of  nerve- 
cells,  a  tendency  for  this  action  to  spread  unduly  among  the  cells, 
and  a  diminution  in  the  possible  strength  of  action.  In  the  laugu;ige 
of  modern  physiology,  we  may  say  that  the  "  resistance  "  is  lowered 
alike  in  the  cells  themselves,  and  in  the  connections  between  the 
cells,  by  which  the  character  and  degree  of  their  associated  action 
is  determined.  The  derangement  of  function  in  the  motor  cells  of 
the  cortex  (according  to  the  view  here  adopted)  often  begins  on  one 
side  and  spreads  to  the  other,  just  as  does  the  discharge  which  causes 
a  convulsion  ;  in  the  latter  the  over-action  of  the  cells  has  a  tendency 
to  excite  the  over-action  of  other  cells  that  are  connected  with  the 
first,  and  a  similar  tendency  to  the  extension  of  functional  action  may 
be  the  mechanism  by  which  the  disorder  of  movement  extends  in 
chorea  to  structures  also  predisposed  to  suffer. 

(3)  By  what  morbid  influence  is  the  derangement  of  function 
of  the  nerve-cells  produced  ?  This  is  the  essential  problem  of  the 
pathology  of  the  disease,  but  the  changes  observed  in  the  fatal 
cases  are  too  variable  and  too  uncertain  in  their  significance  to  be 
trusted  alone.  We  must  also  consider  the  facts  of  causation,  and 
the  analogies  supplied  by  allied  affections. 

The  first  important  etiological  fact  is  the  distinctly  predisposing 


616  CHOEISA. 

influence  of  age  and  sex.  Chorea  is  especially  a  disease  of  later 
childhood ;  that  is,  it  occurs  when  the  functional  development  of  the 
nerve-centres  has  been  effected,  but  their  exercise  has  not  yet 
secured  stability  of  f  uuction,  and  the  motor  processes  are  prone  to 
become  active  independently  of  deliberate  volition.  The  normal 
restlessness  of  childhood  manifests  the  predisposition  to  chorea. 
Moreover,  the  age  and  sex  most  liable  are  also  those  in  which  ernotimi 
is  most  active,  and  exerts  the  greatest  influence  on  the  motor  nervous 
system — in  which,  indeed,  as  Sturges  has  insisted,  the  physiological 
expi'ession  of  emotion  is  often  by  movements  bearing  no  distant 
resemblance  to  the  slighter  spasms  of  chorea.  With  this  predisposi- 
tion is  to  be  associated  the  important  fact  that  an  emotion  has  been 
recognised,  by  almost  all  observers,  as  the  one  exciting  cause  that  can 
be  traced  with  frequency.  This  emotion  is  alarm,  which,  through- 
out the  animal  kingdom,  has  a  direct  effect  on  the  motor  centres, 
■essential  to  the  safety  of  its  subject.  Were  these  the  only  facts  of 
etiology,  it  would  be  natural  to  regard  chorea  as  a  purely  functional 
disease,  in  the  strictest  sense  of  the  term,  a  disturbance  of  the  func- ' 
tions  of  the  motor  centres  depending  on  their  state  of  functional 
development,  and  owning  no  other  cause. 

But  the  association  of  chorea  with  acute  articular  rheumatism 
is  so  frequent,  and  often  so  close,  as  to  indicate  that  there  is 
another  important  element  in  its  pathology.  Their  close  relation  is 
emphasised  by  the  lesion  which  is  common  in  each,  even  when 
they  are  dissociated — endocarditis,  so  rare  in  other  maladies,  nervous  or 
general.  But  it  is  impossible  to  regard  chorea  as  the  result  of  acute 
rheumatism,  since  each  disease  occurs  so  frequently  without  the  other, 
and  no  close  relation  has  been  traced  between  chorea  and  the  common 
cause  of  rheumatism,  exposure  to  cold. 

The  attempt  to  explain  the  relation  by  assuming  that  chorea  is  the 
result  of  cerebral  embolism  is  now  merely  of  historical  interest. 
According  to  this  theory,  endocardial  disease  must  precede  the  first 
symptoms  of  chorea.  But  it  is  only  in  a  very  small  proportion  of  the 
cases  that  this  precedence  can  be  traced.  Even  in  severe  and  fatal 
cases,  endocarditis  has  been  proved  absent  after  death.  In  the  large 
number  of  slight  cases  in  which  no  sign  of  endocarditis  can  be 
detected  we  are  not  justified  in  assuming  its  existence.  In  other 
cases,  again,  the  signs  of  endocarditis  come  on  during  the  course  of 
the  chorea.  In  these  two  classes,  which  comprise  the  majority  of  the 
cases  of  chorea,  the  embolic  theory  is  quite  untenable.* 

If  the  endocarditis  is  not  the  cause  of  chorea  it  must  be  either  the 
result  of  the  chorea,  or  the  two  must  be  consequences  of  a  common 

*  That  extensive  capillary  embolism  may  give  rise  to  movements  resembling  those 
of  chorea  has  been  proved  by  Dr.  Angel  Money  ('  Med.-Chir.  Trans./  vol.  lxviii)  ; 
but  the  fact  has  little  bearing  on  the  question  of  the  pathology  of  human  chorea. 
The  facts  of  disease  show  that  many  morbid  processes  in  the  brain  may  give  rise  to 
choieoid  movements. 


PATHOLOGY.  6 1 7 

■cause.  This  conclusion  is  supported  by  the  fact  that,  if  we  are  to 
trust  clinical  evidence,  the  endocarditis  is  often  secondary  to  the  chorea 
in  point  of  time.  Pathology  at  present  knows  nothing  of  the  direct 
dependence  of  such  a  lesion  on  an  altered  state  of  the  nervous  system. 
All  known  facts  regarding  the  etiology  of  endocarditis  point  to  its 
dependence  on  morbid  states  of  the  blood.  That  excessive  muscular 
action  changes  the  composition  of  the  blood  is  practically  certain,  but 
the  endocarditis  can  scarcely  be  ascribed  to  this  cause,  since  it  does 
not  occur  in  other  states  of  muscular  over-action ;  it  may  be  present  even 
in  slight  cases  of  chorea,  and  it  may  precede  the  chorea  in  its  deve- 
lopment. The  hypothesis  which  seems  best  to  explain  the  facts  is 
the  old  theory  that  the  common  cause  of  the  endocarditis  and  the 
chorea  is  a  blood-state  allied  to,  but  not  identical  with,  that  which 
causes  acute  rheumatism.  According  to  the  precise  nature  of  the 
blood-change,  chorea  or  acute  rheumatism  or  both,  with  or  without 
endocarditis,  may  be  produced.  The  facts  of  these  diseases  suggest 
a  toxic  change  of  a  chemical  character,  rather  than  an  organised  virus. 
That  which  causes  chorea  seems  to  have  no  tendency  to  affect  the 
joints  and  but  little  to  cause  pericarditis,  and  not  to  be  excited 
directly  by  exposure  to  cold,  but  it  may  be  accompanied  by  the  con- 
dition which  causes  rheumatism  and  which  presents  these  features.* 
Of  the  mechanism  by  which  the  assumed  blood-change  causes  choi-ea 
we  are  still  ignorant.  The  hypothesis  suggested  by  the  facts  of  the 
disease  is  that  a  special  influence  is  exerted  on  the  motor  elements  of 
the  cortex,  deranging  their  function  and  producing  a  disturbance  of 
their  nutrition,  which,  once  excited,  runs  a  certain  course,  varying  in 
severity  and  duration,  but  tending  to  subside.  The  action  of  specific 
blood-states,  especially  such  as  are  of  chemical  nature,  on  certain 
parts  of  the  nervous  system,  is  well  known,  and  we  must  remember 
that,  in  chorea,  the  effect  is  produced  on  structures  that  are  in  a 
peculiar  state  of  predisposition  not  only  to  derangement,  but  to  the 
particular  form  of  derangement  present  in  this  disorder.  The  disturb- 
ance of  function  seems  sometimes  to  last  beyond  its  cause  (since  even 
endocarditis  may  pass  away  before  the  movements),  and  to  leave  also 
a  strong  disposition  to  recurrence.  The  blood-state  may  act  widely  on 
the  cortex  in  some  cases,  and  even  on  the  central  ganglia,  whose  func- 
tion is  still  too  mysterious  to  permit  us  to  assign  to  their  derangement 
a  definite  part  in  the  pathology  of  chorea,  possibly  also  on  lower 

*  If  the  conception  of  a  blood-state  allied  to,  although  not  the  same  as,  that 
which  causes  acute  rheumatism  seems  difficult,  we  may  remember  that  the  varieties 
in  the  manifestations  of  rheumatism  must  be  evidence  of  a  corresponding  variety  in 
the  constitutional  condition  that  predisposes  to  it.  Of  a  number  of  persons  ^vho  get 
their  feet  wet,  for  instance,  one  will  have  a  cold  in  the  head,  a  second  acute 
tonsillitis,  a  third  pericarditis,  a  fourth  acute  general  arthritis,  and  a  fifth  arthritis  • 
with  endocarditis.  The  cause  is  the  same  in  all ;  the  effect  must  be  due  to  the 
previous  condition  of  the  individual.  It  does  not  seem  inconceivable  that  an  allied 
constitutional  condition  should  have  an  influence  on  certain  nerve-centres,  rendering 
their  function  and  nutrition  susceptible  of  derangement. 


618  CHOJREA. 

motor  elements,  as  in  the  spinal  cord,  in  less  degree.  We  may  note 
that  the  excitant  of  the  allied  rheumatism,  exposure  to  cold,  may 
act  on  the  pei-ipheral  motor  structures,  and  cause  multiple  neuritis. 
But  the  visible  changes  especially  in  the  vessels,  and  in  prolonged 
cases  in  the  interstitial  tissue,  may  be  in  part  a  consequence  of  the 
disturbance  of  function  (see  above),  since  it  is  certain  that  they  are 
often  absent.  They  may  be  also,  in  part,  the  effects  of  the  blood- 
change,  which  is  usually  pi-ofound  in  fatal  cases,*  and  to  some 
extent  determined  in  seat  by  the  functional  derangement  and  its 
secondary  effects,  while  the  endocarditis  which  also  usually  co-exists 
apparently  gives  rise  to  some  of  them.  If  due  weight  is  given  to- 
these  considerations,  there  seems  little  room  for  the  opinion  which 
ascribes  the  symptoms  to  these  vascular  alterations.  It  requires 
stronger  evidence  than  is  at  present  forthcoming  to  prove  that  con- 
ditions that  are  occasional  and  variable  are  causes  of  the  disease, 
associated,  as  they  always  are,  with  that  which  seems  the  probable 
cause  in  other  cases. 

We  must  not,  however,  regard  the  blood-change  as  more  than  one 
element  in  the  causation  of  chorea. f  Important  facts,  already  con- 
sidered, demonstrate  not  only  the  influence  of  functional  development  as 
a  predisposition,  but  also  that  of  functional  disturbance  as  an  excitant 
of  the  disease.  The  ascertained  facts  of  etiology  seem  to  show  how 
frequent  and  sometimes  how  close  is  the  effect  of  fright  in  exciting 
the  disease,  an  agency  which  has  a  direct  influence  on  the  motor 
structures  J  which  especially  manifest  both  the  predisposition  and 
the  developed  disease.  The  violent  functional  disturbance  of  this 
-  influence  seems  to  involve  a  shock  to  their  nutrition,  which  may  persist, 
increase,  and  run  a  definite  course,  most  readily  in  those  whose  nerve- 
elements  are  disposed  by  neurotic  inheritance  to  instability  of  nutri- 
tion (as  well  as  through  developmental  instability),  or  who  may  possess 
the  deranging  influence  of  the  morbid  blood-states. 

In  any  theory  of  the  pathology  of  the  disease  these  three  factors 
must  be  kept  in  view,  and  in  any  study  of  the  disease  the  part  played 
by  each  must  be  ascertained  as  far  as  possible. 

The  nature  of  the  influence  which  pregnancy  exerts  on  the  occur- 
rence of  chorea  is  still  unknown.  It  is  commonly  regarded  as  a 
reflex  influence,  analogous  to  that  which  causes  vomiting  ;  but  it  is  to 
be  observed  that  the  period  of  development  of  chorea  is  usually  later, 
and  is  much  more  variable,  than  that  of  the  morning  sickness,  and 

*  Nauwerck  ('  Beitrage  zur  path.  Anat.  u.  Phys.,'  by  Ziegler  and  Nauwerck,  Jena, 
1886,  p.  407)  records  an  instance  of  the  occasional  intense  severity  of  the  blood-state 
and  its  effects,  in  a  child  of  seven.  Foci  of  inflammation  (mycotic  ?)  were  found  in 
the  brain  and  medulla,  and  there  were  also  pericarditis,  endocarditis,  and  pneumonia. 

f  When  the  causation  of  a  disease  is  complex,  it  often  happens  that,  at  different 
periods,  attention  is  too  exclusively  directed  to  one  of  the  elements  in  its  production. 
This  seems  to  be  now  the  case  with  those  who  would  term  chorea  an  "acute 
infectious  disease." 

t  See  above,  p.  616;  also  "Paralysis  Agitans." 


DIAGNOSIS.  619 

ofteu  does  not  cease  immediately  on  the  removal,  by  parturition,  of 
the  source  of  reflex  irritation.  We  know  also  very  little  of  the  occur- 
rence of  chorea  from  other  forms  of  reflex  irritation. 

The  influences  which  determine  the  precise  form  that  the  chorea 
assumes  are  also  unknown.  Maniacal  chorea  is  not  met  with  until 
the  period  of  puberty,  and  is  very  rare  in  the  male  sex.  It  occurs 
in  girls  between  fourteen  and  twenty,  and  not  unfrequently  during 
pregnancy, — conditions  of  age  and  sex  in  which  emotional  disturbance 
is  readily  produced. 

Thus  the  chorea  of  early  life  is  due  to  a  predisposition  depending 
on  the  state  of  development  and  training  of  the  motor  centres,  vary- 
ing in  intensity  according  to  temperament  and  age,  much  increased 
by  the  residual  effects  of  a  previous  attack,  and  reproduced  also  as 
part  of  the  peculiar  state  of  the  nervous  system  during  pregnancy. 
In  addition,  two  other  influences  may  be  traced,  the  rheumatic  and 
the  neurotic,  each  as  either  a  predisposing  or  exciting  influence. 
They  may  exist  apart  or  may  be  combined,  the  one  predisposition 
with  the  other  excitant,  less  commonly  with  both  excitauts,  or  both 
predispositions  with  one  or  both  exciting  causes.  In  any  future  in- 
vestigation it  is  important  that  the  distinct  classes  should  be  sepa- 
rately considered,  apart  from  those  that  present  the  combined  influ- 
ences, since  facts  may  be  true  of  one  class  and  not  of  the  other,  and 
be  imperceptible  when  all  are  taken  together. 

Diagnosis. — No  disease  is  more  easily  recognised  than  chorea  in  its 
common  form.  The  peculiar  movements  at  once  attract  attention ; 
their  character  is  unmistakable ;  and  their  recent  onset  distinguishes 
the  case  from  the  only  condition  in  which  similar  movements  occur — 
that  of  infantile  disease  of  the  brain.  The  expression  of  countenance, 
with  its  listless,  somewhat  vacant  aspect,  often  by  itself  suggests  the 
nature  of  the  malady.  It  is  only  in  some  special  varieties  that  the 
affection  is  less  readily  recognised.  In  a  slight  case  of  unilateral 
chorea,  if  the  patient  grasps  simultaneously  the  observer's  hands,  the 
contrast  between  the  uniform  muscular  contraction  on  the  one  side, 
and  the  unsteadiness  of  the  grasp  with  the  affected  band,  is  readily 
perceived.  In  the  rare  cases  in  which  the  legs  suffer  more  than  the 
arms,  the  intei'ference  with  standing  and  walking  may  resemble  that  of 
paraplegia,  but  the  spasmodic  movements  are  always  distinct  enough 
to  show  the  nature  of  the  case.  A  greater  difficulty  is  sometimes  pre- 
sented by  the  cases  of  "  paralytic  chorea,"  in  which  there  is  very  little 
spontaneous  spasm,  and  the  loss  of  power  alone  attracts  the  attention  of 
the  friends,  and  sometimes  also  of  the  medical  attendant.  Tbe  distinc- 
tion rests  on  the  facts  that  the  loss  of  power  is  confined  to  one  arm, 
and  does  not  involve  the  face  or  leg,  and  that  it  comes  on  gradually  (in 
the  course  of  a  few  weeks)  in  later  childhood.  Close  observation 
reveals  slight  occasional  choreic  movements  in  the  weak  arm,  and 
often  elsewhere,  or  distinct  inco-ordination,  especially  when  the  hand 


620  CHOREA. 

is  held  over  the  head — an  action  that  often  reveals  the  existence  of 
choreic  movements  otherwise  unperceived.  In  some  cases  sustained 
muscular  action  is  impossible ;  the  grasping  fingers,  for  instance, 
relax  involuntarily,  or  desired  relaxation  is  for  a  moment  delayed. 
Once  aware  of  the  possible  nature  of  the  case,  the  diagnosis  is  not 
difficult.  As  a  rule,  when  a  child  between  seven  and  twelve  years  of 
age  is  said  to  have  gradually  lost  the  use  of  one  arm,  the  disease  is 
chorea.* 

Maniacal  chorea,  when  the  muscular  spasm  is  slight,  may  be  mis- 
taken for  simple  mania.  There  is,  however,  less  continuous  garrulity 
than  in  simple  mania ;  usually  there  is  some  characteristic  spasm, 
and  the  patients  are  younger  than  most  subjects  of  acute  mania.  The 
greatest  difficulty  arises  in  the  rare  cases  in  which  the  muscular  spasm 
ceases  when  the  mental  disturbance  becomes  considerable,  and  there 
is  only  the  history  of  the  spasm  to  guide  the  diagnosis. 

The  diagnosis  of  hysterical  from  ordinary  chorea  rests  on  the  sud- 
denness and  isolation  of  the  muscular  contractions,  on  their  frequently 
rhythmical  character,  on  the  age  and  sex  of  the  patient,  and,  in  many 
cases,  on  the  origin  of  the  disease  by  imitation.  The  sudden  shock- 
like character  of  the  contractions  is  characteristic  also  of  "  electrical 
chorea,"  described  in  a  separate  section. 

Peognosis. — In  the  vast  majority  of  cases,  even  of  severe  chorea, 
the  prognosis  is  favorable.  As  long  as  the  disease  is  free  from  com- 
plications, and  the  patient  obtains  a  fair  amount  of  sleep,  no  anxiety 
need  be  felt,  but  it  is  important  that  the  uncertain  duration  of  the 
disease  should  be  remembered  at  its  onset,  and  that  the  parent  of  a 
patient  should  be  prepared  for  it.  The  chief  source  of  danger  is 
exhaustion  from  the  violence  of  the  movements,  and  from  the  defi- 
ciency of  sleep.  The  endocarditis  has  little  influence  on  the  immediate 
prognosis ;  the  chief  risk  to  life  that  it  entails  depends  on  the  embolic 
process,  and  this  is  extremely  rare.  Intercurrent  rheumatism  is 
also  commonly  of  a  mild  type,  and  the  gravest  complications  of  rheu- 
matism— pericarditis  and  hyperpyrexia — are  very  seldom  met  with  in 
choi'ea.  Preceding  heart  disease  renders  the  prognosis  worse  in  pro- 
portion to  the  gravity  of  the  cardiac  lesion,  but  is  rarely  a  source  of 
anxiety  during  the  attack  of  chorea  itself.  The  prognosis  is  worse  in 
the  maniacal  than  in  the  ordinary  form,  and  considerably  worse  in 
the  chorea  of  pregnancy  than  in  that  of  youth.  It  is  somewhat  better 
in  a  recurrence  than  in  a  first  attack,  but  to  this  rule  the  chorea  of 
pregnancy  is  an  exception. 

The  more  severe  the  disease,  the  longer  will  be  its  probable  dura- 
tion. A  recurrence  will  probably  terminate  sooner  than  a  first  attack. 
Etiological  conditions  of  age,  sex,  cause,  preceding  rheumatism  or 

*  This  statement  may  seem  too  absolute,  but  it  is  literally  true.  Organic  disease 
either  weakens  the  leg  as  well  as  the  arm,  or  else  it  causes  convulsions  or  some  other 
symptom  that  attracts  attention,  and  is  mentioned  at  the  outset. 


TREATMENT.  621 

heart  disease,  and  present  endocarditis,  afford  no  indications  of  the 
probable  duration  of  the  disease.  This  conclusion  is  drawn  from  a 
careful  analysis  of  the  facts  of  the  cases  which  have  come  under  my 
own  notice.  In  hysterical  chorea  the  prognosis  as  to  life  is  absolutely 
favorable,  but  the  duration  of  the  disease  is  often  long. 

Of  the  sequelae  of  ordinary  chorea,  mental  and  muscular  weakness 
always  pass  away.  It  is  only  when  there  has  been  severe  mania  that 
there  is  any  risk  of  the  persistence  of  dementia.  Convulsive  attacks,. 
if  of  epileptoid  type,  may  continue  to  recur,  and,  as  we  have  seen,  may 
develop  into  epilepsy. 

Treatment. — The  derangement  of  motor  and  psychical  functions, 
in  chorea,  its  frequent  origin  in  emotion,  and  the  distinct  increase  of 
the  symptoms  that  may  often  be  observed  to  result  from  emotional 
disturbance  and  from  mental  and  physical  exertion, — all  teach  the 
lesson,  which  experience  confirms,  that  the  first  important  element  in 
treatment  is  to  secure  the  patient  from  causes  of  mental  and  physical 
fatigue  and  emotional  excitement.  Lessons  should  be  discontinued, 
and  even  in  slight  cases  the  periods  of  physical  rest  should  be  in- 
creased, only  mental  or  physical  occupation  that  interests  without 
fatiguing  should  be  permitted,  its  amount  depending  on  the  degree 
and  duration  of  the  symptoms.  In  severe  cases  there  is  only  too  much 
spontaneous  muscular  action,  and  benefit  is  derived  from  absolute 
rest  in  bed  during  the  height  of  the  disease.  Even  in  moderate- 
cases,  the  good  effect  of  a  few  days'  absolute  rest  is  most  conspicuous,, 
and  is  often  desirable  at  the  commencement  of  treatment.  In  such 
cases,  prolonged  rest  is  seldom  followed  by  a  continued  improvement, 
and  the  patient  may  be  allowed  to  be  up  during  the  greater  part 
of  the  day,  provided  the  movements  are  not  thereby  increased  in 
intensity.  If  the  severity  of  the  disease  does  not  make  prolonged 
rest  in  bed  absolutely  necessary,  the  mental  depression  produced 
thereby  often  more  than  counteracts  any  good  that  is  done  by  the  rest. 
All  sources  of  mental  irritation  should  be  avoided ;  a  cheerful  room 
and  cheerful  companionship  are  most  important. 

When  the  movements  are  severe,  extreme  care  must  be  taken  to 
obviate  the  chance  of  injury  from  the  contact  of  the  limbs  with  hard 
objects.  These  should  be  removed  out  of  the  range  of  the  limbs,  or 
covered  with  soft  padding.  The  importance  of  this  measure  cannot 
be  over-stated.  One  cause  of  death  in  chorea  is  the  effect  of  slight 
mechanical  injuries,  which,  in  the  cachectic  state  of  the  patient,  often 
run  an  unfavorable  course,  and  may  lead  to  blood-poisoning.  The 
risk  that  the  patient  may  be  thrown  out  of  bed  by  the  spasm  must 
not  be  forgotten.  In  severe  cases  it  is  well  to  place  the  patient's  bed 
on  the  floor  in  a  corner  of  the  room,  and  to  cover  the  adjacent  walls' 
with  cushions  or  mattresses.  If  bedsores  are  threatened,  a  water-bed 
should  be  obtained.  The  influence  of  the  spasm  must  be  borne  in 
mind   in  all  proceedings  that  are  adopted.      The  temperature,  for 


622  CHOREA. 

instance,  should  never  be  taken  in  the  mouth.  I  have  known  a  choreic 
patient  to  bite  off  and  swallow  the  bulb  of  a  thermometer  placed  in 
the  mouth  ;  fortunately  the  accident  was  followed  by  no  more  serious 
consequence  than  an  increase  in  the  chorea  from  the  alarm  occasioned  ; 
the  thermometer  bulb  was  safely  passed  next  day  per  rectum. 

It  is  needless  to  insist  on  the  importance  of  an  adequate  supply  of 
easily  digested  food  and  of  absolute  cleanliness.  The  latter  is  of 
great  importance  when  the  patient's  mental  apathy  causes  unnoticed 
evacuations ;  in  such  a  condition  the  spasm  often  lessens,  and  com- 
parative stillness  increases  the  risk  of  bedsores  from  pressure.  The 
bowels  should  be  kept  open,  but  purgation  is  useless. 

In  many  severe  cases  of  chorea  the  skin  is  dry  and  harsh,  and  in 
these,  free  diaphoresis  has  often  a  striking  effect  in  lessening  the 
intensity  of  the  disease.  The  old  method  was  to  give  a  small  dose  of 
antimonial  wine,  and  follow  this  with  a  hot-air  bath,  and  I  have 
seen  excellent  results  from  this  treatment.  But  it  is  only  when 
the  strength  is  good  that  the  antimony  is  admissible ;  the  hot-air 
bath  may  always  be  employed  if  the  state  of  the  skin  indicates 
its  use. 

The  influence  of  drags  on  chorea  is  a  subject  on  which  the  most 
diverse  opinions  have  been  expressed.  It  is  possible  that  the  con- 
clusions would  vary  less  if  the  effects  of  each  therapeutical  agent  were 
observed  separately  in  the  classes  indicated  at  the  end  of  the  section 
on  "Pathology."  Agents  may  be  frequently  useful  in  one  class  that 
have  no  effect  in  the  other.  Many  cases  of  chorea,  admitted  at  an 
early  stage  into  a  well-arranged  hospital,  and  kept  at  rest,  seem  to 
improve  as  speedily  as  the  nature  of  the  disease  will  permit,  and  it  is 
exceedingly  difficult,  in  such  cases,  by  isolated  or  collective  observation 
and  comparison  to  obtain  satisfactory  evidence  of  the  influence  of 
drugs  on  the  disease.  But  this  result  is  not  always  obtained  even 
in  cases  and  conditions  that  are  apparently  promising,  while  in  those 
that  are  seen  as  hospital  out-patients,  or  in  which  the  disease  has  lasted 
for  a  long  time,  the  tendency  to  spontaneous  cessation  is  much  less 
marked,  and  recovery  is  often  exceedingly  slow.  In  such  cases  the 
influence  of  drugs  is  often  so  distinct  as  to  justify  a  doubt  whether 
the  cases  which  have  given  rise  to  the  first  conclusion  are  altogether 
free  from  fallacy,  and  to  suggest  the  desirability  of  employing  those 
agents  which  seem  most  useful,  even  when  their  effect  is  difficult  to 
trace. 

Sedatives  and  tonics  have  both  been  largely  employed  in  the  treat- 
ment of  chorea.  Of  the  former,  bromide  of  potassium  is  of  singularly 
little  value.  Chloral  hydrate  is  more  useful.  In  severe  cases  it  is 
often  of  great  service  in  producing  sleep,  but  in  cases  of  moderate 
severity  its  chief  use  (in  my  own  experience)  is  to  increase  the  tran- 
quillity obtained  by  a  period  of  absolute  rest  in  bed  at  the  onset  of 
the  treatment.  Five  or  seven  grains  may  be  given  every  six  hours 
for  a  week  or  so.     Some  physicians  have  described  l'emarkable  improve- 


TREATMENT.  %  623 

ment  when  a  patient  has  been  kept  constantly  asleep  by  chloral, 
but  this  method  of  treatment  is  scareely  commended  by  a  case  recorded 
by  Bouchut,  in  which  continuous  sleep  had  to  be  maintained  for  a 
month  before  the  movements  ceased.  In  other  cases  thus  treated 
it  has  seemed  that  the  period  of  sleep  was  merely  interpolated  in  the 
disease,  the  course  of  this  being  not  otherwise  modified.  The  bene- 
ficial results  have  usually  been  limited  to  a  single  case.  Inhalations 
of  chloroform  have  been  employed  with  advantage  to  secure  rest  in 
severe  cases,  but  they  have  been  practically  superseded  by  chloral, 
which  produces  the  same  effect.  Antipyrine  seems  to  have  a  similar 
action,  distinctly  useful  during  the  acute  stage  in  many  cases,  but 
not  when  this  is  over.  Five  grains  may  be  given  three  times  a  day 
to  a  child  of  seven  to  ten  years.  Morphia  as  a  sedative  is  far  inferior 
to  chloral.  In  smaller,  stimulant  doses  (five  minims  of  the  liquor 
three  times  a  day,  as  advocated  by  Radcliff  e)  it  seems  to  be  useful  in  ■ 
slight  cases,  but  it  should  not  be  given  if  there  is  mental  excitement 
which  may  be  distinctly  increased.  Henbane,  hyoscyamin,  conium, 
Indian  hemp,  Calabar  bean,  cimicifuga,  and  other  sedatives  have  been 
employed,  but  are  of  doubtful  value.  Salicylate  of  soda  is  sometimes 
distinctly  useful  and  sometimes  fails  entirely,  a  difference  that  may 
be  found  to  depend  on  the  associations  of  the  disease  and  the  stage 
of  the  attack.  It  is  most  likely  to  be  of  service  when  there  is  endo- 
carditis and  a  history  of  rheumatism,  family  or  personal. 

Among  the  so-called  nervine  tonics,  arsenic  has  longenjoved  ahigh 
reputation,  which  it  certainly  to  some  extent  deserves.  It  is  usually 
given  by  the  mouth,  and  the  dose  should  be  gradually  increased  to 
nix  or  even  n\xv  of  the  liquor  three  times  a  day.  It  may  be  combined 
with  morphia  (Steiner).  The  comparative  intolerance  of  the  stomach 
for  arsenic  has  led  to  its  hypodermic  injection  (Eulenburg,  Ham- 
mond). By  this  method  much  larger  doses  can  be  given  without 
unpleasant  symptoms,  but  the  emotional  disturbance  occasioned  to 
children  by  the  operation  is  a  drawback  to  the  method  in  a  disease 
in  which  it  is  so  important  to  maintain  emotional  tranquillity.  In 
older  patients  this  drawback  is  of  less  moment.  Hammond  recom- 
mends, as  an  initial  dose,  from  five  to  thirty  minims  (!)  of  Fowler's 
solution,  diluted  with  an  equal  quantity  of  glycerine,  and,  as  the  best 
place  for  the  injection,  the  loose  skin  on  the  front  of  the  forearm. 
Arsenic  may  be  given  by  the  mouth  until  intolerance  is  reached,  and 
then  continued  by  hypodermic  injection. 

Zinc  is  another  drug  that  has  long  been  praised  in  the  treatment 
of  chorea ;  both  the  oxide  and  sulphate  have  been  given,  the  dose 
being  slowly  increased  up  to  a  scruple.  Its  influence,  however,  is 
seldom  clear  when  allowance  is  made  for  the  long  time  necessarily 
occupied  in  gradual  increase  of  the  dose. 

Strychnine  is  of  little  value  in  the  early  stages,  but  it  is  often  dis- 
tinctly useful  at  a  later  period,  especially  when  the  disease  lingers  on 
in  slight  and  stationary  degree.     Calabar  bean  and  eserine  (JT  grain) 


624  CHOREA. 

have  also  been  recommended,  but  not  on  very  convincing  grounds. 
Curara  has  been  employed  in  obstinate  and  chronic  cases  with  alleged 
advantage  (Diamond,  Wright),  but  it  is  doubtful  whether  the  employ- 
ment of  so  dangerous  an  agent  is  ever  justifiable. 

Electricity  has  been  employed  in  various  ways,  especially  the  voltaic 
current  to  the  spine,  but  it  is  very  doubtful  whether  the  agent  has  any 
real  influence.  The  spasms  are  sometimes  lessened  by  the  passage  of 
the  current  through  the  limbs,  but  the  effect  quickly  passes  away,  and 
I  have  never  observed  evidence  of  permanent  benefit.  Any  effect 
from  the  application  of  magnets  is  probably  psychical  and  confined  to 
hysterical  cases.  Massage  is  chiefly  suited  to  the  chronic  stage. 
Another  therapeutic  measure  which  has  been  recommended,  but  is  of 
very  doubtful  value,  is  the  freezing  of  the  skin  over  the  spine  by  ether 
spray. 

Rhythmical  movements  and  mild  gymnastics  are  of  service  when 
movements  persist  as  a  residual  effect  of  the  acute  disturbance,  or  in 
very  slight  cases,  in  which  the  neurotic  element  predominates. 


CHRONIC  ADULT  CHOREA 
(Hereditary  Chorea  ;    Senile  Chorea). 

Adults  after  middle  life  may  suffer  from  an  affection  characterised 
by  movements  closely  resembling  those  of  the  chorea  of  early  life. 
It  differs,  however,  in  its  course,  which  is  not  only  chronic,  but  also, 
as  a  rule,  persistent  and  progressive.  The  spasm,  indeed,  differs  a 
little  from  the  juvenile  form  in  the  far  slighter  degree  with  which  it 
interferes  with  voluntary  movement,  which  often  stills  it.  Two  forms 
may  be  distinguished.  One  is  hereditary,  or  at  least  occurs  in  families, 
and  usually  manifests  itself  soon  after  middle  life,  or  at  least  before 
senility;  in  early  adult  life  only  in  cases  so  rare  as  to  be  strikingly 
exceptional.  The  other  form  is  isolated,  and  occurs  in  old  age,  some- 
what earlier  only  when  the  age  of  the  system  anticipates  the  courses 
of  the  years.  Thus  we  have  hereditary  and  senile  forms,  which, 
however,  differ  but  little  in  other  respects. 

Hereditary  Chorea  ;  Huntington' s  Chorea. — In  1872,  Huntington  of 
New  York  described  a  form  of  chrouic  progressive  chorea,  occurring 
in  families  through  many  generations,  among  the  inhabitants  of  Long 
Island,  New  York  Harbour,  a  favourite  haunt  of  tetanus.  It  had  bet-n 
familiar  to  his  father  and  grandfather,  who  were  both  practitioneis 
of  medicine,  as  presenting  the  uniform  features  of  commencement  in 
middle  life,  chiefly  from  thirty  to  forty,  affecting  the  two  sexes  equally, 


CHRONIC    ADULT  CHOREA.  625 

being  associated  with  mental  failure  and  a  tendency  to  suicide,  and 
continuing  until  death.  If  a  generation  escaped,  the  malady  did  not 
reappear  in  the  family.  Prom  the  attention  the  description  received, 
the  form  is  often  called  Huntington's  chorea,  but  it  would  seem  to  Lave 
been  long  familiar  to  physicians  practising  in  the  adjacent  districts 
of  the  United  States.  Dunglison*  quotes  a  letter  written  to  him  in 
1841  by  Dr.  Waters,  of  Franklin,  New  York,  giving  a  description  of 
the  malady  almost  identical  with  that  of  Huntington,  and  also  a  state- 
ment by  Gorman,  regarding  its  prevalence  in  certain  parts  of  Penn- 
sylvania, possibly  due  to  local  intermarriage.  Since  Huntington's 
description  has  directed  attention  to  the  malady,  many  instances  have 
been  recorded,  especially  in  Germany,f  and  a  few  in  this  country.^ 

The  affection  has  been  traced  through  as  many  as  four  generations, 
and  in  one  instance  no  less  than  nineteen  members  of  the  family  were 
affected  (Remak).  Of  four  families  descended  from  a  choreic  woman, 
two  were  healthy,  but  in  the  other  two,  twelve  persons  became 
choreic  after  thirty. §  The  two  sexes  suffer  equally.  As  a  rule,  it 
begins  without  any  exciting  causes  in  the  middle  period  of  life,  or 
early  part  of  the  second  half,  between  thirty-five  and  fifty.  The  move- 
ments commence  gradually  in  the  muscles  of  the  face  and  upper  limbs, 
and  become  more  severe  as  they  extend.  They  closely  resemble  those  of 
ordinary  chorea,  but  may  present  minor  differences.  Constant  rotation 
of  the  eyes  has  been  observed.  ||  Articulation  may  be  impossible  under 
excitement,  and  swallowing  reduced  to  spasmodic  efforts.  Even  the 
action  of  the  bladder  may  be  deranged.  The  movements  are  often 
arrested  by  voluntary  motion,  and  they  cease  during  sleep  in  most 
cases.  The  intensity  attained  varies,  but  is  usually  considerable,  and 
constitutes  a  grave  distress  to  the  sufferer.  Mental  changes  are  gene- 
rally associated,  especially  mental  weakness,  and  hence  many  of  the 
cases  have  been  reported  from  asylums.  Rarely  the  mind  has  been  un- 
affected. Sensation  is  normal,  almost  invariably  ;  a  loss  to  pain  has, 
however,  been  noted.  Reflex  action  is  unchanged.  The  symptoms 
usually  continue  until  the  end  of  life,  which  may  be  near  or  distant,  but 
one  case  is  on  record,  seemingly  of  this  form,  in  which  the  movements 
ceased  under  the  influence  of  arsenic  in  large  doses. %  "When  th6 
malady  shortens  life,  it  is  rather  through  the  indirect  influence  of  the 
mental  state  conjoined  with  the  exhausting  effect  of  the  spasm,  than 
in  consequence  of  the  latter  alone. 

The  morbid  appearances  that  have  been  found  in  the  brain,  and 
which  can  be  connected  directly  with  the  symptoms,  seem  chiefly  to 

*  Dunsrlison's  '  Pract.  of  Med..'  3rd  ed..  Philad.,  1848,  ii,  216. 
f  By  Ewald,  Peretti,  Huber,  Zicher,  Hoffmann,  Eichorst,  Reraak,  and  others. 
J  West,  at  Stoke-on-Trent,  '  Brit.  Med.  Journ./  1887,  i,  43o  ;  Suckling,  '  Lancet,' 
1889. 

§  Peretti, '  Berl.  klin.  Wochensch.,'  1885. 
II  Cazenave,  'Un.  mel./  1853. 
%  '  Lancet,'  1890,  i,  1435. 

vol.  ii.  40 


626  CHOREA. 

be  the  result  of  the  over-action  of  the  nerve-elements  of  the  cortex,  and 
do  not  indicate  the  primary  process  of  the  disease.  Slight  menin- 
gitis, and  the  accumulation  of  cell-elements  about  the  vessels  and  cells, 
with  some  increase  of  the  interstitial  tissue,  have  been  the  chief 
changes.  Nothing  is  definitely  known  of  the  pathology  of  the  disease 
and  its  relation  to  the  hereditary  causes.  It  has  been  thought  to  be  the 
result  of  the  development  of  embryonal  interstitial  tissue-elements, 
stationary  until  late  life,  and  then  causing  irritation  of  the  nerve- 
structures  ;*  but  this  is  a  pure  conjecture,  intrinsically  improbable. 

The  isolated  senile  form,  sometimes,  although  rarely,  met  with 
under  fifty-five,  differs  from  that  last  described,  not  only  in  the 
absence  of  any  family  tendency,  but  in  the  more  frequent  freedom  of 
the  mind,  and  in  the  occasional  benign  course  of  the  affection,  which 
may  pass  away  after  lasting  for  a  few  months  or  a  year.  Usually, 
however,  it  continues  until  the  end  of  life,  which  it  does  not  always 
seem  to  shorten.  This  variety  is  less  rare  in  this  country  than  is  the 
hereditary  form,  f  to  which,  indeed,  it  bears  a  close  resemblance  so 
far  as  the  special  symptoms  are  concerned.  The  difference  does  not 
depend  on  the  age  of  the  sufferer  or  on  the  severity  or  extent  of  the 
symptoms. 

The  malady  may  begin  at  any  period  of  late  life,  even  up  to 
eighty  years  of  age,  and  affects  both  sexes,  males  rather  more  often 
than  in  youth.  Other  neuroses  may  often  be  traced  in  the  families 
of  the  sufferers,  apart  from  chorea  itself.  It  may  come  on  without 
obvious  excitation,  but  often  follows  depressing  anxiety.  Sudden 
alarm  has  preceded  the  onset  only  in  middle  life.  A  marked 
difference  from  the  chorea  of  youth  is  the  absence  of  any  relation  to 
rheumatism  or  endocarditis  ;  coincident  heart  disease  is  degenerative 
only. 

The  spasm  presents  the  same  irregular  movements  as  in  other 
forms  of  chorea,  and  often  the  same  inco-ordination  of  voluntary 
movement.  The  spasm  is  often  most  severe,  and  may  render 
intended  actions  almost  impossible.  The  affection  of  the  face  and 
tongue  may  be  so  extreme  as  to  greatly  derange  articulation,  and  to 
make  it  almost  impossible  to  understand  what  the  patient  says.  The 
spasm  is  usually  increased  by  emotion,  and  a  patient,  who  is  thrown 
into  the  most  violent  physical  agitation  by  the  visit  of  a  stranger, 
maybe  comparatively  still  when  free  from  excitement ;  sleep  as  a  rule 
(but  not  invariably)  brings  quiet.  The  affection  of  the  legs  is  slighter 
than  that  of  the  arms,  but  may  be  sufficient  to  render  standing 
impossible.     Thei'e  may  be  some  loss  of  muscular  power,  but  it  is 

*  Greppin,  'Neurol.  Cent.,'  Oct.,  1892. 

f  Cases  have  been  described  by  Russell,  '  Med.  Times  and  Gaz.,'  1878 ;  in  a  woman 
of  74,  ending  in  recovery,  by  Ferguson,  '  Lancet,'  1885  ;  Macleod, '  Journ.  of  Ment. 
Science,'  July,  1881 ;  McLearn,  'Lancet,'  1885,  No.  8;  Saundby,  'Lancet,' 
Nov.  29,  1884  (with  references  to  other  cases  recorded  by  Graves,  Sinkler,  &c.) ; 
Suckling,  *  Brit.  Med.  Journ.,'  1888. 


CHRONIC  ADULT  CHOREA.  627 

seldom  considerable,  so  far  as  the  spasm  permits  the  strength  to  he 
ascertained. 

The  duration  of  the  disease,  in  the  rare  cases  that  have  recovei-ed, 
has  been  from  a  few  months  to  one  or  two  years,  but  that  of  the 
persistent  form  is  often  long,  since  it  has  so  little  tendency  to  shorten 
life.  Charcot  mentions  two  cases  at  the  age  of  seventy-one,  in  one 
of  which  the  disease  commenced  at  fifty-nine,  and  in  the  other  at 
sixty.  In  a  case  recorded  by  McLearn  the  disease  commenced  at 
forty,  and  had  already  lasted  fifteen  years  when  the  patient  came 
under  observation. 

In  senile  chorea  changes  have  been  occasionally  found  in  the  brain, 
but  frequently  the  examination  has  failed  to  reveal  any  alterations 
that  can  be  regarded  as  the  cause  of  the  disease.  Slight  degenerative 
changes,  such  as  were  found  extensively  distributed  through  the 
central  nervous  system  by  Berkeley,  in  a  case  of  seven  years' 
duration,  are  probably  in  part  of  secondary  origin.  In  one  of 
the  cases  recorded  by  Harbinson  there  was  evidence,  through- 
out the  brain,  of  degeneration  of  the  nerve-cells,  together  with  an 
increase  of  the  lymphoid  elements,  which  were  aggregated  around 
the  vessels  and  nerve-cells ;  this  has  been  the  most  frequent  morbid 
appearance,  combined  in  cases  of  long  duration  with  signs  of  slight 
general  meningitis.  In  all  the  three  cases  recorded  by  Macleod  (see 
p.  626),  in  which,  however,  there  was  also  motor  palsy,  disease  of  the 
motor  region  of  the  cortex  was  found ;  in  two  the  convolutions  were 
compressed  by  cystic  thickening  of  the  membranes,  in  the  other  there 
were  small  tumours.  Choreoid  movements  are  occasional  effects  of 
chronic  lesions  at  the  surface  of  the  brain,  such  as  haematoma,  and 
some  cases  of  the  kind  have  been  erroneously  described  as  examples 
of  simple  senile  chorea. 

The  treatment  of  the  two  forms  of  chronic  chorea  of  the  adult 
presents  little  difference.  Rare  cases  of  apparent  cure  by  arsenic  and 
other  remedies  suitable  to  the  common  form,  with  relief  to  the 
symptoms  by  bromide,  cocain,  exalgin,  antipyrine,  and  other  sedatives, 
constitute  all  the  results  that  have  been  obtained. 


"ELECTRICAL    CHOREA." 

The  term  "  electrical  chorea  "  has  long  been  applied  to  a  peculiar 
malady  that  is  met  with  chiefly  in  Lombardy  and  some  adjacent  parts 
of  Italy.  The  affection  resembles  chorea  in  being  manifested  by  spas- 
modic movements,  but  differs  in  the  character  of  the  movements  and 
in  the  course  of  the  disease,  and  also  in  the  addition  of  progressive 
palsy  and  muscular  wasting.  The  muscular  contractions  are  sudden 
and  shock-like,  and  thus  resemble  those  that  are  caused  by  momentary 


023  CHOREA. 

electrical  stimulation.  The  course  of  the  disease  is  progressive,  and 
a  large  proportion  of  the  cases  terminate  fatally.  It  is  doubtful 
whether  the  disease  has  any  resemblance  to  chorea  in  nature,  and 
hence  it  has  been  called  "  Dubini's  disease,"  from  the  physician  who 
first  described  it  in  1846.  It  affects  both  sexes  and  occurs  at  all 
ages.  Its  causes  are  unknown,  but  it  has  been  ascribed  to  some 
obscure  malarial  influence,  on  account  of  its  occurrence  chiefly  in 
certain  districts.  Even  in  these,  however,  it  appears  to  be  rare. 
Cases  have  been  described  in  which  the  symptoms  commenced  after  a. 
fright,  but  it  is  doubtful  whether  these  are  of  the  same  nature.  The 
sudden  clonic  character  of  the  contractions  is  not,  as  we  have  seen, 
confined  to  this  disease;  it  is  met  with  in  some  cases  of  ordinary 
chorea,  in  the  hysterical  variety,  and  in  some  choreoid  attacks  in 
adults  and  the  old.*  The  term  has  been  misapplied,  not  only  to  the 
general  clonic  spasm  of  hysterical  chorea,  but  also  to  the  violent  local 
shock-like  muscular  contractions  sometimes  met  with  in  that  affection,, 
especially  in  the  muscles  of  the  shoulder.  Such  contractions  occur  also 
in  the  cases  described  as  "  paramyoclonus  multiplex."  But  all  these 
forms  differ  from  the  Italian  malady  in  their  benign  and  isolated 
character,  which  at  present  seems  the  most  important  diagnostic 
feature. 

The  shock-like  muscular  contractions  that  constitute  the  first  and 
most  prominent  symptom  of  the  disease,  usually  commence  gradually 
in  one  arm — often  in  the  upper  part  of  the  arm — and  spread  thence, 
usually  to  the  leg  on  the  same  side  before  they  invade  the  opposite 
limbs.  After  a  few  months  or  less,  the  limbs  first  affected  gradually 
become  feeble,  the  muscles  waste,  with  loss  of  faradic  irritability,; 
and  the  palsy  spreads  until  it  becomes  general.  In  many  cases  there 
are  epileptiform  convulsions,  which  may  be  unilateral.  In  the  more 
acute  cases  there  may  be  considerable  elevation  of  temperature 
throughout  the  course  of  the  disease. 

In  fatal  cases,  no  constant  morbid  changes  are  found  in  the  central 
nervous  system,  and  not  only  the  nature  of  the  disease,  but  also  the- 
precise  part  of  the  nervous  system  primarily  disturbed,  is  a  matter  of 
conjecture.  The  most  plausible  theory  assumes  that  the  cerebral 
cortex  is  the  part  first  affected  (and  thus  the  unilateral  commence- 
ment and  convulsions  are  accounted  for),  but  that  the  spinal  cord 
suffers  secondarily  and  causes  the  changes  in  muscular  nutrition 
and  irritability.  It  has  indeed  been  regarded  as  the  manifestation  of 
a  special  form  of  myelitis  (Pignacca  and  Stefanini)  due  to  some 
peculiar  paludal  influence.  It  is  doubtful  whether  any  treatment 
influences  the  disease,  but,  from  the  rarity  of  the  malady,  therapeutical 
experience  can  accumulate  but  slowly. 

>  *  The  term  "  electrical  chorea "  has  been  applied  by  some  writers  to  the  cases 
that  do  not  otherwise  differ  from  ordinary  chorea.  But  since  it  has  long  been  used 
as  a  designation  for  the  Italian  malady,  this  use  of  the  word  seems  undesirable. 


MYOCLONUS   MULTIPLEX.  629 


"  MYOCLONUS  MULTIPLEX." 


Clonic  spasm  is  a  symptom,  that  occurs  in  various  forms  and  distri- 
bution, and  constitutes  part  of  the  manifestation  of  many  morbid 
states  of  the  nervous  system  ;  and,  moreover,  these  are  linked  together 
by  intermediate  forms,  so  as  to  render  it  difficult  to  separate  them  into 
definite  types.  Such  spasm  characterises  one  form  of  hysterical 
chorea,  and  also  the  grave  "  electrical  chorea  "just  desci'ibed.  Besides 
these,  a  few  years  ago  Friedreich*  described,  under  the  name  "  para- 
myoclonus multiplex, "f  a  case  of  clonic  spasm  affecting  the  limbs  of 
an  adult,  and  other  cases  of  more  or  less  similar  character  have  been 
since  described.  J  Males  have  suffered  more  often  than  females.  The 
symptoms  have  begun  at  any  time  of  life  between  puberty  and  sixty 
years  of  age,  spontaneously  or  after  a  fright,  rheumatism,  or  malarial 
fever.  The  last  cause  may  remind  us  of  the  Italian  "  electrical 
chorea,"  but  myoclonus  has  not  the  grave  character  of  the  latter. 
Heredity  has  not  been  distinct ;  when  several  cases  have  occurred  in 
a  family  they  have  deviated  from  the  common  form. 

The  contractions  are  sudden  and  involve  the  whole  or  a  con- 
siderable part  of  a  muscle,  often  causing  an  actual  movement.  They  are 
usually  symmetrical,  although  not  equally  strong  on  the  two  sides,  and 
quickly  pass  from  one  part  to  another.  In  frequency  they  vary  from 
ten  to  fifty  a  minute,  but  usually  occur  in  paroxysms,  or  rather  in 
series,  irregular  intervals  separating  the  shocks.  In  some  cases,  occa- 
sional tonic  spasms  accompany  them,  in  others  fibrillary  contrac- 
tions are  also  observed.  The  muscles  most  affected  are  those  of  the 
upper  parts  of  the  limbs  (especially  the  deltoid,  triceps,  biceps,  supi- 
nator, quadriceps  femoris,  hamstiing  and  calf  muscles)  and  the  facial 
muscles  (chiefly  of  the  lower  part),  sometimes  those  of  the  neck.  The 
muscles  of  the  hands  and  feet  may  contract,  but  seldom  cause  move- 
ment. The  diaphragm  may  be  involved,  producing  a  peculiar  hic- 
cough, or  an  odd  respiratory  sound,  in  which  the  larynx  probablv 
takes  part.  The  first  contractions  have  usually  been  in  the  muscles 
of  the  shoulders  and  upper  arms  or  face.  Voluntary  movement 
lessens  the  spasm  in  most  cases,  and  may  even  arrest  it.  The  con- 
tractions are  also  generally  diminished  by  alcohol  and  increased 
by  mental  excitement.  The  mind  has  usually  been  normal,  but  occa- 
sionally there  has  been  some  abnormal  state,  such  as  the  presence  of 
"  fixed  ideas." 

Myotatic  irritability  has  usually  been  increased;   the  attempt  to 

*  Friedreich,  '  Virchow's  Archiv,'  Bd.  lxxxvi,  p.  421. 

t  The  prefix  "  para  "  is  often  omitted. 

J  Seeligmuller,  *  Deut.  med.  Wochenschr.,'  1886;  Eemak,  '  Arch.  f.  Psych.,' 
sm  ;  Marie,  'Prog,  med.,'  1886;  Homen,  '  Arch,  de  Neurologie/  1887;  Allen  Starr, 
"•Am.  Journal  of  Nervous  and  Mental  Diseases,'  July,  1S87,  and  others. 


630  MYOCLONUS   MULTIPLEX. 

obtain  the  knee-jerk  has  sometimes  excited  the  spasm,  and  that  in  the 
extensors  of  tbe  knee  may  even  be  provoked  by  the  attempt  to  obtain 
tbe  foot-clonus.  In  one  case  the  movements  continued  during  sleep. 
In  a  few  cases  the  clonic  spasm  bas  occurred  only  in  paroxysms,  occa- 
sionally of  extreme  violence.  Thus,  in  a  case  recorded  by  Allen  Starr, 
tbe  movements  of  the  body  occasioned  by  the  violence  of  tbe  spas- 
modic contractions,  alternately  in  the  muscles  of  the  front  and  back  of 
tbe  trunk,  were  so  violent  tbat  "  the  head  was  thrown  about  and  the 
body  was  tossed  about  in  the  chair,"  and  if  the  attack  came  on  when 
the  patient  was  walking  he  was  sometimes  thrown  down.  A  similar  case 
of  paroxysmal  clonic  spasm  was  recorded  by  Pritcbard  in  1822  as 
"  Convulsive  Tremor  ;"  and  several  others,  differing,  however,  con- 
siderably among  themselves,  have  been  described  by  Hammond 
under  the  same  generic  designation.  On  the  other  hand,  in  some 
recorded  cases,  the  spasm  bas  been  trifling  in  degree,  even  insufficient 
to  cause  any  movement  of  the  parts,  and  only  to  be  seen  when  the 
skin  was  bai-ed,  resembling  tbe  quivering  "  live  flesh  "  to  which  so 
many  persons  are  liable.  It  is  thus  clear  that  the  cases  present  such 
differences  that  it  is  doubtful  whether  any  should  be  placed  together 
that  do  not  present  the  common  features  of  the  sudden  shock-like 
character  of  the  muscular  contractions,  their  bilateral  symmetry,  and 
the  comparative  freedom  of  the  extremities.  In  most  of  the  cases  tbe 
symptoms  have  passed  away  in  time,  a  very  marked  contrast  to  the 
course  of  those  of  "  electrical  chorea."  In  most  instances  no  morbid 
changes  have  been  found  to  explain  the  condition. 

The  affection  bas  been  regarded  by  some  as  closely  allied  to  facial 
spasm  ;  by  others  as  related  to  the  form  of  chorea  in  which  the  spasm 
is  clonic,  and  is  associated  with  hysteroid  symptoms  or  other  mental 
-changes  (forms  termed  by  tbe  French  "  Tic  convulsif  "  and  "  Mala- 
dies des  tics  convulsil's  ").  The  disease  is  perhaps  most  nearly  allied 
to  senile  chorea.  We  have  seen  that  senile  chorea  sometimes  runs  a 
favorable  course,  and  that,  even  when  severe,  it  seldom  causes  death. 
It  is  doubtful  whether  the  bilateral  symmetry  of  the  affection  affords 
any  real  ground  for  placing  it  far  from  other  diseases  that  it  resembles. 
One  curious  case  has  come  under  my  notice  in  which  paroxysms  of  clonic 
spasm,  somewhat  resembling  those  of  myoclonus  multiplex,  had  an.  irre- 
gular distribution.*    The  most  effective  treatment  has  been  by  nervine 

*  The  patient  was  a  healthy-looking  man,  aged  thirty-nine,  who  presented 
the  following  condition.  His  head  was  in  constant  movement,  jerked  to  the 
right,  and  constantly  rotated,  as  in  torticollis,  while  coincident  spasm  involved  the 
right  shoulder  muscles.  Slight  tonic  contraction  of  the  muscles  of  the  face  caused 
the  eyes  to  be  partially  closed,  the  eyebrows  raised,  and  the  angles  of  the  mouth  to 
be  drawn  down,  and  gave  to  the  face  an  expression  of  suffering.  The  least  excite- 
ment increased  the  spasm.  If  he  was  spoken  to,  for  instance,  the  clonic  spasm 
extended  to  the  muscles  of  tbe  forearm  and  to  those  of  mastication  and  of  the  face, 
changing  the  expression  of  pain  to  one  of  anguish.  When  he  himself  attempted  to 
speak,  the  resulting  disturbance  almost  baffles  description.  The  jerkings  of  the  arms 
became  most  violent,  and  the  head  was    rotated   from  side  to  side  with  extreme 


SALTATORIC    SPASM.  631 

tonics,  with  bromide  as  a  sedative,  and  the  use  of  voltaic  electricity, 
which  has  in  some  way  produced  a  striking  result  in  many  cases.  A 
current  as  strong  as  the  patient  can  conveniently  bear  should  be 
passed  from  the  spine  to  the  affected  muscles  daily  for  a  quarter  of  an 
hour.  If  this  fails  and  the  spasm  is  severe,  the  hypodermic  injection 
of  morphia  may  be  tried,  or  solanin  given  by  the  mouth. 


SALTATORIC   SPASM. 


The  term  "  saltatoric  spasm"  is  applied  to  a  rare  form  of  clonic 
spasm  in  the  legs,  which  comes  on  when  the  patient  attempts  to  stand, 
and  causes  springing  or  jumping  movements,  whence  the  name.* 
It  was  first  described  by  Bamberger  in  1859,  and  only  a  few  cases 
have  been  recorded. f  The  affection  occurs  in  both  sexes,  and  seems 
to  be  rather  more  frequent  in  males  than  in  females.  The  ages  of 
the  sufferers  have  varied  between  ten  and  seventy  years.  In  some 
there  has  been  a  history  of  previous  functional  nerve- disturbance, 
epilepsy,  hysteria,  &c,  and  in  most  the  onset  has  been  preceded  by 
influences,  physical  or  other,  depressing  the  nervous  system.  Imme- 
diate exciting  causes  have  not,  as  a  rule,  been  traceable.  In  a  few 
there  have  been  premonitory  symptoms,  slight  tremor,  stiffness,  or  a 
feeling  of  stiffness,  in  the  legs.  In  one  instance  the  spasm  followed 
a  convulsive  seizure.  The  actual  onset  has  generally  been  sudden. 
The  symptoms  consist  of  alternating  contractions  in  the  flexors  and 
extensors  of  the  legs,  following  each  other  with  great  rapidity,  and 
causing  jumping  movements  of  such  violence  that  the  feet  may  leave 

rapidity  for  a  few  seconds.  A  similar  paroxysm  occurred  on  rising  from  the  recum- 
bent posture  in  the  presence  of  a  stranger ;  he  would  stoop  for  a  moment,  bend  the 
head  as  if  in  expectancy,  and  then  the  violent  movement  occurred.  Over  the  slighter 
movements  he  had  some  control,  so  that  by  a  great  effort  he  could  open  the  eyes ; 
the  eyeballs  were  usually  directed  to  the  right,  but  he  could  slowly  turn  them  in  any 
direction.  So  violent  were  the  paroxysms  on  an  attempt  to  speak,  that  for  weeks  he 
never  uttered  a  word.  He  could,  however,  write  fairly  well,  with  occasional  inter- 
ruptions from  the  spasm.  The  man's  history  showed  no  cause,  immediate  or  remote, 
for  the  affection,  which  had  commenced  gradually  six  months  before.  Under  treat- 
ment, rest  and  hypodermic  injections  of  morphia,  he  gradually  improved,  and  became 
able  to  speak  to  the  other  patients  in  the  ward,  although  it  was  much  longer  before 
he  became  able  to  speak  to  a  stranger.  Ultimately  the  spasm  became  trifling,  but  it 
had  not  quite  disappeared  when  he  passed  from  observation. 

*  It  has  been  also  called  "  static  reflex  spasm"  by  Erlenmeyer. 

f  Bamberger,  '  Wien.  nied.  Wochenschr.,'  1859;  Guttmann,  'Berlin,  med. 
Wochenschr.,' 1867,  and  '  Arch,  fur  Psych.,5  Bd.  v,  1876;  Frey,  ib.,  Bd.  vi,  1875 ; 
Gowers,  '  Lancet,'  ii,  1877  ;  Kollmann,  '  Deut.  med.  Wochenschr.,'  1883,  No.  40,  and 
18S4,  No.  4;  Erlenmeyer,  'Cent.  f.  Nervenkrank.,'  1S87. 


632  SALTATOEIC    SPASM. 

the  floor  at  each  spasm,  and  the  patient,  is  thrown  to  the  ground 
unless  supported.  In  some  cases  the  spasm  has  been  slighter,  and 
only  the  heels  have  been  raised  from  the  floor.  The  spring  is  the 
result  of  spasm,  not  only  in  the  calf  muscles,  but  also  in  those  of  the 
hip-  and  knee-joints,  while  in  many  instances  the  muscles  of  the 
back  have  also  contracted  and  have  caused  a  backward  inclination  of 
the  trunk.  This  peculiar  spasm  occurs  only  on  an  attempt  to  stand; 
as  the  patient  sits  or  lies  down  the  muscular  contractions  cease,  often 
entirely,  although  sometimes  a  little  clonic  spasm  or  rigidity  has 
persisted  for  a  short  time.  In  some  cases,  pressure  on  the  feet,  as 
the  patient  lay,  caused  slight  spasm,  similar  to  that  produced  by  an 
attempt  to  stand.  In  uo  case  did  the  spasm,  excited  by  standing, 
spread  to  the  arms,  but  in  some  instances  other  voluntary  movements, 
even  in  the  recumbent  posture,  caused  a  little  clonic  spasm,  which 
involved  also  the  arms.  Motor  power  has  been  normal  in  most 
cases,  but  in  some  there  was  trifling  weakness  after  the  spasm  had 
existed  for  some  time.  Sensation  was  uuaffected  in  all,  but  dull 
pain  in  the  legs,  or  tenderness  of  the  spine,  was  present  in  some  of 
the  patients.  In  one  of  Bamberger's  cases  there  were  other  peculiar 
symptoms, — palpitation,  dyspnoea,  inequality  of  pupil,  with  spasm  on 
one  side  of  the  face.  In  Kallmann's  patient  other  severe  disturbances 
of  the  nervous  system  led  to  death. 

The  affection  has  generally  continued  for  some  months ;  in  only 
two  cases  was  its  duration  less  than  one  month,  while  in  one  it 
continued  till  the  death  of  the  patient,  six  years  after  the  onset  of 
the  symptoms.  The  cessation  of  the  spasm  has,  in  most  cases,  been 
gradual. 

The  spasm  is  evidently  reflex  in  character,  and  has  been  regarded 
by  most  writers  on  the  subject  as  proceeding  from  the  spinal  cord, 
and  the  result  of  a  peculiar  exalted  irritability  of  the  spinal  reflex 
centres,  especially  of  those  that  subserve  the  co-ordinated  movement 
of  jumping,  &c.  Freusberg*  has  shown  that  alternating  contractions 
in  the  flexors  and  extensors  of  the  legs  may  be  co-ordinated  in  the 
lumbar  enlargement  of  animals,  and  I  have  found  evidence  of  a 
similar  fact  in  man :  in  a  case  of  paraplegia,  with  absolute  motor 
palsy,  and  evidence  of  a  transverse  lesion  in  the  dorsal  region, 
pressure  on  the  soles  set  up  alternate  flexion  and  extension  of  the 
hip-,  knee-,  and  ankle-joints,  by  which  the  feet  were  successively 
drawn  up  and  pushed  dowu.f  Apparently  the  area  of  increased  irri- 
tability varies  in  different  cases,  since  in  a  few,  apart  from  standing, 
a  peripheral  impression  has  caused  movements  that  sju'ead  widely. 

*  '  Pfluger's  Archiv,'  Bd.  ix. 

t  It  is  to  be  noted,  however,  that  Woroschiloff  (Ludwig's  '  Arbeiten,'  1874, 
p.  110)  obtained  evidence  of  a  centre  in  the  upper  part  of  the  spinal  cord  of  the 
rabbit,  by  which  springing  movements  of  the  legs  were  apparently  co-ordinated.  A 
discussion  of  some  other  experimental  facts  bearing  on  the  subject  will  be  found 
in  my  paper  on  the  disease  ('  Lancet,'  1877). 


HABIT-SPASM.  633 

The  disease  in  most  cases  has  not  appeared  to  be  readily  influenced 
by  treatment.  The  spasm  has  continued  in  spite  of  the  administra- 
tion of  sedatives  ;  the  most  important  and  effective  measure  appears 
to  be  the  improvement  of  the  general  health,  and  of  the  strength  of 
the  nervous  system,  by  tonics.  The  case  of  shortest  duration  is  one 
recorded  by  myself,  in  which  slight  but  characteristic  symptoms 
(another  case  having  previously  been  under  my  observation)  were  at 
once  cut  short,  on  the  second  day  of  their  existence,  by  a  copious 
■diaphoresis  in  a  hot-air  bath. 


HABIT- SPASM. 


Children  often,  and  adults  sometimes,  present  spasmodic  movements 
such  as  winking,  twitching  the  mouth,  jerking  the  head,  movements 
that  have  a  half- voluntary  aspect,  but  which  the  individuals  are  unable 
to  control.  The  patient  is  said  to  have  "  got  a  trick  "  of  moving 
the  part.  This  condition  has  been  termed  "habit-chorea"  by  Weir 
Mitchell,  but  the  term  "  chorea  "  is  not  strictly  applicable  to  it,  and 
'"  habit-spasm  "  is,  I  think,  a  better  name. 

The  condition  is  met  with  chiefly  in  childhood,  especially  in  the 
second  half,  but  it  sometimes  commences  in  youth,  and  even  in  adult 
life.  In  young  women  it  is  often  associated  with  symptoms  of  hysteria, 
.and  there  may  be  a  difficulty  in  deciding  whether  certain  spasmodic 
movements  are  to  be  regarded  as  examples  of  this  affection  or  of  hyste- 
rical spasm.  When  it  commences  in  childhood  the  affection  commonly 
•ceases  after  a  few  months  or  years,  but  it  occasionally  goes  on  to  middle 
life  or  even  longer.  Barely  it  begins  late  in  life,  and  is  then  generally 
permanent.  In  early  life  it  occurs  especially  in  nervous  and  excitable 
children.  The  affection  is  said  to  be  more  common  in  females  than 
in  males,  but  it  is  very  often  seen  in  boys.  It  usually  begins  between 
the  ages  of  six  and  fourteen  ;  I  have,  however,  known  it  to  commence 
as  early  as  four.  Some  impairment  of  general  health  often  precedes 
the  development  of  the  movements  ;  occasionally  they  appear  to  be  due 
to  some  special  influence  depressing  the  nervous  system,  over- work  at 
school,  a  fright,  or  some  injury.  In  one  case,  for  instance,  the  onset 
followed  a  fall  into  the  water.  They  may  succeed  true  chorea,  or  some 
local  irritation  in  the  part  that  is  the  seat  of  tbe  movements  ;  conjunc- 
tivitis, causing  blepharospasm,  may  set  up  winking  movements.  In 
boys  the  affection  is  often  due  to  masturbation,  and  from  this  cause 
very  severe  cases  are  sometimes  met  with. 

Frequently  there  is  a  history  of  other  neuroses  in  parents  or  other 
relatives.  More  than  one  child  in  the  same  family  may  suffer,  but 
they  seldom  present  quite  the  same  movements.     I  have  seen,  for 


634  HABIT-SPASM. 

instance,  a  different  habit-spasm  in  twin  sisters.  It  is  probable 
that  the  affection  often  arises  by  imitation.  There  is  not  often  perhaps 
direct  imitation,  but  the  witnessing  such  movements  is  apt  to  produce 
a  peculiar  excitability,  which  finds  expression  and  relief  in  movements 
of  a  similar  nature.  In  cases  in  which  something  like  direct  inheritance 
can  be  traced,  it  is  probable  that  this  influence  has  been  at  work.  A 
father,  for  instance,  had  such  movements  in  the  face  all  through  his 
life,  and  two  of  his  children  likewise  presented  them.  In  many  cases, 
however,  no  causes  can  be  traced,  and  the  affection  seems  to  be  the 
result  of  the  restlessness  of  childhood,  specialised,  as  it  were,  in  a 
particular  direction. 

The  movements  usually  occur  at  intervals  of  a  few  minutes,  but 
sometimes  they  are  almost  continuous.  Their  character  varies  much 
in  different  cases,  and  even  in  the  same  individual.  One  kind  of 
action,  after  lasting  for  a  time,  may  give  place  to  another,  or  two  or 
three  kinds  may  alternate  at  the  same  period.  The  most  common  is 
blinking  of  the  eyelids,  by  a  sudden  contraction  of  the  orbicularis 
palpebrarum,  sometimes  accompanied  with  depression  of  the  eyebrows. 
Another  that  is  very  common  is  a  contraction  of  the  zygomatic  muscles, 
moving  the  angles  of  the  mouth  first  to  one  side  and  then  to  the  other. 
A  movement  of  the  head  is  also  common,  a  lateral  deviation,  a  rotation, 
or  a  nod.  In  one  case  there  was  a  backward  movement  of  the  head 
with  simultaneous  elevation  of  the  eyebrows,  as  in  looking  up.  In 
another  case  spasm  at  the  back  of  the  neck  was  succeeded  by  a  con- 
traction in  the  sterno-mastoid.  Movement  of  the  arms  is  also  common, 
shrugging  the  shoulders,  or  a  peculiar  fidgety  action  of  the  hand,  or 
some  other  movement  of  the  arm.  One  boy  would  put  both  his  arms 
forward  and  then  stoop,  and  he  did  this  under  all  circumstances,  even 
in  church.  A  movement  of  the  leg  is  less  common ;  the  patient  last 
mentioned  afterwards  got  into  the  way  of  kicking  his  leg  forwards  in 
walking,  doing  so  about  every  dozen  steps.  Of  the  twins  mentioned 
above,  in  one,  in  whom  the  spasms  began  after  a  fall  at  three,  there 
was  a  slight  movement  of  the  leg  and  a  twist  of  the  arm,  while  in  the 
other  a  slight  movement  of  the  head  was  accompanied  by  a  peculiar 
action  in  walking,  a  half-turn,  as  if  she  were  looking  for  something 
that  she  had  dropped. 

Respiratory  spasm  is  also  very  common ;  there  may  be  a  sudden 
inspiration,  sometimes  accompanied  by  a  laryngeal  sound,  or  there  may 
be  a  sudden  audible  sniff,  or  a  kind  of  sob.  These  may  be  combined 
with  some  other  action.  Thus,  in  a  boy  of  eleven,  a  quick  movement 
of  the  mouth  alternated  with  closure  of  the  eyes,  or  with  a  sudden 
inspiration  that  was  attended  by  a  slight  nasal  snore.  A  peculiar  cough 
is  also  common  in  these  cases  ;  often  it  has  a  laryngeal  character,  and 
it  may  be  extremely  troublesome.  It  is  occasionally  first  excited  by 
some  laryngeal  catarrh  and  actual  cough.  One  boy  began  by  making 
a  noise  in  his  throat  every  few  minutes,  half  cry,  half  cough,  so  loud 
that  it  could  be  heard  outside  the  house  ;  he  said  that  it  was  occasioned 


HABIT-SPASM.  635 

"by  a  sense  of  difficulty  in  breathing.  It  continued  for  two  years,  and 
then  ceased,  but  soon  afterwards  twitching  commenced  in  the  left  side 
of  the  mouth,  and  gradually  extended  to  the  whole  of  the  left  half 
of  the  body ;  and  this  continued,  varying  in  degree,  for  a  year. 
Occasionally  these  laryngeal  sounds  are  repeated  several  times  in 
succession.  In  a  case  recorded  by  Blachez  the  noise  made  was 
a  piercing  cry,  compared  to  the  squeak  of  the  child's  toy,  but  much 
louder. 

These  habit-movements,  as  we  have  already  seen,  usually  cease  after 
a  time,  but  they  sometimes  persist,  and  become  a  source  of  great  annoy- 
ance to  a  patient  who  has  reached  adult  life.  The  inability  to  control 
them  by  an  effort  of  the  will  becomes  very  marked  in  such  cases.  In  one 
instance  a  girl,  who  began  to '  blink  the  eyes  in  early  childhood,  still 
did  so  at  nineteen.  In  another  case,  a  clergyman  of  thirty-seven  was 
greatly  annoyed  by  an  involuntary  smile,  of  somewhat  meaningless 
aspect,  which  would  cross  his  face  from  time  to  time,  without  the 
slightest  corresponding  emotion,  and  even  when  he  was  engaged  in 
reading  in  public  the  most  solemn  parts  of  the  Church  service.  It 
never  troubled  him  when  he  was  preaching  or  in  conversation,  but  it 
often  occurred  when  he  was  looking  at  another  person,  and  sometimes 
gave  rise  to  misconception.  It  commenced  at  the  age  of  sixteen,  and 
was  at  first  more  than  a  smile,  being  actual  laughter,  but  it  gradually 
subsided  into  its  permanent  form.  In  another  case  a  lad  of  eight 
began  to  suffer  from  twitchings,  now  in  one  arm,  now  in  the  other,  two 
or  three  quick  movements  at  a  time.  Such  movements  persisted, 
changing  their  form,  until  he  came  under  observation  at  twenty- 
four,  when  he  presented  frequent  movements  of  the  face,  elevation 
of  the  eyebrows,  twitching  of  eyes,  &c,  and  occasionally  a  sudden 
up  and  down  movement  of  the  jaw.  He  could  prevent  them 
"  when  he  thought  of  it,"  but  when  his  mind  was  otherwise 
occupied  the  spasm  increased.  Again,  a  young  man,  aged  twenty- 
two,  presented  frequent  winking  of  the  eyes  and  movement  of  the 
mouth  which  had  existed  for  ten  years,  and  had  succeeded  a  peculiar 
condition  that  began  at  ten  years  old,  in  which,  besides  twitching 
movements  of  the  hands,  he  had  an  irresistible  impulse  to  repeat 
actions  ;  if  he  had  touched  an  object  he  felt  obliged  to  touch  it 
again. 

These  habit-spasms  are  generally  increased  by  observation,  and  it  is 
very  important  that  little  notice  should  be  taken  of  them  by  the 
friends  of  the  patient.  Sometimes  the  movements  will  then  cease 
without  further  treatment.  They  are  seldom  under  direct  voluntary 
control,  and  the  endeavour  to  prevent  their  occurrence  may  be  futile, 
especially  if  the  attempt  is  made  under  the  influence  of  fear  of 
threatened  punishment.  But  the  promise  of  a  reward  at  the  close  of 
each  day  on  which  the  spasm  has  not  occurred  will  sometimes  gradu- 
ally cause  their  disappearance  ;  a  strong  desire,  free  from  any  depress- 
ing emotion,    effects    that  which   the  will  cannot  directly  achieve. 


{536  PARALYSIS    AGITANS. 

Any  obvious  defect  in  the  general  health  must  be  made  good,  and 
change  of  air  is  often  very  beneficial,  especially  when  a  change  in 
■companionship  can  be  secured  at  the  same  time.  The  deterring 
influence  of  strangers  is  often  very  marked.  Of  drugs,  arsenic  has 
•certainly  most  influence.  Weir  Mitchell  has  known  the  hypodermic 
injection  of  arsenic  to  succeed  when  other  things  failed.  Nerve-tonics, 
especially  strychnia,  may  with  advantage  be  alternated  with  arsenic. 
If  there  is  much  excitability  of  brain,  or  if  the  spasmodic  movements 
are  severe,  bromide  of  potassium  may  be  needed,  and  it  is  especially 
useful  for  the  spasmodic  cough.  Occasionally  a  local  blister  is  of 
service,  and  gymnastics  may  be  employed  when  the  spasm  is  in 
the  limbs.  The  smiling  clergyman  mentioned  above  ceased  to  be 
troubled  after  he  had,  for  a  few  weeks,  taken  some  arsenic  and  iodide 
of  iron,  and  a  dose  of  bromide  each  time  he  had  to  conduct  the  service 
in  church. 


PAEALTSIS  AGITANS. 


Paralysis  Agitans,  or  Shaking  Palsy,  is  a  disease  of  the  second  half 
•of  life,  characterised  by  the  symptoms  indicated  by  its  name,  muscular 
weakness  and  tremor,  and  also  by  muscular  rigidity.  The  symptoms 
usually  commence  locally  and  gradually,  but  tend  to  spread  and  to 
become  general.  Prom  the  fact  that  it  was  first  fully  described  by 
Parkinson  in  1817,  it  has  been  called  "  Parkinson's  disease,"  but  the 
name  which  he  gave  to  it  of  "  shaking  palsy  "  is  as  apt  and  adequate* 
as  the  designations  of  most  diseases,  and  both  it  and  its  Latin  form 
•are  firmly  established. 

Causes. — The  disease  is  about  twice  as  frequent  in  men  as  in 
women  (73  males  to  42  females  in  an  unselected  series  of  cases  that  have 
come  under  my  notice).  It  usually  commences  after  40  years  of  age. 
Two  fifths  begin  between  50  and  60,  and  about  one  fifth  in  each  of 
the  two  decades,  40—50  and  60—70;  but,  on  account  of  the  lessened 
number  of  persons  living,  it  is  probably  twice  as  frequent  in  the 
latter  as  in  the  former  decade.  It  occasionally  begins  between  30 
and  40,  very  rarely  under  30.  f  Over  65  it  is  rare ;  my  series 
includes  two  cases  (males)  beginning  at  73,  and  one  (female)  at  74. 

*  To  the  name  "paralysis  agitans"  it  has  been  objected  by  Charcot  that  either 
the  weakness  or  tremor  is  sometimes  slight  and  occurs  late,  but  this  fact  does  not 
lessen  the  general  applicability  of  the  name,  since  in  the  majority  of  the  cases  both 
symptoms  ;ire  conspicuous. 

t  Of  my  cases,  the  earliest  began  at  twenty-nine,  but  commencement  has  been 
recorded  at  twenty-five  (Hadden),  twenty-one  (Buzzard),  nineteen  (Ducbenne),  and 
seventeen  (Berger). 


PARALYSIS   AGITANS.  637 

It  is  thus  essentially  a  disease  of  the  earlier  degenerative  period  of 
life.  Little  variation  exists  between  the  sexes  in  their  relative 
liability  at  different  ages  ;  I  have  found  the  average  age  at  com- 
mencement to  be,  in  males,  53  years,  in  females,  51. 

Heredity  can  seldom  be  traced,  perhaps  in  not  more  than  15  per 
cent.  In  one  case  the  affection  commenced,  after  anxiety,  at  33, 
and  was  extreme  at  39 ;  the  patient's  father  and  uncle  had  sufferrd 
from  it  in  late  life.  This  is  the  proportion  in  my  cases,  and  also  in  a 
series  of  cases  observed  by-Berger.*  The  sister  of  one  patient,  and  the 
mother  of  another,  and  in  two  other  cases  the  father,  suffered  also 
from  paralysis  agitans.  Non-progressive  tremor  occasionally  exists 
throughout  life  in  some  near  relation.  In  other  cases  there  has  been 
a  history  of  insanity  or  epilepsy  in  near  relatives.  The  disease  has  been 
thought  to  be  more  frequent  in  the  "  labouring  "  classes,  but  the 
influence  of  station  in  life,  and  also  of  occupation/is  certainly  small. 

Exciting  causes  cannot  be  traced  in  more  than  one  third  of  the 
cases,  and  vary  much  in  character.  The  most  frequent  are  emotion, 
physical  injury,  and  acute  disease.  Prolonged  anxiety  and  severe 
emotional  shock  are  the  most  common  antecedents.  Sudden  alarm 
may  cause  general  tremor,  so  that  the  verb  "  to  tremble  "  is  in  process 
of  conversion  into  a  synonym  with  "  to  fear."  Usually  the  tremor 
subsides  when  the  alarm  is  over,  but  it  has  been  known  to  persist  and 
develop  into  this  disease,  or  the  tremor  may  commence  a  day  or  two 
after  the  shock.  A  man  was  waked  by  a  bell  on  account  of  a  fire  ; 
for  a  year  and  a  half  the  same  bell  always  caused  transient  tremor, 
which  then  became  permanent,  and  passed  into,  the  typical  form  of 
paralysis  agitans.  It  is  noteworthy,  moreover,  that  the  direction  of 
alarm  may  localise  the  commencement  of  the  affection.  A  remark- 
able example  of  this  was  presented  by  a  woman  who,  at  thirty-seven 
years  of  age,  was  sitting  quietly  at  work,  when  a  stream  of  water- 
suddenly  flowed  from  a  tap  on  to  her  left  wrist.  She  was  much 
startled  ;  the  left  arm  immediately  began  to  shake,  and  the  tremor 
persisted,  passing  to  the  leg  and  afterwards  to  the  limbs  on  the  oppo- 
site side.  When  I  saw  her,  a  year  later,  she  presented  all  the  cha- 
racters of  the  disease  in  its  typical  form.  Physical  injury  is  occa- 
sionally a  distinct  excitant,  but  it  must  be  remembered  that  this 
usually  involves  also  emotional  shock.  That  the  physical  injury  is. 
not  merely  coincident  is  shown  by  the  fact  that  the  tremor  usually 
commences  in  the  part  injured.  Thus  in  two  of  my  cases  the  exciting 
cause  was  a  fall  on  the  shoulder,  and  in  each  the  tremor  commenced 

*  In  senile  maladies  the  facts  that  can  be  ascertained  regarding  heredity  pro- 
bably fall  short  of  the  truth  to  a  greater  extent  than  in  the  maladies  of  earlier  life, 
because,  as  life  goes  on,  the  death  of  older  relations  lessens  the  opportunities  of' 
ascertaining  the  facts.  It  is  often  astonishing  how  much  disease  inquiry  sometimes 
reveals  in  the  families  of  those  who  imagine,  before  the  inquiry  is  made,  that  they 
are  absolutely  free  from  all  morbid  heredity,  so  carefully  have  unpleasant  facts  been, 
concealed  by  those  to  whom  they  are  known. 


638  PARALYSIS   AGITANS. 

in  the  arm  injured.*  A  contusion  of  the  thigh  has  been  followed  by 
tremor  in  the  limb,  ultimately  becoming  general  (Charcot).  The 
disease  has  also  followed  an  injury  to  the  radial  nerve  (San  Martin). 
Local  diseases  causing  pain  sometimes  excite  it ;  it  began  in  the  leg, 
in  one  patient,  immediately  after  sciatica.  In  a  woman  of  forty-seven 
it  began  in  the  left  hand  after  left-sided  pleurisy  which  needed  tapping. 
Injury  may  determine  the  spi-ead  of  tremor  which  has  already  com- 
menced. Thus  in  one  case,  recorded  by  Charcot,  dislocation  of  the 
jaw,  immediately  reduced,  was  followed  by  tremor  in  it,  which  per- 
sisted. Traumatic  influences  sometimes  seem  to  be  effective  by  the 
concussion  of  the  nerve-centres.  In  one  of  the  most  severe  cases  I 
have  seen,  which  commenced  at  forty,  the  only  traceable  cause  was  a 
fall  from  a  horse  four  months  before  the  onset ;  there  was  no  injury 
to  limb.  I  have  seen  one  other  similar  case.  Muscular  exertion 
seems  to  have  far  less  influence  than  might  be  anticipated  from  the 
effect  of  prolonged  and  unaccustomed  effort  in  causing  tremor.  It 
seemed  to  determine  the  onset  in  one  case  in  which  emotion  probably 
co-operated  ;  a  woman  was  much  shocked  at  a  neighbour  being  killed  in 
a  railway  accident ;  she  went  to  the  funeral,  carrying  a  heavy  child  on 
the  left  arm ;  the  arm  felt  very  tired  afterwards,  and  the  feeling  of 
fatigue  persisted  and  gradually  changed  to  one  of  stiffness,  which 
proved  to  be  the  local  commencement  of  paralysis  agitans.  Exposure 
to  cold  was  the  apparent  cause  in  one  or  two  recorded  instances.  Of 
acute  diseases,  I  have  known  dysentery  and  typhoid  fever  to  precede 
the  onset.  Malaria  is  commonly  regarded  as  one  of  the  causes  of 
the  affection,  but  on  evidence  which  is  not  conclusive.  Paralysis  agitans 
is  more  frequent  in  England,  where  ague  is  almost  unknown,  than  in 
most  malarious  countries.  I  have  seen  one  case  in  which  the  disease 
followed  repeated  attacks  of  remittent  fever,  but  the  patient  was  at 
the  same  time  (during  the  American  war)  exposed  to  great  privation 
and  fatigue.  Sexual  excess  is  a  doubtful  cause.  Toxic  influences 
which  cause  general  tremor  (alcohol,  lead,  brass-working,  &c.)  seem  to 
have  little,  if  any,  influence  in  producing  true  paralysis  agitans. 

Symptoms. — In  a  well-marked  case  of  this  disease,  such  as  is 
shown  in  Eig.  148,  the  aspect  of  the  patient  is  very  characteristic. 
The  head  is  bent  forward,  and  the  expression  of  the  face  is  anxious  and 
fixed,  unchanged  by  any  play  of  emotion.  The  ai-ms  are  slightly  flexed 
at  all  joints  from  muscular  rigidity,  and  (the  hands  especially)  are  in 
constant  rhythmical  movement,  which  continues  when  the  limbs  are  at 
rest  so  far  as  the  will  is  concerned.  The  tremor  is  usually  more  marked 
on  one  side  than  on  the  other.  Voluntary  movements  are  performed 
slowly  and  with  little  power.  The  patient  often  walks  with  short 
quick  steps,  leaning  forward  as  if  about  to  run. 

*  In  one  curious  case  the  arm  in  which  the  symptoms  commenced  had  heen  the 
seat  of  slight  tremor  since  a  burn  of  the  palm  in  youth. 


SYMPTOMS. 


639 


A  prodromal  stage  characterised  by  rheumatoid  and  neuralgic  pains 
has  preceded  the  onset  in  rare  cases.  Usually  the  initial  symptoms 
come  on  very  gradually,  as  tremor,  stiffness,  or  weakness  in  one  hand. 
The  tremor  may  at  first  occur  only  on  emotion  or  fatigue,  sometimes 
only  on  moyement ;  but  it  is  afterwards  constant,  and  slowly  spreads 
from  the  part  in  which  it  was  first  noticed 


Fro.  148.— Paralysis  agitans.     (After  St.  Leger.) 

In  the  majority  of  cases  (two  thirds)  the  tremor  is  the  earliest 
symptom.  Of  ninety-two  cases  in  which  the  mode  of  onset  was  noted, 
it  was  by  tremor  alone  in  sixty-six.  Weakness,  with  or  without  a 
sense  of  "  stiffness,"  precedes  tremor  in  about  a  fifth  of  the  cases 
(sixteen  cases),  and  occasionally  is  conspicuous  with  tremor  from  the 
first  (six  cases).  The  commencement  is  six  times  as  frequently  in  the 
arm  as  in  the  leg,  very  seldom  in  both  (arm  eighty-six,  leg  fourteen, 
both  five  cases),  and  more  frequently  in  the  left  arm  than  in  the 
right  (left  fifty,  right  thirty-six  cases).* 

In  the  arm  the  tremor  usually  commences  in  the  hand,  sometimes 
in  the  forefinger  and  thumb,  but  I  have  met  with  five  otherwise 
typical  cases  in  which  it  began  in  the  shoulder.  In  two  of  these  the 
cause  was  a  fall  on  the  shoulder.  From  the  part  first  affected  the 
tremor  slowly  spreads,  and  the  usual  mode  of  extension  is  from  the 
arm  to  the  leg  on  the  same  side,  next  to  the  opposite  arm,  and  lastly 
to  the  opposite  leg.  The  disease  is  thus  hemiplegic  in  its  progress. 
Much  less  commonly  the  opposite  arm  is  affected  before  the  leg  on  the 

*  In  my  cases  the  affection  began  in  the  two  legs  with  nearly  equal  frequency, 
but  the  numbers  are  too  small  to  justify  the  inference  that  this  is  the  rule. 


640  PARALYSIS    AGITANS. 

same  si>le.*  I  Lave  known  the  symptoms  to  extend  to  the  leg  on  the 
same  side  and  thence  to  the  opposite  leg,  and  it  has  been  known  to 
pass  from  the  arm  on  one  side  to  the  leg  on  the  other.  The  extension 
from  arm  to  leg  on  each  side  is  by  far  the  most  common  course. 

When  the  disease  begins  in  the  leg,  the  march  of  the  tremor  is  less 
uniform.  Usually  (as  in  seven  cases)  the  extension  is  from  the  leg 
to  the  arm  on  the  same  side  and  then  to  the  opposite  arm.  In  two 
cases  it  was  to  the  other  leg,  then  to  the  arm  on  the  side  first  affected, 
and  lastly  to  the  other  arm.  In  several  instances,  in  which  the 
tremor  passed  from  the  leg  to  the  arm  on  the  same  side,  it  commenced 
at  the  shoulder  and  continued  greatest  in  the  upper  part  of  the  arm — 
a  point  of  interest  in  connection  with  the  fact  that  not  uncommonly 
in  hemiplegia,  when  the  leg  suffers  more  than  the  arm,  the  upper  pai't 
of  the  arm  is  paralysed  in  greater  degree  than  the  hand.  In  one- 
such  case  the  second  arm  was  also  invaded  at  the  shoulder.  Often,, 
when  the  affection  begins  in  the  leg  and  passes  to  the  arm,  it  speedily 
attains  a  much  greater  degree  in  the  latter  than  in  the  former. 

The  weakness  and  fixation  of  limb  usually  succeeds  the  tremor,  and 
is  greatest  where  the  tremor  has  existed  longest  and  is  most  marked. 
In  exceptional  cases,  however,  the  loss  of  power  and  rigidity  precede 
the  tremor  at  the  onset,  and  still  more  frequently  are  marked  in  parts 
to  which  the  tremor  has  not  yet  extended.  Thus  in  one  case,, 
the  tremor,  beginning  in  the  left  arm,  passed  to  the  left  leg  and  then 
to  the  right  leg,  and  was  absent  in  the  right  arm,  although  the  latter 
was  much  weaker  than  the  leg.  On  the  other  hand,  there  is  some- 
times little  weakness  although  there  is  much  tremor.  The  several 
symptoms  may  now  be  considex'ed  in  greater  detail. 

The  tremor  is  an  alternating  contraction  in  opposing  muscles, 
causing  a  rhythmical  movement  of  the  parts  to  which  they  are- 
attached.  It  is  usually  greatest  in  the  hands  and  fingers,  partly  from 
the  contraction  of  the  forearm  muscles,  partly  from  that  in  the 
thenar  muscles  and  interossei ;  the  latter  cause  a  movement  of  the 
fingers  at  the  metacarpo-phalangeal  joints  similar  to  that  by  which 
Orientals  beat  their  small  drums.  This  movement  may  be  chiefly 
in  the  thumb  and  forefinger,  as  in  the  act  of  rolling  a  small  object 
between  their  tips.  Not  rarely  the  movement  is  chiefly  at  the  wrist,, 
lateral  or  antero-posterior,  or  there  is  distinct  pronation  and  supi- 
nation ;  sometimes  the  two  alternate,  or  flexor-extensor  movements 
may  have  a  slight  lateral  direction.  The  muscles  of  the  upper  arm 
are  usually  less  affected,  and  those  of  the  shoulder  still  less.  Iu 
exceptional  cases,  as  already  mentioned,  the  upper  part  of  the  arm  is 
most  affected,  and  the  tremor  is  less  in  the  forearm  and  still  less  in 
the  hand.  In  one  such  case  the  chief  contractions  were  in  the 
pectoralis,  deltoid,  and  teres  major,  slighter  in  the  triceps  and  biceps, 

*  One  such  case  deviated  from  the  ordinary  type  in  that  the  upper  arm  muscles 
•were  more  affected  than  tliose  of  the  forearm,  and  the  intriusic  muscles  of  the- 
hands  were  free  from  spasm. 


SYMPTOMS.  Oil 

and  very  slight  in  the  forearm  muscles.*  In  the  legs  the  tremor  is 
usually  greatest  in  the  muscles  moving  the  ankle-joint,  especially  in 
the  calf  muscles,  and  the  heel  may  beat  the  floor  as  the  patient  is 
sitting ;  it  may  «closely  resemble  the  contractions  of  the  foot-clonus, 
though  no  clonus  is  obtainable.  It  is  slight  in  the  toes,  but  may  be 
distinct  in  the  thigh ;  sometimes  in  the  adductors  it  is  very  con- 
siderable, rarely  in  the  flexors  of  the  knee.  The  trunk  muscles, 
especially  those  of  the  back,  are  occasionally  involved.  I  have  never 
met  with  tremor  in  the  muscles  of  the  abdomen,  even  when  the 
lumbar  muscles  were  distinctly  affected.  Usually  the  head  is  free 
from  tremor  except  such  as  may  be  communicated  to  it  from  the 
distant  oscillation.  It  does  not,  however,  always  escape,  as  some 
have  asserted.  In  perfectly  characteristic  cases  of  paralysis  agitans  the 
head  may  present  conspicuous  tremor  in  consequence  of  contractions 
in  the  trapezius,  splenius,  and  even  in  the  sterno-mastoids, — con- 
tractions which  may  be  distinctly  felt,  and  are  sometimes  considerable, 
as  in  a  patient  with  shaking  of  the  arms,  stiffness  of  the  legs,  and 
typical  aspect ;  all  the  neck  muscles  were  involved,  but  those  at  the 
back  of  the  neck  in  greater  degree.  I  have  once  met  with  a  slight 
rotatory  tremor  of  the  head  due  to  the  deeper  muscles. f  The 
masseters  are  occasionally  affected,  causing  a  movement  of  the  jaw, 
which  may  amount  to  one  sixth  of  an  inch ;  the  contractions  may  be 
greater  on  the  side  on  which  the  limbs  are  most  involved.  The  jaw 
is  usually  affected  late — after  the  limbs,  but  in  one  case  the  affection 
of  the  jaw  came  on  after  the  limbs  on  one  side  were  involved  and 
before  the  affection  spread  to  those  on  the  other  side.  Occasionally 
the  tongue  is  affected ;  very  rarely  the  muscles  of  the  face.  I  have 
once  seen  distinct  persistent  tremor  in  the  orbicularis  palpebrarum  ; 
tremor  in  the  lower  facial  muscles  has  been  noted  by  Westphal,  and 
existed  in  the  lower  lip  and  chin  muscles  (as  well  as  in  those  of  the 
jaw)  in  a  case  in  which  only  one  arm  was  involved.  When  there  has 
been  tremor  of  the  tongue,  I  have  never  detected  any  movement  in  the 
soft  palate. 

The  movement  varies  much  in  its  range.  It  may  be  so  slight  as  to 
need  close  observation  to  detect  it,  or  may  amount  to  two  inches  at 
the  extremity  of  the  fingers.  It  is  always  slight  at  the  commencement 
and  increases  with  the  progress  of  the  disease. 

The  time  of  the  movement  (according  to  many  tracings  that  I  have 
taken)  varies  from  about  4-8  to  7  complete  oscillations  per  second  (see 
Fig.  149).  It  lessens  in  frequency  as  it  increases  in  range;  the  fine 
tremor  of  the  early  stage  is  often  distinctly  quicker  than  the  coarser 
tremor  of  the  later  period.     Thus  in  an  early  case,  the  very  fine  tremor 

*  I  may  remark  that  in  all  the  exceptional  cases  mentioned  in  the  text,  the 
diagnosis  of  the  disease  was  certain  ;  all  doubtful  cases  have  been  excluded. 

f  Slight  but  distinct  tremor  can,  indeed,  be  felt  in  the  neck  muscles  not  at  all 
rarely.  Since  I  have  carefully  searched  for  it,  I  have  found  it  in  no  less  than  eight 
out  of  thirty-seven  cases. 

VOL.  II.  41 


642  PAEAXYSIS  AGITANS. 

varied  from  6'4  to  7  oscillations  per  second ;  -whereas  in  a  later  case, 
with  a  range  of  movement  of  the  hand  from  one  to  two  inches,  the 
frequency  was  from  5  to  5  4  per  second.  The  tremor  in  the  leg  has 
nearly  the  same  i-ate  as  that  in  the  arm  in  the  same  case.  In  one 
patient,  the  frequency  in  the  arm  was  6  per  second,  and  that  in  the 
leg  was  68.  The  degree  of  movement  is  sometimes  very  uniform,  in 
others  it  is  somewhat  irregular,  but  it  never  approaches  the  irregu- 
larity of  some  other  forms  of  tremor.  I  have  only  once  observed  a 
tendency  to  a  rhythmical  variation. 

The  great  characteristic  of  the  tremor  of  paralysis  agitans  is,  as 
Parkinson  pointed  out,  that  it  continues  during  rest.  The  hands  go 
on  moving  when  they  are  resting  on  the  patient's  knee,  and  the  legs 
when  he  is  sitting.  A  voluntary  movement  may  stop  the  tremor  for 
a  few  seconds,  sometimes  for  many,  but  it  recommences  and  ac- 
companies the  movement.  Hence  the  patient's  handwriting  reveals 
his  disease ;  the  letters  may  be  fairly  formed,  but  every  line  is  a 
zigzag.  In  slight  cases  the  irregularity  may  be  so  fine  as  to  need  a 
magnifying  glass  to  recognise  it.  By  an  effort  the  patient  can  often 
stop  the  shaking  for  a  moment,  but  it  then  recurs  with  augmented 
violence.  Although  it  is  the  rule  for  the  tremor  to  continue  during 
rest,  the  rule  is  not  invariable  :  exceptions  are  occasionally  met  with. 
In  the  early  stage  of  the  disease,  prolonged  rest  frequently  lessens 
the  tremor  considerably,  and  this  in  cases  in  which,  at  a  later  stage, 
such  rest  is  without  influence.  Moreover,  in  a  very  early  stage  of 
the  disease,  the  tremor  may  be  distinct  and  even  considerable  on 
voluntary  movement,  and  may  almost  or  quite  cease  as  soon  as  the 
limbs  are  at  rest. 

Lastly,  rare  cases  are  met  with  in  which  the  disease  has  evidently 
existed  for  some  time,  and  yet  tremor  occurs  on  movement  only. 
This  is  especially  the  case  when  the  fixation  of  limb  preponderates 
over  the  tremor.  For  instance,  a  woman,  aged  sixty,  had  gradually, 
during  four  years,  passed  into  a  condition  in  which  the  features  had 
become  expressionless ;  there  were  the  characteristic  posture  and 
slowness  of  movement  to  be  presently  described,  considerable  weakness 
of  limb,  and  great  sense  of  heat.  During  rest  there  was  no  con- 
spicuous shaking,  and  only  the  finest  possible  tremor  could  be 
discerned  in  the  right,  the  weaker,  hand.  But  every  voluntary  move- 
ment was  attended  by  regular  coarse  typical  tremor,  and  this  not  only 
in  the  limbs,  but  in  the  masseters,  face,  and  tongue.  In  another  case, 
with  constant  tremor  in  the  fingers,  tremor  at  the  elbow-joint  occurred 
only  on  movement.  Occasionally  the  tremor  in  one  hand  is  constant, 
and  in  the  other,  last  affected,  occurs  only  on  movement.  Fine  tremor 
during  rest  sometimes  becomes  coarser  during  movement.  It  must, 
therefore,  be  remembered  that  the  persistence  of  the  tremor  dminc 
rest,  although  usual,  is  not  universal,  and  its  limitation  to,  or  increase 
by,  voluntary  movement,  does  not  disprove  the  indication  of  other 
symptoms  that  the  case  is  one  of  paralysis  agitans. 


SYMPTOMS. 


643 


If  the  tremor  is  unilateral,  and  the  shaking  of  the  hand  is  prevented 
by  force,  the  other  hand,  previously  free,  usually  begins  to  shake. 
The  same  result  may  follow  the  arrest  of  the  movement  by  an  effort 
of  the  will,  if  this  can  be  effected.     Sleep  usually  brings  stillness  to 


M\KKW 


Fig.  149. — Myographic  tracings  of  various  forms  of  tremor  taken 
di'  ectly  from  the  moving  parts.     Reduced  to  one  half.* 

1.  Tremor  after  hemiplegia;  very  fine,  rather  irregular. 

2 — 6.  Paralysis  agitans;  2  and  3,  very  fine  tremor ;  4,  5,  6,  coarse 
tremor. 

7.  Insular  sclerosis ;  very  irregular  in  range,  although  regular  in  time. 

8.  General  paralysis  of  the  insane. 

9.  Hysterical  tremor. 


*  These  tracings  are  fairly  typical  of  a  large  number  I  have  taken  of  various 
forms  of  tremor. 


044  PAEALYSIS    AG1TANS. 

the  shaking  limbs,  and  this  although  the  tremor  is  considerable  ;  it 
returns  on  waking,  usuaWy  slowly,  but  on  sudden  waking  from  a  dis- 
tressing dream  there  may  be  at  once  severe  tremor.  Rarely  some 
tremor  persists  during  sleep.  I  have  known  the  tremor  to  persist, 
during  sleep,  in  the  arm,  and  to  cease  in  the  leg.  In  rare  cases 
there- are  also  paroxysmal  exacerbations  of  the  tremor  in  the  waking 
state,  excited  especially  by  emotion.  The  legs  in  one  instance,, 
always  stiff,  were  only  at  times  the  seat  of  tremor. 

Muscular  weakness  and  rigidity  usually  come  on  together,  and  are  as 
characteristic  of  the  disease  as  is  the  tremor.  The  loss  of  power  varies 
much. in. degree.^  At  first  slight,  it  gradually  increases,  and  is  usually 
greatest  in  the  part  in  which  the  tremor  developed  first  and  most. 
The  patient  may  ultimately  be  unable  even  to  move  the  index  of  the 
dynamometer,  or  to  rise  from  his  seat.  But  the  paralysis  is  never 
absolute, — some  power  always  persists.  Voluntary  movement  is  not 
onlv  feeble  ;  it  is  also  slow.  It  may  be  slow  in  execution,  or  there 
may  be  a  delay  in  the  commencement  of  movements  that  are  performed 
with  fair  rapidity.  This  seems  to  be,  in  part  at  least,  the  result  of 
muscular  rigidity,  which  causes  a  resistance  to  passive  movement. 
Another  effect  of  the  rigidity  is  to  impress  certain  characteristic 
postures  on  the  limbs.  These  are  determined  by  the  fact  that  the 
rigidity  preponderates  in  certain  muscles,  chiefly  in  the  flexors.  The 
arms  are  flexed  at  the  elbow-joints,  sometimes  slightly,  sometimes 
almost  at  a  right  angle.  The  wrists  are  usually  slightly  extended. 
The  position  of  the  fingers  varies ;  in  many  cases  they  are  slightly 
flexed  at  all  joints,  in  the  position  that  they  naturally  assume  during 
rest;  often  they  are  flexed  at  the  metacarpophalangeal  joints  and 
extended  at  the  others,  from  preponderant  contraction  in  the  inter- 
ossei.*  Thei*e  may  even  be  over-extension  of  the  last  phalanx,  most 
marked  in  the  thumb,  perhaps  because  the  tip  of  the  thumb  is 
pressed  against  the  first  finger.  The  rest-posture  is  especially 
frequent  when  rigidity  preponderates  over  tremor.  When  the  inter- 
ossei  contract  in  the  tremor,  the  "interosseal  posture  "is  generally  very 
marked.  Usually  the  rigidity  can  be  readily  overcome,  but  in  extreme 
cases  (as  shown  in  Figs.  150  and  151)  the  contracture  of  the  inter- 
ossei  .may  go  on  to  the  degree  of  permanent  shortening,  so  that  the 
metacarpophalangeal  joints  cannot  be  passively  extended  beyond  a 
rio-ht  angle,  just  as  in  contraction  of  the  palmar  fascia. f  Occasionally 
only  one  finger  (as  the  index)  is  thus  affected.  In  the  legs  the 
rioidity  involves  chiefly  the  hip-  and  knee-joints,  causing  slight  flexion 
of  each,  and  adduction  of  the  thighs.  It  may  extend  to  the  feet,  and 
even  cause  talipes  equino-varus  and  distortion  of  the  toes — extension 
of  the  first  and  flexion  of  the  other  phalanges,  so  as  to  cause  a  claw-like 

*  In  rare  cases  the  digits  deviate  towards  the  ulnar  side,  as  in  chronic  rheuma- 
toid arthritis. 

f  The  contraction  in  these  cases  is  not  of  the  palmar  fascia,  Mr.  "W.  Adams  was 
good  enough  carefully  to  examine  one  case  for  me,  and  fully  confirmed  this  statement. 


SYMPTOMS. 


645 


■deformity.  Permanent  contraction  of  these  muscles  is  very  rare,  but 
I  have  known  each  foot  to  be  fixed  in  inversion. 

The  head  is  usually  carried  forwards,  and  the  upper  part  of  the 
spine  is  bent  in  the  same  direction  (Fig.  148).  In  very  rare  cases 
there  is  extension  of  the  spine  and  neck,  and  this  has  even  been 
known  to  replace  the  flexion.  The  facial  muscles  seem  to  be  unable 
to  respond  to  the  varying  changes  of  emotion  ;  the  expression  of  face 
is  a  fixed  anxious  look,  unvaried  by  smile  or  frown.  In  very  rare 
cases,  which  must  be  regarded  as  paralysis  agitans,  the  head  is  bent 
strongly  backwai'ds.  In  one  such  case  the  affection  commenced  in  the 
head,  but  I  have  seen  a  similar  case  in  which  the  arms  first  suffered. 
There  is  sometimes  a  difficulty  in  protruding  the  tongue. 

In  consequence  of  the  muscular  rigidity,  certain  complex  move- 
ments are  performed  in  a  peculiar  and  characteristic  manner.  One  of 
these  is  walking.  The  patient  rises  up  slowly  from  the  chair  with 
head  and  shoulders  bent  forwards.  His  steps  are  short,  and  the  first 
may  be  taken  slowly  and  with  difficulty,  but  they  become  quicker  and 
quicker,  until  the  patient  seems  to  be  about  to  run  ("  festination  "), 
and  often,  from  the  inclination  of  the  body,  to  be  on  the  point  of 
falling  forwards  ("propulsion").  It  has  been  thought  that  this 
tendency  to  run  is  due  simply  to  the  forward  inclination  of  the  body  ; 
the  patient,  as  Trousseau  expressed  it,  has  to  run  after  his  centre  of 


Fig.  150. 


Fig.  151. 


Fig.  150. — Paralysis  agitans.  Posture  of  hands  from  contracture  of  the 
interossei :  a,  left  hand  ;  b,  right  hand.  In  the  left  hand  the  contracture 
is  greater  than  in  the  other,  and  has  led  to  some  permanent  shortening  of 
the  interossei,  so  that  the  fingers  cannot  be  extended  even  passively.  The 
maximum  passive  extension  is  shown  at  c. 

Fig.  151. — Contraction  of  fingers  in  paralysis  agitans;  Maximum 
voluntary  extension. 


646  PARALYSIS    AG1TANS. 

gravity  ;  but  that  this  is  not  the  whole  explanation  is  shown  by  the  fact 
that  some  patients,  suddenly  jerked  backwards,  may  exhibit  a  tendency 
to  walk  backwards  which  they  are  unable  to  avoid  ("  retropulsion  "), 
and  this  although  they  stoop  forwards.  It  is,  indeed,  not  uncommon 
for  patients  to  be  able  to  walk  backwards  better  than  forwards.  In 
one  case,  an  irresistible  tendency  to  run  backwards  existed  only  on 
first  rising  in  the  morning.  Usually  the  patient's  equilibrium  is  easily 
disturbed,  and  even  when  they  walk  faii'ly  well  they  have  considerable 
difficulty  in  turning  suddenly.  One  patient,  in  turning,  often  took  a 
few  unintended  steps  to  one  side. 

The  slowness  of  muscular  action  is  usually  conspicuous  in  all  move- 
ments, but  it  rarely  affects  the  muscles  of  the  eyes.  If  the  patient  is 
to  look  in  a  given  direction,  the  eyes  are  instantly  turned,  while 
the  head  slowly  follows  them.*  Speech  has  usually  well-marked 
characteristics :  the  voice  is  monotonous,  being  no  more  varied  by 
emotional  expression  than  is  the  face.  There  is  a  delay  in  commencing 
a  sentence,  but,  once  commenced,  the  words  are  uttered  rapidly,  often 
with  some  confluence  of  syllables;  there  is  "  festination "  in  speech 
analogous  to  that  in  walking — a  condition  opposite  to  the  separation 
of  syllables  met  with  in  disseminated  sclerosis.  It  is  as  if  the  patient 
tried  to  speak  with  a  minimum  of  exertion,  and  to  get  his  utterance 
over  as  soon  as  possible. 

As  already  stated,  although  the  weakness  and  rigidity  are  usually 
secondary  to  the  tremor,  they  may  come  first.  We  have  seen  that 
they  precede  marked  tremor  in  one  sixth  of  the  cases.  It  is  not  at  all 
rare  for  them  to  precede  the  tremor  in  parts  secondarily  affected. 
Thus  a  patient  may  present  the  ordinary  tremor  and  weakness  in  one 
hand,  and  there  may  be  no  tremor  in  the  other,  which  may  yet  be 
weak  and  present  the  characteristic  posture,  position,  and  slowness  of 
movement.  "When  the  rigidity  and  weakness  constitute  the  first 
symptom  of  the  disease,  they  sometimes  become  general  before  the 
tremor  is  conspicuous.  Often,  however,  in  such  cases,  slight  shaking 
may  be  perceived  if  it  is  carefully  looked  for,  or  may  occur  on  move- 
ment, sometimes  for  a  few  moments  only.  On  the  other  hand,  there 
is  sometimes  very  little  loss  of  power  although  the  tremor  is  great. 
In  one  man,  for  instance,  with  severe  shaking  in  the  left  arm,  slight 
in  the  left  leg,  and  scarcely  any  in  the  right  arm,  the  grasp  of  the  right 
hand  was  sixty-two  kilogrammes,  and  that  of  the  left  was  fifty-six. 

The  myotatic  irritability  in  the  limbs  is  usually  normal,  the  knee- 
jei'k  is  not  increased,  and  although  the  foot,  when  resting  on  the 
ground,  may  be  moved  by  clonic  spasm  in  the  gastrocnemius,  just  as 
it  is  in  the  foot-clonus,  no  clonus  can  be  obtained  by  passive  flexion 
of  the  ankle.  In  exceptional  cases,  however,  there  is  distinct  excess 
in  these  contractions,  generally  limited  to  an  increase  of  the  knee- 

*  Debove,  however,  has  noted  a  retardation  in  the  movement  of  the  eyes  which, 
if  the  patient  was  reading,  occasioned  a  characteristic  pause  at  the  end  of  each  line, 
but  this  is  extremely  rare. 


■SYMPTOMS.  647 

jerk ;  in  very  rare  instances  a  typical  foot-clonus  can  be  obtained. 
The  superficial  reflex  action  is  also,  as  a  rule,  normal.  The  sphincters 
are  rarely  affected ;  occasionally,  in  the  advanced  stage,  the  power  of 
retaining  the  urine  is  weakened,  but  I  have  never  met  with  actual 
incontinence. 

The  nutrition  of  the  muscles  does  not  suffer  until  late  in  the  disease. 
The  continuous  activity  might  be  expected  to  lead  to  hypertrophy,  and 
it  has  been  said  to  occur,  but  it  is  doubtful  whether  there  is  ever  a  real 
.increase  in  bulk.  In  most  cases,  as  the  disease  goes  on,  and  rigidity 
sets  in,  the  muscles  lessen  in  size,  and  there  may  even  be  conspicuous 
wasting.  The  electric  irritability  of  muscles  and  nerves  may  be  un- 
changed, but  a  slight  increase  may  often  be  detected  when  the  unilateral 
character  of  the  disease  permits  comparison  of  the  two  sides,  and, 
at  a  late  period,  there  may  be  a  slight  diminution  in  irritability.  I 
have  seen  instances  of  both  these  changes.  The  alteration  is  never 
considerable,  and  is  always  the  same  to  each  form  of  electricity. 

Sensory  and  Vaso-motor  Symptoms. — Cutaneous  sensibility  is  never 
affected  in  paralysis  agitans,  but  subjective  sensations  are  frequent. 
Aching  pains  in  the  limbs,  more  or  less  "  rheumatic  "  in  character,  are 
occasionally  complained  of  in  the  early  stage,  and  they  may  corre- 
spond in  seat  with  the  commencing  tremor.  When  the  movement  is 
considerable,  it  occasions  a  great  sense  of  fatigue,  which  is  accom- 
panied, after  a  time,  by  extreme  restlessness,  and  every  few  minutes 
some  slight  change  of  posture  is  desired.  Frequently  also  (in  three 
quarters  of  the  cases)  there  is  some  abnormal  sensation  of  tempera- 
ture. The  most  common  is  a  sense  of  heat,  to  which  Charcot  first 
directed  attention.  I  have  found  this  to  be  present  in  half  the  cases 
in  which  the  point  was  investigated.  When  slight,  it  may  only  cause 
the  patient  to  dislike  hot  rooms  or  many  bedclothes ;  but  when 
more  considerable  it  is  a  source  of  much  discomfort,  and  only  the 
thinnest  covering  can  be  endured  at  night,  even  in  the  depth  of  winter. 
Such  sufferers  are,  as  a  rule,  more  comfortable  in  winter  than  in 
summer.  The  sensation  may  be  referred  to  the  interior  of  the  body 
or  to  the  limbs,  and  sometimes  it  is  localised  in  the  most  affected 
limb,  especially  in  the  extremity.  One  patient  whose  right  hand 
alone  shook,  complained  of  burning  heat  in  the  palm,  passing  up  the 
radial  side  of  the  forearm  to  the  bend  of  the  elbow.  Another,  with 
tremor  in  the  left  arm,  never  would  allow  this  arm  to  be  under  the 
bedclothes.  G-rasset  asserts  that  this  local  sense  of  heat  is  always 
the  accompaniment  of  an  actual  elevation  of  the  peripheral  tempera- 
ture, which  is  higher  than  iu  another  individual  in  the  same  part ; 
but  this  is  not  generally  true  :  the  temperature  of  the  body,  as  a 
rule,  is  normal,  and  I  have  known  actual  coolness  of  the  extremities 
to  co-exist  with  a  sense  of  heat  in  them.* 

The  sensation  of  heat  may  be  absent,  when  the  tremor  is  violent, 

*  I  have,  however,  once  found  the  affected  side  (in  which  there  was  an  intense 
sense  of  heat)  '6°  F.  warmer  than  the  other. 


648  PARALYSIS    AGITANS. 

and  it  may  precede  tlie  movement.  Thus  in  one  of  my  patients,  the 
sensation  preceded  any  tremor  for  four  years.  In  a  few  cases,  instead 
of  a  feeling  of  heat,  there  is  an  abnormal  sensation  of  cold ;  the 
patient  always  feels  chilly,  or  there  is  a  special  sense  of  coldness  in 
the  affected  limbs.  Such  patients  like  warmth,  and  may  shake  more 
-when  cold.  Sensations  of  cold  and  heat  may  alternate ;  in  one  case, 
as  the  disease  progressed,  the  occasional  sensations  of  cold  gradually 
yielded  to  an  enduring  sense  of  -warmth,  but  the  alternation  may  per- 
sist even  nntil  the  late  stages  ;  at  one  time  the  patient  feels  cold,  and 
at  another  bursts  into  perspiration.  Very  rarely  there  is  a  sense  of 
heat  in  one  part  and  of  coldness  in  another.  It  is  probable  that  these 
sensations,  and  the  local  elevation  of  temperature,  are  due  to  vaso- 
motor conditions.*  The  sense  of  heat  is  very  frequently  accompanied 
by  increased  perspiration,  -which  may  be  general  and  profuse  on  the 
least  exertion  of  mind  or  body.  One  patient,  could  not  dictate  the 
simplest  letter,  even  in  winter,  without  first  having  his  coat  taken  off, 
so  intense  was  the  perspiration  caused.  Sometimes  sweating  is  local, 
corresponding  to  the  sense  of  heat.  In  one  patient,  with  left-sided 
agitation,  the  left  axilla  was  always  wet  with  perspiration,  while  the 
right  was  always  dry.  This  phenomenon  sometimes  corresponds  with 
another  indication  of  disturbed  function  of  the  sympathetic,  a  small 
pupil.  In  unilateral  paralysis  agitans,  I  have  several  times  observed 
the  pupil  on  the  affected  side  to  be  smaller  than  on  the  other,  and  iu 
one  of  these  cases  the  patient  perspired  much  on  the  corresponding 
side  of  the  head.  Frequently  both  pupils  are  small,  but  this  may  be 
merely  the  common  senile  rnyosis.  They  always  act  to  light  in  un- 
complicated cases.  (Edema  of  the  legs  may  exist  in  the  later  stages 
of  the  disease.  The  urine  is  sometimes  increased  in  quantity.  Accord- 
ing to  Cheron  it  usually  contains  an  excess  of  phosphates. 

The  intellect  may  be  unaffected  throughout,  except  by  the  irri- 
tability which  usually  accompanies  the  physical  restlessness,  or  by 
mental  depression,  which  is  chiefly  the  natural  result  of  the  physical 
ailment.  Pronounced  mental  symptoms  are  occasionally  present, 
however,  in  the  later  stages  of  the  disease,  especially  mental  weakness 
and  loss  of  memory,  and  they  may  occur  early  in  its  course.  If 
tremor  is  inconspicuous,  they  add  considerably  to  the  misleading 
aspect  of  the  ease.  Very  rarely  they  are  accompanied  by  a  tendency 
to  delusions,  and  occasionally  they  amount  to  actual  dementia. 

Varieties. — The  aspect  of  a  case  of  paralysis  agitans  varies  consider- 
ably according  to  the  extent  and  distribution  of  the  symptoms,  which 
led  Marshall  Hall  to  distinguish  "  hemiplegic "  and  "paraplegic" 
forms  ;  and  to  these  a  "  monoplegic  "  fomi,  in  which  only  one  limb  is 
affected,  has  been  added  by  Berger.  These  are  not,  however,  varieties, 
and   should  not  be  described  as  such  ;  they  are  merely  prolonged 

*  It  is  also  possible  that  the  sensation  may  be  due,  in  part  at  least,  to  changes  iu 
the  sensory  centres  of  the  brain,  and  that  the  vaso-motor  disturbance  may  be  an 
associated  effect  of  these  or  other  central  changes. 


SYMPTOMS.  649 

stages  of  a  disease  which  tends  to  become  universal.  The  aspect  of 
the  case  is  also  influenced  by  the  kind  of  tremor,  whether  fine  or 
coarse.  It  also  depends  on  the  amount  of  weakness  and  fixation  of 
limb,  and  the  relation,  in  point  of  time,  between  this  and  the  tremoi', 
since,  as  already  mentioned,  the  general  aspect,  rigidity,  position  of 
limb,  and  muscular  weakness  may  be  conspicuous  before  the  tremor 
is  perceptible.  It  is  this  feature  that  gives  rise  to  the  best  marked 
variety  of  the  disease.  A  distinction  has  been  made  (by  Charcot) 
between  the  flexor  and  extensor  types,  but  it  is  unimportant  on  account 
of  the  rarity  of  the  latter. 

Complications. — An  attack  of  ordinary  hemiplegia  may  occur  during 
the  course  of  paralysis  agitans  without  evidence  of  any  closer  connec- 
tion between  the  two  diseases  than  is  involved  in  the  patient's  age. 
As  already  stated,  the  hemiplegia  arrests  the  tremor,  but,  if  the  para- 
lysis is  not  permanent,  the  shaking  returns  with  power  of  movement, 
and  often  becomes  much  greater  than  before  the  palsy,  as  Parkinson 
long  ago  pointed  out.  It  is  said  that  sudden  transient  hemiplegic 
weakness  may  occur  from  time  to  time  without  any  lesion  being  found 
in  the  brain  to  explain  it  (Berger),  and  I  have  known  occasional 
sudden  attacks  of  transient  general  powerlessness  to  occur.  Early 
mental  failure  has  been  already  mentioned.  I  have  once  met  with 
convulsive  attacks  resembling  ordinary  epilepsy,  as  a  complication  of 
paralysis  agitans.  The  patient  was  a  woman,  and  both  symptoms 
commenced  at  the  same  time,  at  fifty-nine  years  of  age.  Buzzard  has 
recorded  a  case  in  which  there  was  a  semi-cataleptoid  condition  of 
the  limbs  ;  when  raised  they  remained  so  for  several  minutes,  and 
then  slowly  fell.  Cramp  in  the  legs  and  soles  of  the  feet  is  very 
troublesome  in  some  cases. 

Course. — The  disease  is  always  chronic,  and  usually  progressive,  in 
its  course.  The  varieties  which  it  presents  in  its  mode  of  extension 
have  been  already  described.  The  rate  of  progress  is  sometimes 
extremely  slow.  It  may  remain  for  two  or  three  years  limited  to  the 
limb  first  attacked.  Usually,  if  commencing  in  the  arm,  the  leg  on 
the  same  side  is  involved  within  two  years.  Sometimes  the  extension 
to  the  leg  takes  place  in  two  or  three  months,  and  occasionally  the 
arm  and  leg  are  affected  at  the  same  time.  The  date  of  extension  to 
the  opposite  side  varies  from  six  months  to  three  or  four  years  after 
the  onset.  The  shortest  time  in  which  I  have  known  all  four  limbs 
to  be  affected,  in  a  case  beginning  locally,  was  nine  months.  Not 
unfrequently  the  tremor  is  limited  to  one  arm  for  a  considerable  time 
and  then  rapidly  spreads.  For  instance,  in  one  case  the  left  arm  was 
alone  affected  for  two  years,  then  extension  to  the  leg  occurred,  and, 
three  months  later,  to  the  right  arm  and  leg.  In  other  cases,  again, 
the  affection  may  spread,  in  the  course  of  a  few  months,  from  the  arm 
to  the  leg  on  the  same  side,  and  two  or  three  years  may  elapse  before 
the  other  side  suffers.  Usually  the  tremor  spreads  when  it  is  still 
moderate    in  the  part   first   attacked,  and   there  is  a  gradation  of 


650  PARALYSIS    AGITANS. 

severity  in  the  different  limbs,  roughly  proportioned  to  the  duration 
of  the  tremor.  Sometimes,  however,  it  becomes  severe  in  the  part 
first  attacked  before  it  spreads,  or  it  maybe  slight  in  other  parts  even 
when  general,  and  intense  in  the  limb  in  which  it  began.  Very  rarely 
the  tremor  lessens  as  the  disease  advances,  and  rigidity  fixes  the  limbs. 
Thus,  in  one  patient,  as  the  second  hand  became  affected,  the  first 
became  stiff  and  rigid,  and  the  tremor  lessened  until  it  was  much  less 
than  in  the  second  arm  The  variations  in  extension  are  thus  so 
great  as  to  make  it  difficult  to  foretell  the  course  of  a  commencing  case. 
Duration  and  Cause  of  Death. — Paralysis  agitans  does  not  directly 
cause  death,  and  the  advanced  age  of  most  of  its  subjects  renders  its 
duration,  and  its  influence  in  shortening  life,  difficult  to  determine. 
It  usually  lasts  several  years.  The  longest  case  which  has  come 
under  my  own  observation  has  existed  for  ten  years,  but  the  disease 
has  been  known  to  last  for  twenty  and  even  for  thirty  years.  Death 
sometimes  occurs  from  exhaustion,  bedsores,  &c,  in  the  later  stage; 
more  frequently  from  intercurrent  affections,  especially  of  the  respira- 
tory organs,  facilitated  by  the  progressive  muscular  weakness,  which 
involves  the  thoracic  muscles  as  well  as  others.  The  tremor  has  been 
observed  to  cease  before  death. 

Pathological  Anatomy. — In  most  of  the  cases  of  paralysis  agitans- 
that  have  been  examined  by  modern  methods  and  by  competent  ob- 
servers (Charcot,  Westphal,  Berger,  &c),  no  changes  have  been  dis- 
covered in  the  central  nervous  system  or  in  the  sympathetic  ganglia; 
and  this  although  some  of  the  cases  were  well  marked  and  unilateral, 
so  that  the  two  halves  of  the  nerve-centres  could  be  compared.  This 
fact  renders  it  doubtful  whether  the  changes  described  by  some — for 
the  most  part  older — observers,  had  any  relation  to  the  disease.  An 
hypertrophy  of  the  nerve-cells  of  the  pons  Varolii,  which  was  de- 
scribed by  Luys,  has  not  been  found  by  others,  and  may  be  dismissed 
from  consideration.  An  induration  of  the  pons,  medulla,  and  cord  was 
noted  by  Parkinson,  and  has  since  been  reported  by  several  observers, 
but  it  probably  belongs  to  the  changes  which  alone  are  found  with 
comparative  frequency,  those  due  either  to  senility  or  to  the  indirect 
consequences  of  the  long  disturbance  of  function,  which  are  without 
significance  as  to  the  seat  of  its  source  or  the  nature  of  its  cause. 
Among  the  senile  changes  is  the  common  wasting  of  various  parts  of 
the  cerebral  nervous  system,  cortex,  and  spinal  cord,  increase  of  the 
interstitial  tissue,  and  degeneration  of  the  arteries.  These  are  all,  how- 
ever, frequently  absent.  Especial  weight  has  been  attached  to  inter- 
stitial sclerosis  of  the  peripheral  nerves  and  traces  of  chronic  changes  in 
the  muscles,  supposed  to  suggest  inflammation  in  them  ;  but  these 
may  reasonably  be  regarded  as  among  the  second  class  of  changes, 
those  that  result  from  the  long-continued  functional  disturbance.* 

*  For  some  recent  observations  on  the  pathological  histology  of  the  disease  see 
Roller,  'Virchow's  Arch.,'  Bd.  cxxv,  and  Ketscher,  'Neur.  Cent.,'  March,  1893. 


PATHOLOGY.  651 

Pathology. — In  the  absence  of  any  anatomical  evidence  of  the  seat 
and  nature  of  the  disease,  the  pathology  of  paralysis  agitans  has  been 
the  subject  of  copious  speculation,  into  much  of  which  it  is  not  pro- 
fitable to  enter  at  length.  The  facts  of  the  disease  suggest,  however, 
certain  conclusions  which  may  be  briefly  pointed  out.  We  are  justi- 
fied in  regarding  the  affection  as  one  of  the  central  nervous  system, 
since  we  know  nothing  of  clonic  spasm  in  whole  muscles  (and  emphatic- 
ally nothing  of  such  contractions  alternating  in  opposing  muscles), 
in  consequence  of  a  primary  disease  of  the  muscles  themselves, 
or  in  consequence  of  idiopathic  disease  of  the  nerves.  Such  clonic 
contractions  must  be  ascribed  to  the  abnormal  action  of  nerve-cells. 
Tonic  contractures  may  be  the  result  of  primary  muscular  changes,  but 
they  also  are  more  commonly  the  result  of  a  morbid  state  of  the  nerve- 
centres,  and  the  correspondence  in  seat  of  the  clonic  spasm  and  con- 
tracture of  paralysis  agitans  makes  it  almost  certain  that  both  are  due 
to  the  same  cause;  the  fact  that  tonic  contracture  may  precede  clonic 
spasm  prevents  us  from  regarding  the  former  as  the  result  of  muscular 
changes  induced  by  the  latter.  That  the  morbid  action  is  not  primarily 
in  the  spinal  cord  is  probable  from  the  facts  that,  as  a  rule,  even  when 
severe,  the  tremor  ceases  during  sleep,  and  that  the  unilateral  com- 
mencement and  hemiplegic  extension  are  unlike  those  of  spinal  cord 
disease.  The  regions  which  have  been  thought  to  be  the  seat  of  the 
morbid  process,  by  different  authorities,  are  the  pons,  the  corpora 
quadrigemina,  and  the  cerebellum.  Regarding  the  two  former,  the 
theories  are  purely  speculative.  We  know  at  present  little  of  the 
function  of  the  large  amount  of  grey  matter  which  is  interspersed 
among  the  fibrous  tracts  of  the  pons,  or  the  symptoms  of  its  disease  ; 
but  the  effects  of  lesions,  degenerative  or  acute,  of  other  parts  of  the 
pons  lend  no  support  to  the  hypothesis.  Nor  have  symptoms  in 
any  way  resembling  paralysis  agitans  been  observed  in  disease  of 
the  corpora  quadrigemina.  The  theory  that  regards  the  cerebellum 
as  the  part  affected  is  due  to  Dr.  Hughlings  Jackson,  but  the 
only  actual  fact  on  which  it  is  based  is  that  in  some  rare  cases  of  cere- 
bellar disease  the  interosseal  position  of  the  hands  has  been  con- 
spicuous. This  has  led  him  to  suppose  that  there  is  a  normal 
antagonism  between  the  cerebral  and  cerebellar  influence,  the  former 
tending  to  cause  flexion  of  all  the  phalangeal  joints,  the  latter 
flexion  of  the  metacarpophalangeal  and  extension  of  the  others  by 
the  interossei.  But  the  symptom  is  extremely  rare  in  cerebellar 
disease ;  as  a  rule,  it  is  absent,  and,  by  the  converse  process  of 
reasoning,  it  might  with  equal  cogency  be  ascribed  to  unantagonised 
cerebral  influence.  The  same  posture  of  hand  is  seen  in  tetany,  in 
many  cases  of  post-hemiplegic  disorder  of  movement,  and,  what  is- 
less  equivocal,  it  is  a  common  posture  of  the  hand  during  epileptic 
convulsions,  in  which  the  excess  of  nerve  force  is  certainly  not  evolved 
from  the  cerebellum.  If  we  turn  to  another  class  of  facts,  the  cases 
in  which  tremor  results  from  orgauic  disease  of  the  nervous  system, 


652  PAEALYSIS    AGITANS. 

we  find  the  disease  situated,  as  a  rule,  within  the  cerebral  hemi- 
spheres, in  the  optic  thalamus,  posterior  part  of  the  internal  capsule, 
foot  of  the  corona  radiata  (Notbnagel),  parietal  lobe  of  the  cortex 
(Chvostek),  and  island  of  Eeil  (Leyden). 

In  considering  further  the  indications  afforded  by  the  symptoms  as 
to  the  part  of  the  brain  that  is  the  seat  of  the  primary  disease,  the 
first  obvious  considerations  are  those  that  are  mentioned  in  the 
discussion  of  the  pathology  of  chorea,  and  are  equally  applicable  to 
paralysis  agitans. 

That  man,  as  regards  his  physical  frame,  is  a  member  of  the 
animal  world  is  generally  admitted,  and  makes  it  instructive  to  trace 
the  indications  of  the  relationship  in  disease  and  its  causation. 
Tremor  is  an  effect  of  fear  in  animals  as  in  man,  and  doubtless 
depends  upon  a  relation  between  the  centres  concerned  in  the  emotion 
and  those  which  produce  the  motion  needed  to  save  from  danger,  and 
which  underlies  the  meaning  of  the  original  word.  It  is  when  the 
motion  cannot  take  place  that  the  influence  on  the  motor  centres 
•deranges  their  action  in  the  manner  that  is  manifested  as  spontaneous 
tremor  (see  under  Exophthalmic  G-oitre).  The  profound  disturbance 
may  even  be  associated,  in  man,  with  an  inhibition  of  voluntary 
motion,  as  when  a  person  is  "  paralysed  by  fear,"  an  expression  by 
no  means  merely  symbolical.  Such  a  disturbance  must  have  a  pro- 
longed influence  on  the  nutrition  of  the  disturbed  structures,  and  it 
is,  therefore,  not  surprising  that  it  should  lead  to  disease  in  those 
who  are  predisposed — in  the  old  to  paralysis  agitans,  in  the  still 
unstable  centres  of  the  young  to  chorea.  Such  considerations  lead 
us  to  regard  the  motor  centres  of  the  cortex  as  being,  in  both  diseases, 
the  seat  of  the  derangement  on  which  the  symptoms  depend. 
If  we  ascend  the  motor  path  from  the  spinal  cord,  the  first  nerve- 
•cells  we  meet  are  those  of  the  motor  cortex ;  and  if  the  stimulation 
causing  the  tremor  comes  from  the  brain,  it  must  proceed  immediatelv 
from  these  cortical  nerve-cells.  That  it  does  so  is  rendered  addi- 
tionally probable  by  the  fact  that,  as  I  have  observed,  an  attack  of 
cerebral  hemiplegia  at  once  arrests  the  spasm  on  the  affected  side. 

The  question  then  presents  itself — Are  not  these  cortical  cells  the 
primary  seat  of  the  disease?  The  early  symptoms  of  paralysis 
-agitans  are  almost  exclusively  motor,  and  there  is  nothing  in  them 
that  is  inconsistent  with  their  origin  in  this  part  of  the  cortex.  Their 
peculiarities  must,  on  any  hypothesis,  be  due  less  to  the  seat  than  to 
the  nature  of  the  morbid  process.  The  only  sensory  symptoms  that 
are  present  are  secondary  in  time  and  inconstant  in  occurrence ;  they 
are,  therefore,  probably  secondary  in  their  origiu  and  distiuct  in 
their  som-ce.  We  do  not  at  present  know  on  what  they  depend, 
whether  the  abnormal  sense  of  temperature  is  due  to  derangement 
of  the  sympathetic,  or  is  the  result  of  a  change  in  the  sensory  centres 
in  the  brain.  In  the  occasional  inequality  of  the  pupil,  which  is 
smaller  on  the  most  affected  side,  we  have  evidence  of  diminished 


PATHOLOGY.  653 

action  of  the  sympathetic ;  and  the  local  increase  in  temperature,, 
occasionally  observed,  may  have  a  similar  significance.  But  we  know 
of  no  mechanism  by  which  the  motor  symptoms  can  arise  from  a 
primary  derangement  of  the  sympathetic,  and  it  is  probable  that  this  is 
simply  secondary.  It  is  certain  that  the  functions  of  the  sympathetic 
are  represented  in  the  cortex,  and  may  be  deranged  by  cortical  dis- 
ease. Lastly,  it  may  be  remarked  that  the  tremor  of  fear  just 
referred  to*  is  most  readily  conceived  as  of  cortical  origin.  At  the 
same  time  it  must  be  remembered  that  all  disturbed  function  of  high 
motor  centres  is  expressed  through  lower  centres  (e.  g.  through  the 
motor  nerve-cells  of  the  spinal  cord),  the  functions  of  which  are  thus, 
disturbed  in  a  similar  though  secondary  manner,  aud  such  secondary 
disturbance,  when  long  continued,  may  tend  to  acquire  relative 
independence. 

The  slight  change  in  the  electric  irritability  of  the  peripheral 
nerves  may  have  the  same  significance  as  in  chorea,  and  the  remarks 
on  p.  600  are  equally  applicable  to  paralysis  agitans.  The  structural 
changes  in  the  muscles  present  in  rare  cases  are  no  doubt  merely  the 
result  of  their  long-continued  active  contraction. 

The  precise  character  of  the  motor  disturbance  in  shaking  palsy 
must  depend  on  the  nature  of  the  morbid  process.     This  is  apparently 
one  that  leads  to  a  treble  change.     There  is  the  intermitting  release 
of  nerve-force,  causing  the  tremor ;  there  is  a  more  continuous  and 
slighter  activity  of  the  cells,  producing  the  rigidity ;  and  there  is. 
lessened  capacity  for  activity,  causing  the  weakness.     It  is  possible 
that  these  are  the  result  of  slight  differences  in  the  precise  character 
of  the  morbid  change  in  the  same  cells.     What  that  change  is  we- 
have  as  yet  no  indication.     The  persistence  of  the  disturbance  of 
function  shows  that  it  must  depend  on  changes  in  nutrition,  but  the.-e 
are  apparently  far  too  fine  to  be  revealed  by  alterations  of  structure 
recognisable  by  the  microscope.     Their  relation  to  age  as  well  as  then- 
character  justifies   us  in  regarding  them  as  "  degenerative,"  while 
their  character  on  the  one  hand,  and  the  negative  results  of  micro- 
scopical research  on  the  other,  alike  show  that  the  alterations  innutri- 
tion must  begin  in  the  nerve-elements  themselves.     Tremor  no  doubt 
depends  immediately  on  physiological  arrangements  in  the  nervous 
system,  which  determine  the  relative  action  of  antagonistic  muscJes. 
We  have  already  considered  this  question  in  connection  with  the 
pathology  of  nystagmus.     Every  contraction  of  one  set  of  muscles 
involves  a  related  contraction  of  their  opponents,  essential  for  the 
steadiness  of  muscular  action  and  facilitating  the  alternation  of  move- 
ments ;  it  is  easy  to  conceive  that  tremor  may  result  from  its  de- 
rangement. 

*  In  connection  with  the  probable  source  of  the  movement,  a  curious  symptom 
described  by  one  patient  may  be  mentioned.  There  was  tremor  in  the  arm,  and. 
rigidity  in  the  leg  with  a  constant  feeling  that  it  was  going  to  shake. 


654  *  PARALYSIS    AGITANS. 

Diagnosis. — When  its  symptoms  are  well  marked,  no  disease  is 
more  easily  recognised  than  paralysis  agitans.  The  patient's  aspect, 
carriage  of  body  and  limb,  and  continuous  movement  make  up  an 
unmistakable  picture.  A  difficulty  arises  chiefly  in  cases  in  which 
the  tremor  is  absent  or  quite  indistinct,  and  the  evidence  of  the 
disease  consists  only  of  the  loss  of  power  and  the  fixity  of  feature  and 
of  limb,  the  slowness  of  movement,  and  the  forward  stoop.  A  know- 
ledge of  the  significance  of  these  symptoms,  which  are  as  characteristic 
as  is  the  tremor,  will  prevent  error.  It  is  important  that  their  aspect 
(as  distinct  when  tremor  is  present  as  wben  it  is  absent)  should  be 
firmly  fixed  in  the  student's  memory.  The  greatest  difficulty  is  when 
weakness  and  stiffness  of  the  limbs  come  on  without  the  usual  attitude 
and  facial  expression,  and  especially  if  there  is  also  chronic  mental 
failure.  I  have  known  the  nature  of  such  a  case  to  be  either  mis- 
taken or  mysterious  during  many  years.  The  absence  of  increase  in 
the  myotatic  irritability  constitutes  a  difference  from  most  other 
diseases  causing  similar  weakness  ;  but,  as  a  rule,  the  aspect  of  the 
patient  and  mode  of  movement  are  at  once  distinctive. 

In  some  cases  the  weakness  of  the  legs  is  the  chief  source  of  incon- 
venience to  the  patient,  and  the  case  may  be  thought  at  first  to  be 
one  of  disease  of  the  spinal  cord ;  but  attention  to  the  state  of  the  arms 
and  face  willgenerally  show  the  nature  of  the  case,  and  a  knowledge 
of  the  occasional  limitation  of  the  symptoms  to  weakness  and  rigidity 
of  the  legs  is  sufficient  to  prevent  a  mistake. 

There  are  certain  other  diseases,  however,  from  which  there  may 
be  a  difficulty  in  distinguishing  cases  that  are  not  very  well  marked. 
Old  persons  sometimes  present  fine  tremor  of  limb  which  bears  con- 
siderable resemblance  to  that  of  commencing  paralysis  agitans,  but 
does  not  present  the  same  tendency  to  increase,  or  the  associated 
rigidity.  This  "  senile  tremor "  occurs  chiefly  in  extreme  old  age, 
while  paralysis  agitans  usually  commences  somewhat  earlier.  In  senile 
tremor  the  head  is  especially  affected,  and  often  is  the  part  in  which 
the  shaking  commences,  while  in  paralysis  agitans  it  usually  escapes, 
and  its  affection  is  seldom  considerable.  Senile  tremor  often  com- 
mences on  both  sides,  paralysis  agitans  almost  always  on  one.  There 
is  not,  however,  a  sharp  line  of  demarcation  between  the  two  affections, 
and  it  may  be  difficult  to  say  in  which  category  some  cases  should  be 
placed.  Moreover,  simple  tremor  sometimes  exists  throughout  life, 
especially  in  males,  beginning  about  the  time  of  puberty  and  per- 
sisting with  only  slight  variations  in  degree.  When  such  a  patient 
reaches  the  late  period  of  life,  he  may  be  thou-ht  to  be  the  subject  of 
paralysis  agitans,  but  the  other  symptoms  of  this  disorder  are  absent, 
the  tremor  is  less  regular,  affects  the  head  in  conspicuous  degree,  and 
the  history  of  the  two  affections  is  different.  Nevertheless  it  is 
possible  that  some  examples  have  been  published  as  instances  of  para- 
lysis agitans  beginning  in  early  life. 

In  "  disseminated"  or  "insular"  sclerosis,  tremor  occurs  on  move- 


PROGNOSIS.  655 

merit  only,  and  is  usually  more  jerky  and  irregular  in  character  than 
in  paralysis  agitaus.  In  the  cases  of  shaking  palsy  in  which  the 
tremor  ceases  during  rest,  thei-e  are  the  general  aspect,  carriage,  and 
rigidity  which  are  absent  in  disseminated  sclerosis.  Moreover,  insu- 
lar sclerosis  usually  occurs  before,  paralysis  agitans  after,  thirty-five. 
In  the  former  the  head  is  usually  conspicuously  affected,  and  there  is 
nystagmus,  a  symptom  unknown  in  the  latter.  In  sclerosis,  articula- 
tion is  syllabic  ;  in  paralysis  agitans  the  words  are  uttered  quickly, 
and  there  is  a  tendency  to  run  them  together,  rather  than  to  separate 
the  syllables.  In  the  majority  of  cases  these  indications  will  enable 
the  diagnosis  to  be  made  without  difficulty.  In  very  rare  cases 
(Herterich,  Schultze)  insular  sclerosis  is  said  to  have  been  found  after 
death,  although  the  symptoms  of  paralysis  agitans  were  present  dur- 
ing life,  but  the  precise  nature  of  these  cases  is  not  clear ;  we  have 
seen  how  variable  and  even  equivocal  may  be  the  manifestations  of 
insular  sclerosis,  and  a  fine  tremor  is  alone  of  little  diagnostic  value. 
The  cases  are,  moreover,  too  rare  to  be  of  practical  diagnostic  im- 
portance. 

The  tremor  that  succeeds  hemiplegia  is  fine,  and  is  limited  to  the 
seat  of  paralysis,  of  which  there  is  the  history  to  guide  the  diagnosis. 
The  differences  between  clonic  retrocollic  spasm*  and  paralysis  agitans 
might  seem  to  preclude  the  possibility  of  error.  But  the  rare  cases 
of  paralysis  agitans  in  which  the  head  is  carried  backwards  may  be 
mistaken  for  retrocollic  spasm,  and  the  finer  clonic  form  of  retrocollic 
spasm  may  also  (as  I  have  known)  be  mistaken  for  paralysis  agitans. 
The  diagnosis  rests  on  the  characteristic  affection  of  the  hands  in 
paralysis  agitans,  which  commonly  precedes  the  affection  of  the  head, 
on  the  limitation  of  the  spasm  to  the  muscles  moving  the  head  in 
retrocollis,  and  on  the  fact  that  in  this  disease  there  are  contractions 
in  the  frontal  muscles,  synchronous  with  those  at  the  back  of  the  neck. 

In  all  cases  of  paralysis  agitans  the  general  posture  and  carriage 
of  the  patient  are  of  great  diagnostic  importance,  since  they  are 
seldom  absent,  are  easily  recognised,  and  probably  never  mislead. 

The  Prognosis  of  a  typical  case  of  paralysis  agitans  is  very  un- 
favorable, so  far  as  recovery  is  concerned.  The  disease  seems  to  con- 
sist in  degenerative  changes,  which  are  usually  as  incapable  of  arrest 
as  are  the  advancing  years.  A  trifling  amelioration  or  retardation  of 
progress  is  all  that  can  be  hoped  for.  When  the  symptoms  depart 
from  the  ordinary  type,  the  prognosis  is  so  far  better  in  that  there  is 
a  little  more  chance  of  doing  good,  since  in  a  few  of  these  cases 
remarkable  improvement  has  been  obtained  by  treatment.  The 
danger  to  life,  however,  is  almost  as  small  as  is  the  chance  of  recovery. 
The  disease  always  lasts  several  years,  and  its  duration  is  likely  to  be 
the  longer,  the  slower  its  advance.     The  more  the  case  approaches 

*  The  form  of  wry-neck  in  which  the  muscles  at  the  back  of  the  neck  are 
involved  on  both  sides. 


656  PARALYSIS    AGITANS. 

to  senile  tremor, — that  is,  the  finer  the  movement  and  the  slighter  the 
tendency  to  rigidity,  the  less  is  the  disease  likely  to  interfere  with  the 
patient's  comfort. 

Treatment. — A  malady  that  depends  on  changes  in  the  finer  nutrition 
of  the  nerve-elements,  which  have  no  tendency  to  proceed  to  the  degree 
of  destructive  degeneration,  might  be  expected  to  be  amenable  to  treat- 
ment, were  it  not  for  the  persistent  character  of  the  disturbance  of  func- 
tion that  is  induced,  and  for  the  commonly  senile  nature  of  the  change. 
The  absence  of  spontaneous  variations  and  of  spontaneous  subsidence 
seems  to  indicate  alterations  of  a  character  which  resists  all  attempts 
to  induce  their  subsidence,  and  this  is  not  surprising  if  they  are,  to  a 
large  extent,  the  expression  of  the  influence  of  age,  or  of  the  same 
state  produced  before  senility  by  influences  that  have  an  equivalent 
effect.  For  the  most  part  the  object  of  treatment  has  therefore  to  be 
merely  relief  or  retardation. 

All  causes  of  mental  strain  and  of  physical  exhaustion  should,  as. 
far  as  possible,  be  prevented.  Life  should  be  quiet  and  regular,  freed, 
as  far  as  may  be,  from  care  and  work.  All  treatment  that  may 
fatigue  or  exhaust  the  patient's  strength  should  be  avoided.  Among 
internal  remedies,  all  varieties  of  nerve  sedatives  have  been  employed,, 
and  each  has  been  praised  by  some  and  found  to  fail  by  others.  Many 
of  them,  especially  morphia,  conium  (Berger),  hyoscyarnin  (Charcot 
and  Oulmont),  hyoscin,  solanin,  and  Indian  hemp,  quiet  the  tremor 
for  a  time.  Of  tonics  that  have  been  recommended,  carbonate  of  iron 
(Parkinson),  chloride  of  barium  (Brown-Sequard),  and.  strychnine 
have  seldom  been  found,  on  extended  trial,  to  deseiwe  confidence ;. 
the  last,  however,  occasionally  seems  to  exert  a  good  influence,  and  it 
has  been  found  to  lower  the  motor  function  of  the  cortex  of  the  brain 
when  it  exalts  that  of  the  spinal  cells.  Arsenic,  by  the  mouth,  occa- 
sionally seems  to  do  some  real  good  ;  its  subcutaneous  use  has  been 
recommended  by  Eulenburg.  Curara  and  bromides  are  valueless. 
My  own  experience  is  to  the  effect  that  arsenic  and  Indian  hemp,  the 
latter  sometimes  combined  with  opium,  are  of  most  use.  I  have 
several  times  seen  a  distinct  improvement  for  a  considerable  time 
under  their  use.  In  one  case  tremor  had  commenced  in  the  right 
arm  and  leg  an  hour  after  a  railway  accident,  and  extended,  three 
months  later,  to  the  left  arm.  Two  years  subsequently  there  was 
constant  lateral  movement  at  the  wrist-joints,  but  no  tremor  of  the 
fingers.  A  great  improvement  occurred  on  Indian  hemp,  and  a  year 
later  the  tremor  had  almost  ceased,  being  occasional  only.  It  is  in 
cases  which,  like  this  one,  present  some  deviation  from  the  common- 
type  that  benefit  is  most  frequently  experienced.  Electricity  in  all 
forms  is  useless.  Static  electricity  was  suggested  long  ago  by 
Reynolds,  and  later  by  Charcot.  I  have  tried  it  in  several  cases  very 
thoroughly,  but  could  not  observe  improvement  from  its  use.  So,  too, 
with  voltaic  electricity.      I  can  entirely  confirm  the  conclusion  of. 


OTHER  FORMS  OF  TREMOR.  657 

Berger,  who  treated  twenty  cases  sedulously  in  this  maimer  without 
any  of  them  being  in  the  least  improved  by  it.  Nerve-stretching  has 
been  employed,  but  without  any  enduring  result  (Westphal).  In  one 
case  stretching  the  brachial  plexus  is  said  to  have  lessened  the  tremor 
in  the  leg  and  removed  it  in  the  arm,  but  it  caused  paralysis  of  the 
limb  with  extensive  wasting  of  the  muscles.  Considerable  transient 
relief  is  given  by  very  gentle  superficial  hand-rubbing  of  the  part 
which  is  the  seat  of  the  tremor  ;  this  is  markedly  lessened  for  the  time, 
and  the  patients  express  themselves  as  much  more  comfortable  for  it. 
Although  not  permanent,  the  temporary  effect  is  not  to  be  despised 
in  advanced  and  severe  cases.  Charcot  has  recently  suggested  the 
employment  of  a  "  shaking  seat "  as  a  mode  of  treatment,  on  the 
ground  that  some  patients  describe  relief  after  riding  in  a  conveyance 
which  causes  vibration,  but  this  is  certainly  not  the  usual  experience 
of  sufferers  from  this  disease. 


Other  Forms  of  Tremob. 

Senile  Tremor. — In  extreme  old  age  slight  tremor  is  often  observed 
without  the  muscular  weakness  and  rigidity  that  occur  in  paralysis 
agitans.  At  first  it  is  noticed  only  on  voluntary  movement,  and  is 
generally  influenced  to  a  greater  extent  by  movement  than  is  paralysis 
agitans,  ceasing  or  almost  ceasing  during  rest,  and  always  passing  away 
during  sleep.  It  usually  commences  in  the  arm,  and  often  in  both  arms 
at  the  same  time,  but  the  head  is  affected  early  in  the  course  of  the 
symptoms  much  more  frequently  than  in  shaking  palsy,  and  occa- 
sionally the  tremor  begins  in  the  muscles  of  the  neck.  The  tremor 
is  always  fine,  the  range  of  movement  being  very  small.  After  a  time 
it  may  occur  during  rest  as  well  as  on  movement.  It  is  little  influenced 
by  treatment.  As  already  stated,  it  is  doubtful  whether  this  senile 
tremor  is  far  removed  from  paralysis  agitans,  although,  as  a  rule, 
the  other  symptoms  of  shaking  palsy  remain  absent.  Some  cases  are 
met  with  of  a  character  intermediate  between  the  two  affections,  and 
both  may  occur  in  different  members  of  the  same  family. 

Simple  Tremor. — Young  or  middle-aged  persons,  of  both  sexes, 
sometimes  become  affected  with  tremor,  generally  fine  but  sometimes 
irregular  and  unequal  in  the  degree  of  movement,  unaccompanied  by 
weakness  or  rigidity.  It  is  usually  excited  by  movement  and  increased 
by  emotion,  while  it  commonly  ceases  during  rest.  The  will  can  often 
control  it  for  a  time,  and  it  interferes  much  less  with  complex  actions 
than  does  the  tremor  of  paralysis  agitans.  The  handwriting,  for 
instance,  rarely  exhibits  irregularity.  The  parts  affected  are  chiefly 
the  hands  and  head,  but  the  muscles  of  the  face  and  tongue  often 
present  irregular  tremor  on  movement,  and  the  patient's  aspect  may 
closely  resemble  that  of  one  affected  with  delirium  tremens,  general 
paralysis  of  the  insane,  or  the  slighter  tremor  of  chronic  alcoholism. 

vol.  ii.  42 


658  TEEMOE. 

By  its  resembhmce  to  the  last  it  often  ^ives  rise  to  misconception 
regarding  the  habits  of  the  sufferer.  The  shaking,  in  rare  cases,  dis- 
appears for  a  time,  spontaneously  or  as  the  result  of  treatment,  but 
it  usually  persists,  getting  neither  better  nor  worse,  to  the  end  of  the 
patient's  life;  on  the  duration  of  this,  and  on  his  health,  it  seems 
to  exert  no  influence.  Rarely  it  has  commenced  in  early  or  middle 
adult  life,  and,  after  lasting  for  a  few  years,  has  ceased. 

The  causes  of  this  simple  tremor  are  generally  obscure.  It  is  some- 
times apparently  first  excited,  by  emotion,  more  frequently  by  pro- 
longed anxiety,  but  still  more  frequently  no  direct  cause  can  be  traced. 
Its  occurrence  is,  however,  distinctly  favoured  by  an  inherited 
neuropathic  tendency,  and  there  may  even  be  direct  inheritance  of 
the  special  form,  or  several  collateral  members  of  a  family  may  suffer 
from  it.  An  hereditary  relation  to  paralysis  agitans  is  sometimes  to 
be  traced,  but  only  in  rare  instances  ;  a  case  has  been  mentioned  in 
the  account  of  that  disease  in  which  one  member  of  a  family  suffered 
from  it,  and  another  from  simple  tremor.  Two  remarkable  instances 
of  this  inheritance  have  been  related  by  Liegey.*  A  gentleman 
suffered  throughout  his  life  from  tremor,  and  died  at  eighty-two  ;  his 
sister  also  trembled,  and  his  mother,  after  a  mental  shock,  presented 
tremor  during  the  latter  part  of  her  life.  The  other  case  illustrated 
the  occasional  affection  of  collaterals,  since  four  members  of  the  same 
family  suffered  from  tremor  of  hands  and  lips,  interfering  with  speech. 
In  three  it  commenced'  in  early  adult  life,  but  in  one,  a  female,  not 
until  the  cessation  of  the  menses.  A  daughter  of  the  latter  suffered 
from  symptoms  l'esembling  those  of  disseminated  sclerosis. 

Nothing  is  known  of  the  pathological  anatomy  of  the  affection,  and 
it  is  unlikely  that  anything  will  be  ascertained.  General  considera- 
tions lead  us  to  refer  it  to  a  deranged  action  of  the  motor  nerve-cells, 
either  in  the  cortex  of  the  brain  or  in  the  lower  centres  of  the  medulla 
oblongata  and  spinal  cord.  We  cannot  refer  it  to  the  peripheral 
nerves,  since  their  proved  disease  has  no  such  symptom  for  its  conse- 
quence. It  is  possible  that  it  may  be  due  to  altered  function  of  the 
cerebellum  or  of  some  of  the  basal  ganglia  of  the  brain,  but  the  facts 
to  justify  such  an  hypothesis  have  yet  to  be  ascertained. 

This  simple  tremor  has  no  consequences  beyond  its  inconvenience. 

It  does  not,  however,  prevent  the  subject  from  pursuing  his  occupa- 
tion as  efficiently  as  any  other  person.  In  spite  of  the  occasional 
collateral  relation  to  paralysis  agitans,  it  seems  to  have  little  tendency 
to  develop  into  the  latter  disease,  and  certainly  is  less  closely  con- 
nected with  it  than  is  senile  tremor.  When  it  has  lasted  for  several 
years  it  is  seldom  influenced  by  treatment.  In  early  cases,  the  treat- 
ment recommended  for  paralysis  agitans  best  deserves  a  trial,  but 
even  in  them  the  affection  is  remarkably  intractable. 

Hysterical  tremor  is  very  common.     It  may  occur  in  two  forms,  .one 
fine,  the  other  coarse.     The  latter  often  consists  in  a  rhythmical  move- 
*  'Journal  de  Med.  de  Bruxelles,'  1882. 


WEY-NECK.  659 

merit  of  the  hands  or  head,  continuing  apart  from  any  voluntary  effort. 
The  fine  tremor  occurs  especially  on  movement,  and  its  characteristic 
is  irregularity  (see  Fig.  149,  tracing  9).  It  varies  in  degree  from  time 
to  time,  presents  a  transient,  often  jerky  increase  in  range,  or  accele- 
ration in  time,  which  are  almost  pathognomonic.  Its  characters  and 
treatment  are  described  more  fully  in  the  chapter  on  hysteria. 

Asthenic  Tremor. — In  simple  weakness,  such  as  follows  an  acute 
disease,  muscular  tremor  is  common.  It  is  fine  in  range,  occurs 
only  on  movement,  and  is  usually  most  marked  after  some  slight 
exertion,  as  an  effect  of  fatigue.  The  muscular  weakness,  the  con- 
spicuous general  debility,  the  distinct  cause  of  the  asthenia,  and 
the  usual  absence  of  the  tremor,  for  a  time,  after  rest,  render  the. 
nature  of  the  case  clear.  We  do  not  know  whether  it  depends  on 
imperfect  nutrition  of  the  muscles  or  of  the  motor  nerve-cells ;  the 
svmptoms  can  be  explained  on  either  hypothesis. 

Toxic  Tremor. — In  mercurial  poisoning,  tremor  is  the  conspicuous 
symptom,  aud  also  in  some  cases  of  lead  poisoning  and  in  chronic 
poisoning  by  alcohol,  opium,  and  chloral.  These  forms  need  not  be 
farther  considered  here. 


WRY-NECK:  TORTICOLLIS. 

The  term  "torticollis"  or  "wry-neck"  is  applied  to  those  con- 
ditions in  which  contraction  of  the  muscles  of  the  neck  causes  an  un- 
natural position  of  the  head.  The  contraction  may  be  a  permanent 
shortening  of  a  muscle,  or  it  may  be  an  active  spasm  in  one  or  several 
muscles.  Besides  these  two  chief  varieties,  a  similar  effect  may  be 
due  to  two  other  causes,  which  are  chiefly  important  in  respect  to 
diagnosis,  and  may  therefore  be  briefly  mentioned.  One  is  simple 
rheumatism  of  the  muscles  of  the  neck,  impeding  movement.  The 
"stiff  neck"  of  adults  scarcely  merits  the  distinctive  name  of  wry- 
neck, but  in  children  more  pronounced  deviation  to  one  side  or  back- 
wards is  occasionally  met  with.  The  affection  follows  exposure  to 
cold,  and  is  marked  by  considerable  tenderness  of  the  cervical  muscles, 
which  is  clearly  the  chief  cause  of  the  unnatural  position.  These  cases 
are  really  rheumatic  and  not  nervous  in  nature,  and  have  been  alreadv 
alluded  to  in  the  account  of  the  diagnosis  of  meningitis.  The  second 
condition  is  one  that  may  be  termed  "  false  torticollis,"  because  the 
deviation  of  the  head  depends,  not  on  the  state  of  the  muscles,  but  on 
some  other  cause.  The  deviation,  however,  usually  puts  the  sterno- 
mastoid  on  the  stretch,  and  may  thus  give  rise  to  an  erroneous  im- 
pression that  the  muscle  is  contracted,  and  is  the  cause  of  the  devia- 
tion. The  most  common  cause  of  this  form  is  disease  of  the  cervical 
vertebrae.  The  distinction  from  the  true  form  will  be  considered  in 
the  section  on  diagnosis. 


660  WET-NECK. 


Fixed  Wet-neck:  Congenital  Torticollis. 

Fixed  wry-neck  depends  upon  shortening  of  some  muscle,  almost 
always  the  sterno-mastoid,  which  is  often  also  atrophied,  and  some- 
times firmer  than  normal.  The  condition  is  met  with  chiefly  in 
children,  and  is  thought  to  depend,  in  some  cases,  upon  injury 
to  the  muscle  from  the  traction  on  the  neck  that  occurs  during  birth 
(Stromeyer).  In  other  cases  it  is  supposed  to  be  due  to  developmental 
shortening  of  the  muscle,  the  result  of  the  inclined  position  of  the 
head  of  the  child  in  the  pelvis.*  It  may  not  be  noticed  for  some  time 
•after  birth,  in  consequence  of  the  shortness  of  the  neck  of  young 
children.  A  similar  condition  may  arise  in  adult  life  from  an  injury 
to  the  muscle,  leading  to  secondary  inflammation,  and  cicatricial  con- 
traction. 

In  fixed  wry-neck  the  head  deviates  a  little  to  one  side,  in  the 
manner  to  be  presently  described  as  characteristic  of  active  shorten- 
ing of  the  sterno-mastoid,  and  it  cannot  be  turned  towards  the 
side  on  which  the  muscle  is  contracted.  The  cause  of  the  devia- 
tion is  at  once  seen  when  the  neck  is  examined ;  the  sterno-mastoid, 
on  the  side,  towards  which  the  head  cannot  be  turned,  is  rigid, 
and  stands  out  conspicuously  ;  there  is  no  active  spasm.  The  affec- 
tion is  one  of  small  importance.  It  can  be  readily  and  perma- 
nently cured  by  division  of  the  tendon  of  the  contracted  muscle. 
When  secondary  changes  have  taken  place  in  the  articulations,  it 
may  be  necessary  to  keep  the  head  in  a  proper  position,  for  a  time, 
by  some  support. 


Spasmodic  Wry- neck. 

Spasmodic  wry -neck  is  a  very  different  affection  from  that  just 
described,  although  the  two  bave  been  sometimes  confused  in  descrip- 
tions of  the  disorder.  The  spasmodic  form  is  a  malady  analogous  to 
the  facial  spasm  that  has  been  described  in  the  section  on  diseases  of 
the  facial  nerve. 

It  is  necessary  to  consider  together  all  forms  of  active  spasm  in  the 
muscles  of  the  neck.  Neither  the  character  of  the  spasm,  nor  its 
distribution,  affords  ground  for  the  separation  of  the  varieties  that  it 
presents.  The  spasm  may  be  either  tonic  or  clonic,  and  both  kinds  of 
spasm  may  be  met  with  in  the  same  case,  and  even  at  the  same  time. 
The  most  important  difference  in  the  distribution  of  the  spasm  is. 
that  while  in  most  cases  the  spasm  is  either  confined  to  one  side,  or  is 
so  much  greater  on  one  side  as  to  cause  a  lateral  deviation  of  the  head, 

*  It  is  much  more  frequent  on  the  right  side,  which  gives  support  to  the  theory, 
as  Busch  points  out,  since  in  70  cases  out  of  100  the  head  is  in  the  "  first  position," 
which  entails  an  inclination  such  as  would  permit  the  right  sterno-mastoid  to  shorten. 


SPASMODIC    WET-NECK.  661 

in  a  few  cases  the  spasm  is  equal  on  the  two  sides,  and  is  either  eon- 
fined  to,  or  greater  in,  the  muscles  at  the  back  of  the  neck,  so  as  to 
produce  a  backward  movement  of  the  head.  The  second  variety  may 
conveniently  be  distinguished  as  "retrocollic  spasm." 

Etiology. — Spasmodic  torticollis  is  more  common  in  women  than 
in  men.  Of  thirty-two  cases,  of  which  I  have  notes  (all  those  of 
hysterical  nature  being  excluded),  ten  were  in  males  and  twenty-two 
in  females.  It  commonly  begins  in  the  middle  period  of  adult  life, 
between  thirty  and  fifty  years  of  age.  Two  thirds  of  the  cases  com- 
mence during  this  period ;  a  few  commence  between  twenty-five  and 
thirty.*  It  occasionally  begins  after  fifty  ;  the  latest  case  that  has. 
come  under  my  notice  began  at  sixty-six.  Both  sexes  seem  to  suffer 
in  about  the  same  proportion  at  the  different  ages.  Cases  in  females 
under  thirty  are  often  of  hysterical  nature,  and  this  is  also  probably 
true  of  the  rare  cases  in  which  similar  spasm  is  met  with  in  boys.f 
In  rare  cases,  torticollis,  of  peculiar  and  irregular  forms,  occurs  in 
infants,  chiefly  towards  the  end  of  the  first  year  of  life.  It  usually 
ceases  after  a  few  months'  duration.  Still  more  rarely  it  begins  in 
childhood  and  persists,  as  in  the  case  of  a  boy  in  whom  it  commenced 
•at  the  age  of  four  and  was  still  severe  at  fourteen. J 

Neurotic  heredity  occasionally  predisposes  to  this  as  to  other  mala- 
dies of  the  same  class.  In  some  cases  there  is  a  family  history  of 
epilepsy  or  of  insanity,  and  occasionally  of  diseases  more  closely  allied 
to  torticollis.  The*brother  of  one  patient  had  suffered  from  facial 
spasm,  and  the  sister  of  another  (who  was  suffering  from  the  true,  not 
the  hysterical  form)  had  suffered  from  torticollis  itself,  and  had 
recovered.  In  some  instances  the  patient  has  himself  suffered,  at  a  pre- 
vious time,  from  some  other  functional  disorder  of  the  nervous  system, 
migraine,  &c.  In  one  case  of  persistent  torticollis,  the  patient,  ten 
years  previously,  had  been  affected  with  general  tremor,  which  lasted 
for  three  years  and  then  passed  away.  The  affection  has  followed  an 
attack  of  melancholia. §  It  is  possible  that  true  torticollis  may  grow 
out  of  a  habit-spasm  also;  one  patient  had  been  liable,  for  twenty 
years,  to  nodding  movements  of  the  head  when  he  was  engaged  in 
•earnest  conversation.  ||  In  another  case  there  had  been  for  a  year 
occasional  half- voluntary  movements  of  the  head,  in  the  direction  in 

*  In  the  only  earlier  case  that  I  have  seen,  in  which  the  spasm  commenced  at 
thirteen,  and  still  existed  at  twenty-nine,  the  movement  was  somewhat  unusual  in 
its  character,  and  was  prohahly  a  persistent  habit-spasm,  from  another  form  of  which 
the  patient  had  also  suffered.     The  rare  infantile  cases  are  not  included. 

f  See  note  on  p.  662.  It  is  important  to  remember  that  most  varied  and  obstinate 
forms  of  clonic  spasm  occur  in  the  subjects  of  hysteria,  and  are  apparently  iu  some 
way  due  to  this  disease.     They  are  described  in  the  chapter  on  hysteria. 

X  Southam,  'Lancet,'  Aug.,  1881. 

§  Allen  Sturge, '  Lancet,5  1879,  i,  160. 

|i  Reynolds  states  that  he  has  known  the  disease  to  follow  "writers'  cramp" 
('  System  of  Med.,'  vol.  ii,  p.  787) ;  but  it  is  probable  that  it  was  merely  the  com* 


662  WliY-NECK. 

which  it  was  afterwards  moved  persistently,  by  involuntary  spasm, 
while  in  a  third  true  torticollis  was  distinctly  produced  by  intentional 
turning  of  the  head  to  look  at  a  certain  object,  continued  for  several 
years.  Depressing  emotion  often  precedes  the  onset,  but  less  fre- 
quently than  in  the  case  of  facial  spasm.  In  other  instances  there  is 
a  history  of  some  feebleness  of  general  health.  I  have  more  than  once 
known  the  affection  to  follow  a  fall  at  an  interval  of  a  month  or  two, 
and  a  similar  sequence  has  been  recorded  by  others  ;  in  one  recorded 
case,  spasm  on  the  right  side  of  the  neck  followed  a  fall  on  the  left 
temple.*  In  most  of  the  cases  of  apparently  traumatic  origin,  how- 
ever, the  affection  followed  a  fall  or  other  injury  in  which  the  neck  was 
forcibly  bent  or  twisted.  In  some  cases  the  disease  seems  to  be  dis- 
tinctly excited  by  exposure  to  cold.  Thus  one  patient  had  a  severe 
cold,  and  a  rheumatic  stiff  neck  ;  as  the  stiffness  passed  off,  clonic 
spasm  came  on.  But  an  initial  feeling  of  stiffness  is  sometimes  taken 
as  evidence  of  exposure  to  cold,  without  any  real  grounds  for  the 
assumption.  It  is  remarkable  how  seldom  any  peripheral  irritation  or 
pain  can  be  traced  as  the  cause  of  the  spasm.  It  has,  however,  been 
observed  to  follow  inflammation  of  the  middle  ear;  and  in  the  case 
mentioned  above,  in  which  movements  like  habit-spasm  preceded  the 
torticollis,  the  onset  occurred  during  an  attack  of  severe  neuralgia  of 
the  fifth  nerve,  which  lasted  for  three  months.  The  rarity  of  this 
cause  may  be  due  to  the  fact  that  hardly  any  form  of  pain  about  the 
head  or  neck  is  lessened  by  rolation  of  the  head,  or  induces  such  rota- 
tion for  its  reiief.  Excessive  use  of  the  muscles  is  probably  an  occa- 
sional cause.f  It  is  possible  that,  in  rare  cases,  spasm  in  the  neck  is 
caused  by  malarial  poison  J  In  not  a  few  cases  no  immediate  cause 
can  be  traced ;  the  affection  comes  on  in  robust  individuals,  who  are 
apparently  in  perfect  health  at  the  time  of  the  onset. 

Among  the  causes  of  torticollis  commonly  described  is  paralysis  of 
the  muscles  of  one  side,  permitting  their  opponents  to  draw  the  head 
to  the  other  side.  This  is  a  theoretical  cause,  which  has  little  counter- 
part in  fact.  It  is  doubtful  whether  a  true  paralytic  torticollis  is  ever 
seen.     The  amount  of  muscular  action  that  is  needed  to  keep  the  head 

mencing  spasm  (beginning,  as  it  sometimes  does,  in  the  hand)  that  interfered  with 
writing.    This  was  so  in  one  case  under  my  own  obser\ation. 

*  T.  Fournier,  "  Le  Tic  rotatoire,"  '  These  de  Strasbourg,'  1870. 

t  Annaudale  has  recorded  a  case  of  spasm  in  the  neck  apparently  due  to  this 
cause.  The  subject  was  a  girl  aged  twenty-four,  who,  in  the  course  of  her  work  as 
a  weaver,  had  occasion  to  move  the  head  rapidly  first  to  one  side  and  then  to  the 
other,  but  especially  to  the  left,  and  in  the  spasm  the  head  was  inclined  and  rotated 
to  the  left  side.  But  the  case  was  very  unusual  in  that  there  was  no  spasm  when 
the  head  was  turned  to  the  left,  although  clonic  spasm  came  on  at  once  when  it  was 
moved  out  of  that  posture  ('  Lancet,'  1879,  i,  p.  555). 

J  As  in  a  case  of  intermittent  contractions  of  one  sterno-mastoid  (coming  on 
each  day  at  the  same  time,  and  lasting  four  or  five  hours)  in  a  child  of  four,  recorded 
by  Simon.  The  child  had  had  intermittent  fever,  and  the  attacks  were  quickly 
cured  by  quinine  (ret.  in  'Lancet,'  187y,  i,  26). 


SYMPTOMS.  603 

at  rest  in  the  mid-position  is  extremely  small;  the  rotators  are  nume- 
rous*, and  all  are  never  paralysed. 

Symptoms. — The  spasm  itself  is  usually  the  first  symptom,  "but  in 
a  few  cases  this  is  preceded  or  accompanied  by  pain,  or  by  some  un- 
pleasant sensation.  The  pain  may  be  of  an  acute  neuralgic  character, 
or  it  may  be  a  dull  aching  pain.  It  may  be  felt  in  the  neck,  or  in  the 
occipital  region  on  one  side,  or  behind  the  ear,  or  in  the  arm.  In 
other  cases,  again,  a  sense  of  stiffness  in  the  neck  attends  the  com- 
mencing spasm.  Less  commonly  the  onset  is  preceded  by  sensations 
of  a  more  or  less  vertiginous  character,  which  may  perhaps  indicate 
some  morbid  action  in  the  nerve-centres,  of  which  the  spasm  is  the 
result.  Thus  in  one  case  the  spasm  commenced  a  few  weeks  after  a 
sudden,  brief,  "  whirling  "  sensation  in  the  head.  Another  patient  at 
first,  when  walking,  experienced  a  strong  tendency  to  deviate  to  one 
side,  towards  which  there  was  a  slight  rotation  of  the  head,  but 
as  the  rotation  increased  to  distinct  sjmsrn,  the  tendency  to  deviate 
ceased. 

The  actual  onset  of  the  spasm  is  usually  gradual,  and  some  months 
pass  before  a  considerable  degree  is  attained.  It  may  be  occasional 
only,  even  for  years,  chiefly  during  excitement.  Very  rarely  it  comes 
on  acutely,  in  the  course  of  a  single  week,  or  even  in  a  single  day. 
Once  developed,  its  increase  is  usually  steady,  but  uow  and  then  it 
ceases  after  a  few  months,  and  recommences  before  many  more 
months  have  passed.  Occasionally  the  interval  is  longer,  even  years. 
In  one  case,  of  a  middle-aged  woman,  it  ceased  after  a  year's  duration, 
and  returned  at  the  end  of  two  years  in  persistent  form.  In  the 
case  mentioned  above,  in  which  the  spasm  commenced  during  acute 
neuralgia  of  the  fifth  nerve,  it  was  at  first  tonic,  and  reached  a  high 
degree  of  severity  in  three  months,  but  passed  away  at  the  end  of  six 
months  from  the  onset,  remaiued  absent  for  eight  years  and  then 
returned,  not  again  to  cease.  The  tendency  of  the  head  to  go  to  one 
side  is  often  first  felt  when  the  patient  is  walking  or  excited,  and 
ceases  during  rest  or  mental  tranquillity.  The  seat  of  the  first  spasm 
is  generally  that  in  which  the  contractions  are  ultimately  most  severe  ; 
in  exceptional  cases  it  commences  in  some  other  part.  In  two  cases 
it  began  in  the  hand,  and  in  one  in  the  face,  although  in  each  the  neck 
was  afterwards  chiefly  affected. 

The  symptoms  vary  according  to  the  muscles  that  contract  most 
strongly.  These  are  generally  the  large  muscles  of  the  neck,  and  in  the 
most  common  form,  torticollis  proper,  the  spasm  is  either  confined  to  one 
side,  or  is  greater  on  one  side  than  on  the  other,  and  hence  its  effect 
is  to  cause  a  deviation  of  the  head  to  one  side,  either  a  rotation  or  a 
lateral  inclination.  Less  commonly,  as  already  mentioned,  the  muscles 
of  both  sides  are  equally  involved,  and  the  head  is  then  inclined 
backwards.  Usually  many  muscles  are  affected ;  in  some  cases  one 
only.     The  steruo- mastoid  is  the  muscle  in  which  the  spasm  is  most 


664  WJir-NECK. 

frequent,  and  in  the  cases  of  solitary  spasm,  it  is  almost  always  this 
muscle  that  contracts.  Of  thirty  cases,  there  was  some  spasm  iri  the 
sterno-mastoid,  on  one  side  or  on  both,  in  no  less  than  twenty- 
seven.  In  two  thirds  of  the  cases  (nineteen)  the  muscle  was  affected 
on  one  side  only,  and  in  seven  no  other  was  involved.  The  muscle 
most  frequently  associated  with  the  sterno-mastoid  is  the  upper  part 
of  the  trapezius,  and  it  is  generally  the  trapezius  on  the  same  side. 
Of  seven  examples  of  this  combination,  the  associated  trapezius  was 
on  the  same  side  in  six,  on  the  other  side  in  one.  But  the  splenius 
is  associated  with  the  sterno-mastoid  almost  as  frequently  as  the 
trapezius,  and  it  is  usually  the  muscle  of  the  opposite  side.  The 
scaleni  occasionally  contract ;  I  have  once  known  both  scaleui  to  be 
involved  with  one  sterno-mastoid.  Often  there  is  also  spasm  in  the 
platysma  myoides,  which  draws  up  the  skin  into  characteristic  folds, 
but  does  not  influence  the  position  of  the  head.  In  rare  cases,  of 
which  I  have  only  seen  one,  rotation  of  the  head  is  produced  by  the 
deeper  muscles  alone,  probably  the  recti  and  obliqui,  and  no  accessible 
muscle  can  be  felt  to  contract. 

The  side  on  which  the  muscles  contract  most  strongly  is  more 
frequently  that  on  which  the  muscles  turn  the  head  to  the  left,  and 
hence  this  is  the  common  direction  towards  which  the  head  deviates. 
Thus  the  right  sterno-mastoid  was  involved  most  or  onlv,  rather 
more  frequently  than  the  left.  The  right  trapezius,  which  also 
turns  the  head  to  the  left,  was  likewise  affected  more  frequently  than 
the  left,  and  the  left  splenius,  which  turns  the  head  to  its  own  side, 
was  involved  far  more  frequently  than  the  right.  Although  the  cases 
are  not  numerous,  the  frequency  with  which  this  rule  obtained  can 
scarcely  be  a  matter  of  accident.  It  might  be  anticipated,  a  priori, 
that  the  muscles  which  move  the  head  to  the  right  would  suffer  most, 
because  they  are  associated  in  action  with  the  right  arm;  but  it  must 
be  remembered  that  many  energetic  movements  of  the  right  arm  are 
effected  towards  the  left. 

In  the  cases  in  which  the  muscles  of  the  two  sides  are  equally 
involved,  the  sterno-mastoids  are  also  most  frequently  affected,  but 
usually  in  slight  degree.  The  trapezii  and  sometimes  the  splenii 
contract  strongly.  Rarely  all  the  muscles  of  the  neck  seem  to  be  in 
action. 

The  movement  of  the  head  caused  by  the  spasm  necessarily  differs 
according  to  the  muscles  that  are  chiefly  implicated.  We  have  seen 
that  the  spasm  is  seldom  limited  to  a  single  muscle ;  more  often 
several  muscles  contract  together,  and  the  movement  of  the  head  is 
that  due  to  their  combined  action.  As  the  combinations  ai*e  numer- 
ous, and  the  muscles  contract  in  various  degrees,  the  resulting 
movement  of  the  head  varies  considerably  in  different  cases,  and 
sometimes  in  the  same  case  at  different  stages  of  the  disease. 

The  sterno-mastoid,  acting  alone,  causes  rotation  of  the  head  so  as 
to  bring  the  mastoid  process  nearer  to  the  inner  end  of  the  clavicle. 


SYMPTOMS. 


665 


In  this  movement  the  face  is  turned  towards  the  opposite  side,  the 
•cbin  is  put  forwards,  and  the  head  is  slightly  inclined  towards  the  side 
of  the  acting  muscle  (Fig-  152). 

The  highest  part  of  the  trapezius  attached  to  the  skull,  when  acting 
alone,  slightly  rotates  the  head  towards  the  other  side,  but  it  inclines 
the  head  strongly  towards  its  own  side  and  at  the  same  time  draws 
the  head  backwards.  It  also  raises  the  shoulder,  rotating  the  scapula. 
The  middle  and  lower  parts  of  the  trapezius  are  seldom  involved. 

The  splenitis  of  one  side  inclines  the  head,  and  very  slightly  rotates 
the  face  towards  the  same  side. 

Equal  contraction  of  the  trapezii  and  splenii,  on  both  sides,  causes  a 
backward  movement  of  the  head. 


Fig.  152. 


Fig.  153. 


Fig.  152. — Torticollis  due  to  spasm  in  the  left  sterno- mastoid. 

Fig.  153. — Torticollis.  Spasm,  chiefly  tonic,  in  the  right  sterno-mastoid, 
and  especially  in  the  right  splenius,  with  slighter  spasm  in  the  left  splenius. 
The  patient  was  a  man,  aged  twenty-six,  in  whom  the  spasm  had  existed  for 
six  months;  it  commenced  gradually  after  a  period  of  great  mental  anxiety. 

The  effects  of  the  chief  combinations  are  as  follows : — The  association 
of  the  sterno-mastoid  and  the  trapezius  of  the  same  side  greatly 
increases  the  inclination  of  the  head  towards  the  shoulder,  and  this 
increase  in  the  inclination  prevents  any  increase  in  rotation.  The 
association  of  the  sterno-mastoid  of  one  side  with  the  trapezius  of  the 
opposite  side  prevents  the  inclination  of  the  head,  and  does  not  appre- 
ciably lessen  the  rotation  caused  by  the  former  muscle,  the  trapezius 
being  a  feeble  rotator.  Hence  the  rotation  of  the  head  is  often 
very  great.  The  combination  of  one  sterno-mastoid  and  the  oppo- 
site splenius  causes  extreme  rotation  of  the  head,  so  that  the  face, 
as  in  Fig.  152,  may  be  turned  towards  the  shoulder.  I  have  not  seen 
any  case  in  which  one  sterno-mastoid  was  associated  with  the  splenius 
of  the  same  side,  but  the  resulting  movement  would  probably  be 
similar  to  that  produced  by  the  combination  with  the  trapezius  of  the 


666  WRY-NECK. 

same  side,  a  strong  inclination  of  the  bead  towards  tbe  shoulder.  In 
the  case  shown  in  Fig.  153  both  splenius  muscles  were  involved  (the 
right  most),  as  well  as  the  right  sterno-mastoid,  and  a  strongly- 
backward  inclination,  with  some  rotation,  was  the  result. 

Bilateral  spasm,  equal  on  the  two  sides,  always  causes  a  back- 
ward movement  of  the  head,  because  both  sterno-mastoids  scarcely 
ever  contract  alone,  and  the  spasm  in  the  muscles  at  the  back  of 
the  neck  draws  the  head  backwards,  and  then  the  inclination  is  in- 
creased by  the  sterno-mastoids.  It  is  doubtful  whether  there  is  ever 
a  forward  movement  in  any  case  properly  belonging  to  the  group  now 
under  consideration.  The  retroflexion  of  the  neck  is  sometimes  very 
great ;  the  face  may  even  be  horizontal,  turned  directly  upwards,  as  in 
one  case  that  I  have  seen.  Such  extreme  spasm  is,  however,  rare ; 
more  often  the  contraction  is  moderate  in  degree.  An  interesting 
fact  about  this  retrocollic  spasm  is  that  contraction  in  the  frontales 
muscles  is  almost  always  associated  with  the  spasm  in  the  back  of  the 
neck.  The  association  is  a  physiological  one;  in  the  act  of  looking 
upwards  the  head  is  bent  back,  and  the  eyebrows  are  raised  by  the 
frontales.  If  the  spasm  is  clonic,  the  contraction  in  the  forehead  is 
synchronous  with  that  in  the  muscles  of  the  back  of  the  neck. 

The  spasm  in  all  forms  of  torticollis  may  be  either  tonic  or  clonic, 
and  often  both  kinds  of  spasm  occur  together  ;  clonic  spasm  may 
become  tonic  as  it  becomes  intense,  or,  more  commonly,  tonic  spasm, 
as  it  increases,  becomes  clonic  and  jerky.  It  usually  varies  in 
intensity  from  time  to  time,  and  either  form  may  be  intermittent. 
The  patient  is  able  to  keep  the  head  still  for  a  time,  but  every  now 
and  then  it  is  drawn  to  one  side,  either  steadily  or  in  jerks.  The 
spasm  is  seldom  absent  for  more  thau  a  few  minutes.  As  it  comes 
on,  the  affected  muscles  stand  out  conspicuously  in  their  contraction. 
Occasionally  the  spasm,  either  tonic  or  clonic,  is  practically  continuous. 
The  same  variations  are  seen  in  the  retrocollic  variety,  but  clonic 
spasm  is  relatively  more  common,  and  intermissions  are  less  common. 
The  contractions  are  often  moderate  in  degree  and  frequent  in  recur- 
rence, so  that  the  spasm  (especially  at  first)  bears  more  resemblance  to 
tremor  than  in  the  ordinary  forms. 

In  most  cases  there  is  a  strong  tendency,  in  the  course  of  time,  for 
the  spasm  to  spread  and  to  involve  other  muscles  in  addition  to  that  in 
which  it  commenced.  Even  when  the  contractions  are  limited,  if  the 
movement  of  the  head  is  forcibly  prevented,  the  spasm  often  tempo- 
rarily spreads  to  other  muscles.  Thus,  in  a  case  in  which  one  splenius 
alone  habitually  contracted,  if  the  movement  was  prevented,  the 
sterno-mastoid  began  to  contract. 

In  some  cases  the  spasm  is  not  limited  to  the  muscles  of  the  neck  ; 
it  involves  either  the  arm,  or  the  face,  or  the  muscles  of  mastication. 
The  face  -is  seldom  constantly  involved,  but  muscles  occasionally 
contract  during  a  severe  pai-oxysm.  In  one  instance,  with  clonic 
spasm  in  one  sterno-mastoid  and  trapezius,  at    the   height   of   the 


SYMPTOMS. 


667 


attack,  there  was  often  twitching  of  the  eyelids  and  pouting  of 
the  lips.  The  spasm  in  the  face  may  occur  on  the  side  on  which  the 
sterno-mastoid  contracts,  or  contracts  most  strongly.  In  one  instance, 
in  which  there  was  continuous  clonic  spasm  in  the  right  sterno-mastoid, 
and  very  little  in  the  left,  there  were  almost  constant  contractions  in 
the  right  side  of  the  face.  Rarely  the  spasm  is  equal  on  the  two  sides 
of  the  face  when  the  spasm  in  the  neck  is  unequal,  as  in  a  case  just 
mentioned.  In  retrocollic  spasm  there  may  be  some  bilateral  contrac- 
tion in  the  lower  facial  muscles,  es- 
pecially in  the  elevators  of  the  upper 
lip,  at  the  height  of  a  paroxysm,  in 
addition  to  the  constant  spasm  in  the 
frontales,  already  described.  The 
masseters  are  involved  in  true  torti- 
collic  spasm  rarely,  and  only  at  the 
height  of  a  paroxysm.  In  chronic 
retrocollic  spasm  they  are  sometimes 
constantly  affected. 

When  the  arm  is  involved,  there  is 
always  unequal  spasm  in  the  two  sides 
of  the  neck.  The  sterno-mastoid  that 
is  most  affected  may  be  on  the  same 
side  as  the  arm,  or  on  the  opposite 
side.  In  the  cases  that  I  have  seen 
in  which  the  arm  was  affected  after 
the  neck,  it  was  the  arm  on  the  side 
opposite  to  the  most  affected  sterno- 
mastoid.  When  the  arm  is  affected 
first,  either  sterno-mastoid  may  be  the 
seat  of  the  chief  spasm,  and  the  head 
may  thus  be  turned  from,  or  inclined 
towards,  the  arm  that  is  affected.  In 
one  case  of  clonic  spasm  in  the  right 
sterno-mastoid,  there  was  also  spasm 
in  the  left  deltoid,  but  in  no  other 
muscle.  Another  instance  of  this 
relation  is  presented  by  the  patient 
shown  in  Pig.  154.  In  him  the  spasm 
commenced  in  the  arm  and  spread  to  the  neck,  where  it  involved  the 
right  sterno-mastoid,  the  left  trapezius  and  splenius,  and  the  right 
platysma.  It  became  continuous  in  both  arm  and  neck,  so  that  the 
upper  arm  was  in  constant  strong  adduction,  and  the  forearm  was 
carried  in  front  of  the  body,  while  the  face  was  turned  towards  the 
shoulder. 

As  an  instance  of  the  peculiar  forms  met  with  occasionally  in 
infants  may  be  mentioned  that  of  a  girl,  aged  eleven  months,  whose 
head  was  drawn  strongly  to  the  left,  and  agitated  by  clonic  spasm  for 


Fig.  154. — Spasm,  chiefly  tonic,  in 
the  left  sterno-mastoid,  right  tra- 
pezius, and  the  whole  of  the  right 
arm,  which  was  strongly  adducted 
by  spasm  in  the  pectoralis.  The 
patieut  was  a  man  aged  forty-six, 
in  whom  the  spasm  had  existed  for 
two  years.  It  commenced  gradu- 
ally in  the  hand. 


068  WRY-NECK. 

a  few  minutes,  twelve  to  twenty  times  a  day.  The  affection  had  com- 
menced acutely,  without  obvious  cause.  At  first  each  attack  was 
attended  by  deviation  of  the  left  eye  to  the  right,  and  by  nystagmus 
in  this  eye  during  the  intervals,  but  the  eye  symptoms  ceased  after  a 
few  weeks.  A  sister  of  the  child  was  said  to  have  suffered  in  the 
same  way,  for  a  time,  at  about  the  same  age. 

Considerable  spasm  always  occasions  discomfort  to  the  patient, 
partly  due  to  fatigue  in  the  muscles.  There  is  not  commonly  any 
actual  cramp-like  pain  in  them.  The  neuralgic  pain  that  is  often 
complained  of  at  the  onset  usually  ceases  after  a  time,  but  sometimes 
continues  in  varying  degree.  When  there  is  spasm  in  the  arm,  the 
limb  is  often  the  seat  of  considerable  pain,  and  I  have  known  severe 
pain  in  both  arms  to  attend  the  attacks  of  spasm  in  the  neck.  It  is 
said  that  there  are  occasionally  tender  points  in  the  course  of  the 
cervical  nerves,  but  tbey  are  not  common.  Another  rare  sensory  sym- 
ptom is  tingling  and  numbness  in  the  arm,  from  the  compression  of 
the  nerves  of  the  brachial  plexus  by  the  scaleni. 

The  muscles  that  are  the  seat  of  considerable  spasm  undergo,  in 
time,  some  hypertrophy,  and  may  become  very  distinctly  larger  than 
those  on  the  other  side.  They  never  waste.  The  electrical  irrita- 
bility is  generally  normal,  sometimes  indeed  it  is  abnormally  great,  so 
that  a  very  weak  current  of  either  kind  suffices  to  put  the  muscles  in 
a  state  of  strong  contraction. 

The  course  of  the  disease  varies  in  different  cases.  Often  the  spasm 
slowly  increases  in  intensity  and  widens  in  range,  but  ceases  to  be 
progressive  after  a  few  years,  and  may  remain  stationary  for  the  rest 
of  life.  In  other  cases,  however,  it  remains  slight,  sometimes  con- 
fined to  a  single  muscle,  and  may  not  undergo  perceptible  increase 
during  many  years.  Less  commonly  it  diminishes  after  it  has  lasted 
for  a  few  months  or  years,  and  may  pass  away,  either  spontaneously 
or  as  the  result  of  treatment,  and  it  may  return  after  a  variable  period 
of  freedom,  as  in  the  cases  mentioned  in  the  section  on  causation.  In 
some  instances  it  does  not  disappear  altogether,  although  it  becomes 
slight  and  occasional.  In  a  case  recorded  by  Brodie,  the  spasm  ceased, 
for  the  time,  during  an  attack  of  insanity,  and  I  have  seen  an 
analogous  case.  The  disease  does  not  develop  to  any  disorder  of  more 
serious  character,  nor  has  it  any  tendency  to  shorten  life,  although  it 
may  lessen  very  much  the  pleasure  of  existence. 

Pathology. — In  no  case  of  torticollis  has  a  lesion  been  found  that 
can  be  regarded  as  an  indication  of  the  morbid  process  to  which  the 
spasm  is  due.  The  pathology  of  the  disease  is  therefore  a  matter  of 
inference  from  its  symptoms,  its  causes,  and  from  what  we  know  of 
the  nature  of  allied  diseases,  especially  of  facial  spasm  (see  p.  248). 
It  is  almost  superfluous  to  state  that  the  morbid  process  cannot 
be  in  the  muscles  themselves.  The  facts  that  many  muscles  are 
involved,  and  that  when  the  spasm  commences  in  a  single  muscle  it 


PATHOLOGY.  669 

usually  spreads  to  others,  as  well  as  the  general  pathology  of  spasm, 
make  it  probable  that  the  muscular  contractions  depend  on  the  over- 
action  of  nerve-cells,  and  not  on  any  irritation  of  nerve-fibres.  But 
we  do  not  know  what  nerve-cells  are  primarily  deranged,  whether  they 
are  the  cells  of  the  lower  spinal  centres,  or  those  of  the  higher  cortical 
centres.  The  symptoms  suggest  that  in  some  cases  the  lower,  and  in 
other  cases  the  higher  centre  is  that  from  which  the  discharge  origi- 
nates, because  the  distribution  of  the  spasm  indicates  that  the  func- 
tional level,  so  to  speak,  of  the  discharge  is  not  always  the  same.  In 
some,  the  affected  muscles  are  those  that  act  together  in  producing  a 
given  movement,  although  they  are  supplied  by  different  nerves.  It 
seems  probable  that  such  a  spasm  depends  on  the  over-action  of  a 
centre  in  which  movements,  rather  than  muscles,  are  represented.  On 
the  other  hand,  when  the  spasm  is  of  a  single  muscle,  or  of  muscles 
that  are  not  physiologically  associated,  it  seems  more  probable  that  it 
depends  on  a  lower  centre,  such  as  the  spinal  or  bulbar  grey  matter 
from  which  the  nerves  proceed.  The  physiological  association  of 
muscles  is  specially  noticeable  in  the  contraction  of  the  frontales  in 
retrocollic  spasni.  These  muscles  are  innervated  from  the  facial 
nucleus  in  the  pons,  while  the  muscles  at  the  back  of  the  neck  are  for 
the  most  part  innervated  from  the  spinal  cord.  It  seems  far  more 
probable  that  such  an  associated  spasm  depends  on  the  cortical 
centres  than  that  it  is  due  to  the  lower  centres.  So,  too,  in  the  cases 
in  which  there  is  spasm  in  the  muscles,  on  both  sides  of  the  neck, 
that  are  concerned  in  turning  the  head  to  one  side.  On  the  other 
hand,  such  an  association  as  that  of  the  muscles  which  incline  the 
head  towards  one  shoulder,  or  strong  spasm  limited  to  one  sterno- 
mastoid  and  the  opposite  deltoid  muscles,  seems  more  intelligible  on 
the  assumption  that  the  over-acting  nerve- cells  are  those  of  the  lower 
centres,  since  these  muscles  do  not  commonly  act  together  without 
others.  The  causation  of  the  disease  by  injuries  that  involve  forcible 
bending  of  the  neck  also  suggests  that,  in  such  cases,  the  spasm 
proceeds  from  the  lower  centre.  We  have  seen  reason  to  believe  that 
the  over-action  that  causes  facial  spasm  is  sometimes  in  the  cortical 
centres,  and  sometimes  in  the  lower  centres.  At  the  same  time  we 
must  not  lay  too  much  weight  on  the  significance  of  functional  asso- 
ciation. It  is  probable  that  the  connection  of  the  cells  of  the  lower 
centres  is  determined  by  this  association,  and  the  manner  in  which 
the  spasm  spreads  among  the  muscles  on  both  sides  is  often  more 
intelligible  on  the  assumption  that  the  over-acting  cells  are  those  of 
lower  centres.  It  may  be  noted,  moreover,  that  there  is  reason  to> 
believe  that  structures  in  the  lower  part  of  the  pons  Varolii  influence 
the  associated  action  of  rotation  of  the  head  (see  p.  187).  There  is 
one  important  difference  between  the  spasm  in  torticollis  and  that 
which  occurs  in  the  same  muscles  as  a  consequence  of  cortical  disease. 
In  the  latter  a  conjugate  deviation  of  the  eyes  is  usually  associated 
with  that  of  the  head,  and  this  is  true  also  of  the  spasni  that  results 


670  WRY-NECK. 

from  irritation  of  the  structures  in  the  pons.  In  ordinary  torticollis, 
however  widely  the  spasm  spreads,  the  muscles  of  the  eyeball  are  not 
implicated.  From  these  considerations  it  seems  doubtful  whether  we 
have  at  present  sufficient  evidence  to  justify  us  in  coining  to  any  con- 
clusion regarding  the  seat  of  the  primary  over-action  of  the  cells 
which  causes  the  symptoms. 

The  nature  of  the  morbid  process  is  also  involved  in  as  much 
obscurity  as  it  is  in  all  other  similar  spasmodic  diseases.  That 
there  is  an  unnatural  state  of  the  nerve-cells,  in  consequence  of  which 
nerve-force  is  spontaneously  liberated,  is  scarcely  more  than  a  state- 
ment of  the  observed  facts,  and  leaves  us  still  ignorant  of  the 
condition  on  which  the  phenomena  depend.  There  is  at  present  no 
evidence  that  the  over-action  of  the  cells  depends  on  any  morbid 
process  outside  them,  or  any  lesions  that  could  be  detected  by  naked- 
eye  or  microscopical  examination.  The  fact  that  neurotic  heredity 
can  often  be  traced  as  a  predisposing  cause,  suggests  that  the  over- 
action  has  its  origin  in  a  primary  derangement  of  the  nerve- elements 
themselves.  It  is  to  be  noted  that  this  disease,  in  common  with  other 
spasmodic  affections  of  the  same  class,  comes  on  usually  in  adult  life, 
and  seems  to  depend  on  a  local  failure  in  the  stability  of  function  that 
has  been  long  developed,  and  cannot  therefore  be  ascribed  either  to  an 
imperfect  establishment  of  function  on  the  one  hand,  or  to  actual 
senile  changes  on  the  other.  In  their  occurrence  at  the  time  when 
nerve-action  might  be  expected  to  possess  its  full  stability  and  precision, 
and  also  in  their  local  character,  these  affections  constitute  an  enigma 
to  which  Ave  have  as  yet  no  solution. 

Diagnosis. — The  diagnosis  of  spasmodic  torticollis  seldom  presents 
any  difficulty.  The  condition  that  has  been  termed  "  false  torticollis," 
in  which  there  is  a  deviation  of  the  head  from  some  other  cause  than 
muscular  contraction,  is  readily  distinguished  from  the  variety  that  is 
due  to  shortening  of  one  sterno-mastoid  (with  which  alone  it  is  likely 
to  be  confounded)  by  noting  the  relation  between  the  position  of  the 
head  and  the  side  on  which  the  muscle  is  tense.  In  the  spurious 
form  the  sterno-mastoid  is  tense  on  the  side  towards  which  the  face  is 
turned ;  in  the  true  form  the  tension  is  of  the  opposite  muscle. 
Eetrocollic  spasm,  when  the  movements  are  small  in  range,  is  apt  to 
be  mistaken  for  simple  tremor,  but  the  muscular  contractions  can  be 
felt  to  be  more  violent  than  they  ever  are  in  simple  tremor,  and  the 
associated  spasm  in  the  frontales,  which  has  been  conspicuous  in  all 
the  cases  I  have  seen,  supplies  an  absolute  distinction  between  the 
two  affections.  Another  occasional  difficulty  is  the  distinction  of  true 
torticollis  from  hysterical  spasm  of  torticollic  type.  The  facts  of 
etiology  show  that  under  thirty  true  torticollis  seldom  occurs  in 
females,  and  therefore  at  that  period  there  will  always  be  a  presump- 
tion that  the  affection  is  hysterical,  but  after  thirty  the  mere  fact  of 
sex  must  not  be  allowed  weight.     As  a  rule,  hysterical  spasm  tends  to 


TREATMENT.  671 

spread  from  the  neck  to  the  trunk,  which  becomes  affected  by 
writhing  movements.  In  all  the  cases  that  I  have  seen  in  which  the 
conditions  of  onset  raised  a  suspicion  of  the  hysterical  nature  of  the 
case,  and  the  spasm  was  limited  to  the  neck,  and  was  typical  in  form, 
the  affection  turned  out  to  be  the  true  variety.  There  is,  indeed,  no 
absolute  criterion  by  which  this  point  in  diagnosis  may  be  determined. 
I  have  even  known  recovery,  under  treatment  suited  for  an  hysterical 
affection,  to  be  followed  by  a  return  of  persistent  spasm. 

Prognosis. — The  facts  of  the  course  of  torticollis,  already  men- 
tioned, show  that  the  prognosis  must  be  grave  in  every  developed 
case.  The  more  severe  the  spasm,  the  wider  its  extent,  and  the  longer 
its  duration,  the  smaller  is  the  prospect  that  considerable  relief  or 
cessation  will  he  obtained.  This  is,  however,  greater  in  the  first  half 
of  adult  life  than  in  the  second,  and  it  is  better  when  the  spasm  is 
variable  than  when  it  is  uniform  in  seat. 

Treatment. — The  removal  of  any  influences  that  can  be  regarded 
as  having  helped  to  induce  the  disease  is,  of  course,  of  the  first  import- 
ance. Cases  do  not  often  come  under  treatment  in  the  early  stage, 
but  it  is  desirable  that  any  stiffness  due  to  cold,  that  has  lasted  for  an 
unusually  long  time,  should  be  treated  by  rest  and  hot  applications. 
Unfortunately  it  is  very  rare  for  causal  treatment  to  have  any  appre- 
ciable influence  on  the  disorder.  The  same  may  be  said  of  tonic  treat- 
ment in  general,  necessary  as  it  is  to  give  tonics  whenever  they  are 
indicated.  Drugs  that  may  be  called  "  stimulant  nervine  tonics," 
such  as  valerianate  of  zinc  and  asafcetida,  sometimes  have  a  marked 
influence  on  the  spasm,  even  in  cases  in  which  it  is  certainly  not 
hysterical  in  nature.  In  one,  the  aduiinstration  of  these  two  drugs, 
without  other  treatment,  reduced  severe  spasm  to  a  very  trifling  degree 
of  intensity,  and  the  improvement  continued  for  some  mouths,  but  the 
spasm  then  increased  again  and  resisted  all  remedies.  Sedatives 
frequently  lessen  the  spasm  while  their  action  on  the  system  continues, 
especially  opium,  morphia,  chloral,  succus  conii  in  large  doses  (gra- 
dually increased  to  two  ounces),  bromide  of  potassium,  and  Indian 
hemp.  But  the  discontinuance  of  the  drug  is  usually  followed  by  a 
relapse  to  the  former  degree  of  severity,  although  occasionally  this  does 
not  take  place  for  some  weeks  or  even  months.  I  have  only  once 
known  great  and  permanent  improvement  to  result  from  the  internal 
administration  of  sedatives,  which  in  this  case  consisted  of  the  com- 
bination of  bromide  of  potassium  and  cannabis  indica.  There  is  one 
mode  of  treatment  that  has  in  many  cases  had  a  more  lasting  influence, 
but  it  is  a  remedy  that  has  to  be  carefully  weighed  in  the  balance 
against  the  disease, — the  hypodermic  injection  of  morphia.  Continued 
for  several  months,  in  doses  increased  gradually  to  half  a  grain  or  a 
grain  a  day,  it  has  entirely  removed  the  spasm.  But  the  patients 
so  treated   find  the  discontinuance  of  the  drug  extremely  difficult, 


672  WKY-NECK. 

not  only  on  account  of  the  craving  for  it  that  is  established,  but  also 
because  (what  is  perhaps  part  of  the  craving)  they  feel,  or  imagine 
they  feel,  a  tendency  to  the  return  of  the  spasm  if  the  drug  is  dis- 
continued. In  one  very  severe  and  distressing  case  of  retrocollic 
spasm,  in  a  man  aged  forty-five,  all  muscular  contractions  ceased 
under  the  influence  of  the  drug,  and  the  patient  has  now  been  free 
for  ten  years,  but  has  never  left  off  the  use  of  morphia,  although  he 
has  not  increased  the  dose  above  that  named.  A  patient  so  treated 
should  undergo  a  subsequent  course  for  the  eradication  of  the  morphia 
habit,  before  he  passes  from  the  hands  of  the  practitioner,  and  the  effect 
of  the  withdrawal  of  the  morphia  should  be  carefully  observed.  Co- 
caine may  be  used,  but  for  a  time  only,  as  the  morphia  is  being  with- 
drawn. Unless  these  measures  are  adopted,  the  treatment  is  the 
substitution  of  one  morbid  state  for  another,  and  that  which  is  sub- 
stituted maybe  in  the  end  the  more  harmful  of  the  two.  The  patient 
above  mentioned,  however,  has  had  ten  years  of  perfect  comfort  in 
exchange  for  a  condition  that  was  most  distressing  ;  the  spasm  was  so 
severe  that  he  could  never  enter  a  public  conveyance  on  account  of  the 
painful  observation  he  excited.  Eeynolds  has  also  described  favorable 
results  from  the  treatment.*  The  addition  of  arsenic  to  the  injected 
morphia  has  been  advocated  by  Eadcliffe,  but  arsenic  alone,  either  by 
the  mouth  or  by  hypodermic  injection,  seldom  has  much  influenced 
and  it  is  therefore  probable  that  the  influence  of  the  combination 
is  due  chiefly  to  the  morphia.  The  beneficial  influence  of  internal 
remedies  has  been  chiefly  observed  in  cases  in  the  first  half  of 
adult  life,  in  which  there  is  occasionally  a  distinct  tendency  for  the 
spasm  to  subside  and  even  cease.  The  energetic  and  prolonged  use  of 
morphia  is,  however,  an  exception  to  this,  since  it  has  been  equally 
effective  in  later  life. 

Electricity  has  been  used  in  various  ways  in  the  treatment  of  the 
disease.  The  method  that  has  generally  been  employed  is  the  appli- 
cation of  the  voltaic  current  to  over-acting  muscles,  a  weak  current 
being  used,  which  has  some  sedative  influence.  The  positive  pole 
may  be  placed  just  below  the  occiput  or  on  the  highest  accessible 
part  of  the  nerve,  and  the  negative  on  each  contracting  muscle  for 
five  or  ten  minutes.  Thus  employed,  it  has  been  said  to  do  good  in 
some  cases ;  in  one  of  severe  bilateral  spasm,  recorded  by  Poore,  the 
affection  almost  ceased  under  the  treatment,  but  the  case  was  peculiar, 
and  possibly  allied  to  the  hysterical  form.  In  general,  electricity 
fails  to  do  more  than  produce  a  slight  and  transient  diminution  in  the 
spasm ;  I  have  not  myself  seen  any  permanent  good  result  from 
the  agent,  even  when  long  continued.  Faradisation  of  the  antago- 
nists of   the  over-acting  muscles   has   been   recommended,  but  this 

*  '  System  of  Med.,'  vol.  ii,  p.  797. 

t  A  case  of  clonic  spasm  which  recovered  under  the  administration  of  arsenic, 
recorded  by  Buzzard,  was  certainly  of  hysterical  nature  ('Biit.  Med.  Journ./  1881,. 
p.  937). 


TREATMENT.  673 

method  is  as  destitute  of  rational  foundation  as  it  certainly  is  of 
practical  effect.  The  disease  probably  never  results  from  the  weak- 
ness of  the  opponents,  and  cannot  be  lessened  by  increasing  their 
activity.  A  blister  over  the  contracting  muscles  may  lessen  the  spasm 
for  a  time  in  very  marked  degree,  but  the  effect  is  seldom  as  per- 
manent as  it  often  is  in  hysterical  spasm.  Blistering  over  the  cervical 
spine,  however,  apparently  arrested  the  affection  in  one  instance.* 

Mechanical  supports  afford  occasionally  some  relief,  which  depends 
on  the  fact  that  the  greater  the  movement  and  muscular  contraction, 
the  greater  is  the  discomfort  produced.  Many  patients  are  compara- 
tively easy  when  they  are  sitting  in  a  chair  with  a  high  back,  against 
which  they  can  fix  the  head.  The  best  support  is  one  in  which  a 
rigid  rod  is  carried  up  to  the  back  of  the  head,  and  from  its  top  a 
small  pad  projects  on  the  side  towards  which  the  occiput  is  turned  by 
the  spasm,  so  that  the  patient  is  able  to  press  the  head  against  the 
pad.  The  instrument  needs  careful  contrivance,  having  to  be  specially 
adapted  to  each  individual  case,  and  it  is  only  when  the  spasm  is 
moderate  in  degree  that  the  expedient  is  very  successful.  Instru- 
ments that  are  designed  to  fix  the  head  rigidly,  and  prevent  all  move- 
ment, can  never  be  endured. 

Surgical  measures  have  beeu  frequently  employed  in  the  treatment 
of  torticollis,  but,  with  one  exception,  their  effect  has  been  slight  and 
disappointing.  The  most  useless  procedure  that  has  been  employed 
is  the  division  of  the  tendon  of  the  contracting  muscle.  This  has 
been  sometimes  done  apparently  because  the  operation  cures  the  totally 
different  fixed  wry-neck.  In  active  spasm  it  is  worse  than  useless, 
because  the  division  of  the  tendon  permits  the  muscle  to  shorten, 
while  it  does  not  check  the  spasm,  and  the  greater  the  contraction  of 
the  muscular  fibres  the  greater  is  the  pain  occasioned  by  the  contrac- 
tion. In  one  case  that  came  under  my  notice  some  time  after  the 
operation  had  been  performed,  the  patient's  suffering  was  much  in- 
creased, and,  possibly  in  consequence  of  the  increased  pain,  the  spasm 
had  spread  to  other  muscles. 

In  many  cases  in  which  the  spasm  was  confined  to,  or  greatest  in, 
the  sterno-mastoid,  or  in  this  and  the  trapezius,  the  spinal  accessory 
nerve  has  been  stretched.  Temporary  relief  has  followed,  but  when 
the  effect  of  the  stretching  had  passed  away,  the  spasm  has  almost 
invariably  returned  in  its  original  sevei-ity.f  The  only  operation 
that  can  be  credited  with  an  approximate  or  actual  cure  of  the  affec- 
tion is  division  of  the  nerve,  with  excision  of  a  piece,  half  an  inch  or  so 
in  length,  to  prevent  reunion  of  the  ends.  The  operation  causes,  of 
course,  permanent  paralysis  and  atrophy  of  the  muscular  fibres  to 

*  Morton  Prince,  '  Boston  Med.  and  Surg.  Journ.,'  1886. 

f  The  only  case  in  which  great  improvement  followed  stretching  was  very 
unusual  in  the  fact  that  the  patient  was  a  boy  of  fourteen,  and  the  spasm  affected 
also  the  muscles  of  the  back  and  both  arms.  It  was  probably  more  closely  allied 
to  the  hysterical  than  to  the  ordinary  form.     (Southam,  '  Lancet/  1881,  ii,  p.  369.) 

vol.  ii.  43 


674  TETANUS. 

which  the  nerve  is  distributed,  of  the  whole  muscle  if,  as  in  the  case 
of  the  sterno-mastoid  and  upper  part  of  the  trapezius,  there  is  no 
other  nerve-supply.  All  spasm  in  the  muscle  thus  paralysed  is 
necessarily  abolished.  Campbell  de  Morgan  first  cured  a  patient  (in 
1862)  by  this  procedure,  and  it  has  since  been  employed  with  success 
in  many  cases.  When  other  muscles  have  also  been  involved,  in 
slighter  degree,  the  arrest  of  the  spasm  in  the  muscles  first  and 
most  affected  has  frequently  been  followed  by  a  remarkable  diminution 
in  the  contractions  in  the  other  muscles,  which  have  subsided  to  a 
merely  trifling  degree,  and  sometimes  have  gradually  ceased.  When 
other  muscles,  as  the  splenitis,  complexus,  &c,  have  been  the  seat  of 
severe  spasm,  this  has  commonly  persisted  after  the  operation  on 
the  spinal  accessory  nerve  ;  but  it  has  been  shown  by  Keen  and  Noble 
Smith  that  this  spasm  may  also  be  reduced  to  a  slight  degree,  or  re- 
moved, by  the  subsequent  division  of  the  posterior  branches  of  two  or 
three  of  the  cervical  nerves  supplying  the  muscles  involved.  Neurec- 
tomy is  certainly  the  most  successful  method  yet  employed  in  the 
treatment  of  torticollis.  The  paralysing  effect  of  the  division  of  the 
branches  of  the  spinal  nerves  is  unimportant ;  the  palsy  of  the  sterno- 
mastoid  interferes  with  the  movement  of  the  head  in  some  degree, 
but  very  little  with  its  position  ;  that  of  the  trapezius  lessens  the 
power  of  the  arm,  but  this  is  a  far  slighter  inconvenience  to  the  patient 
than  the  spasm  which  it  replaces.  The  remarkable  subsidence  of 
moderate  spasm  in  other  muscles  than  those  chiefly  affected,  may 
perhaps  be  due  to  the  fact  that  the  operation  necessarily  arrests  the 
transmission,  not  only  of  the  motor  impulses  to  the  muscle,  bat  also  of 
the  afferent  impulses  from  the  muscle  to  the  centre.  These,  generated 
by  the  muscular  contractions,  must  be  intense  and  constant,  and  may 
be  concerned  in  the  extension  of  the  central  over-action.* 


TETANUS. 

Tetanus  is  a  disease  of  the  nervous  system,  characterised  by  persis- 
tent tonic  spasm,  with  violent  brief  exacerbations.  The  spasm  almost 
always  commences  in  the  muscles  of  the  neck  and  jaw,  causing 
closure  of  the  jaws  (trismus,  lockjawf),  and  involves  the  muscles  of 
the  trunk  more  than  those  of  the  limbs.  It  is  always  acute  in  onset, 
and,  of  those  who  are  attacked,  a  very  large  proportion  die.  The 
disease   is   usually  the  result  of  a  wound    (traumatic  tetanus),  but 

*  Among  the  cases  of  successful  neurectomy  described  and  discussed  are  those  of 
De  Morgan,  '  Med.-Chir.  Rev.,'  1866,  and  '  Lancet,'  Aug.,  1867 ;  Annandale, 
"Lancet/ 1879;  Sands,  Tillaux,  and  Hansen;  cases  quoted  by  Bowlby,  'Injuries 
and  Diseases  of  Nerves  ; '  Ballance,  *  St.  Thomas's  Hosp.  Rep.,'  1884 ;  Keen,  '  Annals 
of  Surgery,'  Jan.,  1891 ;  Noble  Smith,  '  Brit.  "Med.  Journal,'  1891,  and  a  pamphlet, 
•  Spasmodic  Wry-neck,'  in  which  are  quoted  the  details  of  all  the  published  cases. 

f  Properly  "  locked  jaw." 


TETANUS.  075 

sometimes  occurs  without  external  injury,  especially  after  exposure  to 
cold  (idiopathic  or  rheumatic  tetanus).  It  occurs  also  in  newly-born 
children  (tetanus  neonatorum,  trismus  nascentium) ,  and,  rarely,  after 
childbirth  or  abortion  (puerperal  tetanus). 

Etiology. — Traumatic  tetanus  is  far  more  common  in  males  than  in 
females,  the  proportion  being  nearly  as  6  to  1.*  The  idiopathic  form  also 
occurs  in  males  more  frequently  than  in  females,  although  the  dispro- 
portion is  not  quite  so  great  as  in  the  traumatic  form.  Of  46  idiopathic 
cases  37  were  males  and  9  females,  a  proportion  of  4  to  1.  Doubt- 
less the  chief  cause  of  the  different  liability  of  the  sexes  is  the  greater 
exposure  to  the  immediate  causes,  involved  in  the  occupations  of  men. 

Tetanus  occurs  at  every  period  of  life.  The  distribution  of  160 
traumatic  cases  and  of  46  idiopathic  cases  is  shown  in  the  tables 
below.  During  the  first  five  years  of  life  (the  first  month  ex- 
cepted) there  is  almost  complete  immunity,  the  cases  under  ten  oc- 
curring after  five.  The  second  decade  of  life  yields  the  largest  propor- 
tion, rather  more  than  a  quarter ;  the  third  and  fourth  decades,  each 
rather  less  than  a  quarter,  so  that,  in  the  thirty  years  of  life  from  ten 
to  forty,  about  three  quarters  of  the  total  number  of  cases  occur.  The 
disease  continues,  with  decreasing  frequency,  up  to  old  age,  and  has 


Teaumatic 

1-9 

10-19 

20-29 

30-39 

40-49 

50-59 

60  + 

Males 

.      5     . 

...     36     . 

..     32     . 

..     29     . 

..     20     . 

..     11      . 

...     5 

Females  . 

.       4 

...       7     . 

4     . 

..       5     . 

2     . 

..       0 

...     0 

Total       . 

.       9 

,..     43     . 

..     36     . 

..     34     . 

..     22     . 

..     11 

...     5 

Per  cent. 

.     55      ; 

...     27     . 

..  22o     . 

..     21     . 

..     14     . 

..       7 

...     3 

Idiopathic 

1-9 

10-19 

20-29 

30-39 

40-49 

50-59 

60  + 

Males 

.       2 

5     . 

..       9     . 

..     12     . 

..       4     . 

..       0     . 

..      3 

Females  . 

.       1 

...       4     . 

0     . 

..       2     . 

..       2     . 

..       0     . 

..      0 

Total      .         .       3     ...       9     ...       9     ...     14     ...       6     ...       0     ...      3 

been  met  with  as  late  as  eighty-nine  (Yandell).  The  few  cases  in 
childhood  (five  to  ten  years)  occur  in  each  sex  with  almost  equal  fre- 
quency ;  from  ten  to  forty  the  proportion  between  the  sexes  is  near  the 
average  (1  to  6)  ;  between  forty  and  fifty,  women  suffer  still  less  fre- 
quently, and  scarcely  ever  after  fifty. 

Dark-skinned  races  have  been  observed  to  suffer  from  all  forms  of 
tetanus  more  frequently  than  Europeans  when  both  are  exposed  to 
the   same   influences.     In   hot  countries,  e.*g.   India  and  the   West 

*  The  published  series  of  cases  at  Glasgow  (Lawrie,  'Glasgow  Med.  Journal,' 
1853,  vol.  i,  p.  339),  and  at  Guy's  Hospital  (Poland,  'Guy's  Hosp,  Rep.,'  1857;  F. 
Taylor,  '  Guy's  Hosp.  Rep.,'  1878),  idiopathic  cases  excluded,  comprise  160,  of  which 
138  were  in  males  and  22  in  females.  Consecutive  series  of  cases  such  as  these  give 
more  accurate  statistics  than  collections  of  cases  which  have  been  published  sepa- 
rately (often  on  account  of  some  special  feature),  and  also  than  the  more  massive  but 
undifferentiated  statistics  of  the  general  mortality. 


676  TETANUS. 

Indies,  tetanus  is  far  more  common  tban  in  temperate  regions,  and 
it  is  especially  prevalent  at  certain  periods  and  in  certain  places.  In 
temperate  climates,  however,  its  incidence  does  not  appear  to'  be 
influenced  by  weather  or  by  season. 

It  is  doubtful  whether  previous  health  exerts  au  influence  on  the 
occurrence  of  the  disease.  The  robust  suffer  as  well  as  the  weakly. 
It  has  been  thought  that  depressing  emotions  predispose  to  it,  and 
especially  a  fear  of  the  disease,  but  it  is  doubtful  whether  this  is 
really  proved  by  ascertained  facts.* 

The  immediate  cause  of  tetanus  is  a  specific  bacillus,  which,  in  the 
usual  traumatic  form,  is  inoculated  at  the  wound.  The  symptoms 
depend,  however,  not  directly  on  the  organism,  but  on  a  toxic  material 
produced  by  it,  which  seems  to  have  an  action  on.  the  central  nervous 
system  analogous  to  that  of  strychnine.  The  evidence  of  this  causation 
is  conclusive  ;  it  has  been  ascertained  by  the  researches  of  numerous 
investigators  during  the  last  six'  years,  and  will  be  described  in  the 
section  on  Pathology.  The  bacillus  exists  chiefly  in  earth- mould, 
especially  where  any  putrefaction  is  going  on,  as  in  manured  soil  ;  but 
it  is  widely  spread,  and  its  spores  are  probably  carried  also  by  the 
air.  The  discovery  explains  many  facts  of  causation  that  were  before 
mysterious,  as,  for  instance,  the  prevalence  in  certain  localities  ;  while 
the  fact  that  the  bacillus  thrives  best  at  a  comparatively  high  tem- 
perature explains  the  frequency  of  the  disease  in  hot  countries.  But 
the  precise  relation  of  other  causal  conditions  to  the  action  of  the 
organism  has  still  to  be  cleared  up.  The  discovery  reduces  to  a  sub- 
ordinate position  the  influences  which  were  formerly  regarded  as  the 
chief  causes  of  the  disease ;  they  must  not,  however,  be  ignored, 
although  they  need  fresh  study  in  the  light  of  the  new  facts.  For 
instance,  the  different  susceptibility  of  the  dark  and  light-skinned 
races  indicates  a  difference  in  the  liability  of  the  individuals,  analo- 
gous to  that  which,  as  we  shall  see,  exists  among  different  animals, 
and  it  suggests  that  variations  in  susceptibility  may  exist  in  the 
same  individual,  at  different  times,  as  the  result  of  influences  which 
formerly  were  alone  discerned. 

In  traumatic  tetanus  the  wound  involves  an  actual  breach  of  the 
surface ;  it  may  be  in  any  position,  of  any  character,  and  of  any 
degree  of  severity.  Cases  have  been  recorded  in  which  tetanus  has 
followed  the  most  trifling  injuries  (the  stings  of  bees  and  wasps,  the 
prick  of  a  thorn,  the  removalf  of  a  foreign  body  from  the  eye),  every 
kind  of  incised,  punctured,  contused,  and  lacerated  wounds,  compound 
fractures,  and  almost  every  form  of  surgical  operation,  from  the 
extraction  of  a  tooth  to  ovariotomy.     But  it  is  far  more  common  after 

*  A  curious  case  (described  in  the  last  edition),  in  which  dread  of  the  disease 
apparently  excited  the  malady,  has  been  deprived  of  its  significance  by  the  recent 
discoveries,  since  the  injury  was  a  lacerated  wound  of  the  hand,  produced  by  its 
contact  with  the  road  in  a  fall  from  a  horse. 

f  Probably  rather  its  presence  there. 


ETIOLOGY.  677 

punctured,  contused,  and  lacerated  wounds  than  after  incised  wounds. 
Hence  it  is  comparatively  rare  after  surgical  operations.     Injuries  of 
nerves  have  been  supposed  to  be  especially  concerned  in  its  produc- 
tion, and  those  of  small  nerves  rather  than  those  of  large  nerve- 
trunks.     It  also  follows  extensive  burns,  and  also  severe  frostbites. 
The  order  of  frequency*  with  which  the  several  parts  have  been  the 
seat  of  the  wound  that  caused  tetanus  is  (1)  hand,  (2)  leg,  (3)  foot, 
(4)  head  and  neck,  (5)  arm,  (6)  trunk.     The  wound  has  sometimes 
been  in  an  unhealthy,  irritated  condition ;   more  frequently  it  has 
been  in  a  perfectly  healthy  state,  and  sometimes  cicatrisation  has  been 
advanced,  or  even  complete.     Since  attention  has  been  given  to  the 
point,  it  has  been  observed  that  in  a  considerable  proportion  of  the 
■cases  the  injury  involved  contamination  of  the  wound  with  soil,  as  in 
falls  on  the  ground,  a  puncture  by  a  broken  stick  or  stake  which 
had  been  in  the  earth,  or  by  a  splinter  from  a  dirty  floor.     Such  a 
splinter  from  the  floor  of  a  skittle  alley,  penetrating  beneath  the  nail, 
produced  it ;  one  fatal  case  was  due  to  a  compound  fracture  of  both 
femora,  from  a  fall  in  which  the  ends  of  the  bones  were  covered  with 
earth ;  gardeners  have  suffered  from  punctures  by  sticks.     In  most 
of  these  cases  the  tetanus  bacilli  were  found  in  the  source  of   the 
contaminating  material ;  their  presence  explains  the  influence  of  these 
injuries.     They  have  been  found  in  spiders'  webs,  aud  tetanus  has 
followed  the  application  of  such  webs  as  a  styptic  (a  popular  custom 
in  some  places),  and  also  the  application  of  earth  to  a  wound.     Spon- 
taneous  disease — ulcers,   for  instance — may   also   occasion   tetanus, 
although  far  less  frequently  than  wounds.     In  such  cases,  and  also  in 
burns,  the  organisms  must  reach  the  local  lesion  either  by  contami- 
nated applications  (possible  in  the  case  of  ulcers,  but  unlikely  in  that 
of  burns),  or  else  through  the  air.     In  rare  instances  the  disease  is 
said  to  have  followed  injuries  which  involved  no  breach  of  surface,  as 
flogging,  and  falls  on  the  back  of  the  head  and  spine.     Such  cases 
ought  perhaps  to  be  provisionally  classed  with  the  idiopathic  form,  in 
respect  to  the  mystery  of  their  direct  causation. 

The  interval  between  the  infliction  of  the  wound  and  the  appearance 
of  the  first  symptoms  of  tetanus  is  usually  from  five  to  fourteen  days 
{in  two  thirds  of  the  cases),  but  the  malady  may  set  in  earlier  or  later. 
Many  cases  have  been  recorded  which  commenced  within  forty-eio-ht 
hours  of  the  injury,  a  few  within  twelve  hours,  and  one  or  two  in 
which  tetanus  came  on  almost  immediately.  In  Robinson's  often- 
quoted  case,  a  negro,  who  cut  his  hand  with  a  piece  of  porcelain,  was 
dead  in  fifteen  minuites.     On  the  other  hand,  tetanus  occasionally 

*  According  to  395  cases  tabulated  by  Thambayn  ('Schmidt's  Jahrbucher/ 
vol.  cxii,  1861).  This  does  not  show  its  absolute  frequency  in  wounds  of  each  part; 
for  the  determination  of  this  no  adequate  statistics  at  present  exist.  It  is  said  by 
some  to  be  very  seldom  caused  by  wounds  of  the  head  and  neck.  Of  505  cases  of 
tetanus  tabulated  in  the  records  of  the  American  civil  war,  only  21  were  due  to 
injuries  of  those  parts.  Nevertheless  one  peculiar  form  of  tetanus  (cephalic  tetanus) 
seems  to  be  produced  chiefly  by  injury  in  the  region  of  the  fifth  nerve  (see  p.  683). 


678  TETANUS. 

comrueuces  during  the  third  or  fourth  week  after  the  injury;  scarcely 
ever  later  than  a  mouth. 

Idiopathic  tetanus  usually  follows  exposure  to  cold,  especially  to 
wet  cold  when  the  body  is  perspiring.  In  many  cases  the  exposure 
has  been  repeated  and  prolonged.  When  due  to  a  single  exposure,  so 
that  the  interval  could  be  ascertained,  it  has  rarely  exceeded  two  days, 
and  has  frequently  been  only  a  few  hours.  In  many  cases  classed  as 
traumatic  tetanus  there  has  been  an  exposure  to  cold  after  the  receipt 
of  the  wound.  This  has  been  thought  to  be  the  chief  cause  of  the 
frequency  of  tetanus  in  soldiers  wounded  in  battle.  The  influence  of 
cold  has  also  been  thought  to  aid  the  occurrence  of  puerperal  and 
neonatal  tetanus.  But  the  relation  of  the  apparent  influence  of  cold 
to  the  infective  agent  has  still  to  be  explained.  The  exposure  to  cold 
may  sometimes  have  been  merely  coincident  with  that  to  opportunities 
of  infection,  as,  for  instance,  in  soldiers  on  the  march.  Some  influ- 
ences may  predispose  the  nervous  system  to  suffer  from  a  minute  dose 
of  the  poison.  The  relation  of  the  organisms  to  idiopathic  tetanus 
has  also  not  yet  been  ascertained.  It  has,  indeed,  been  maintained  that 
all  the  supposed  idiopathic  cases  are  the  result  of  some  unnoticed 
trifling  surface  injury  (Verneuil).  At  present  this  can  scarcely  be 
admitted,  but  the  possibility  of  such  causation  may  be  remembered 
in  connection  with  the  rare  cases  in  which  no  morbid  influence  can  be 
traced,  and  with  those  that  have  been  observed  to  follow  some 
apparently  inadequate  cause,  alcoholic  intoxication,  insolation,  and 
violent  emotion,  and  perhaps  also  the  inflammation  of  some  serous 
membrane,  excited  usually  by  cold.  Intestinal  worms  have  probably 
been  merely  coincident. 

Puerperal  tetanus  is  frequent  in  hot  countries,  and  is  perhaps  the 
most  terrible  form  of  the  disease.  It  is  said  that  in  Bombay,  in  three 
years,  232  women  died  from  this  cause.  Fortunately  it  is  very  rare 
except  in  the  tropics.  Of  fifty  cases  in  temperate  countries*  it 
occurred  in  eighteen  after  abortion ;  in  thirty-two  after  labour  at  or 
near  the  full  time.  The  cases  were  spread  over  the  childbearing 
period  of  life,  the  youngest  patient  being  twenty-two,  the  oldest 
fortv- eight.  Those  after  abortion  occurred  from  the  second  to  the 
fourth  month  of  pregnancy.  In  most  of  the  cases  there  was  severe 
haemorrhage,  and  in  seven  it  is  expressly  stated  that  the  vagina  was 
plugged,  a  procedure  that  has  been  thought  to  influence  the  occur- 
rence of  the  disease.  The  interval  between  the  abortion  and  the  first 
symptoms  varied  from  five  to  thirteen  days,  and  in  two  thirds  of  the 
cases  it  was  from  five  to  ten  days ;  in  no  case  was  it  less  than  five. 
In  two,  instruments  had  been  used  to  procure  abortion,  and  metritis 
had  resulted.  In  only  one  of  these  cases  was  the  tetanus  preceded  by 
exposure  to  cold,  on  the  tenth  day ;  the  first  symptoms  occurred 
on  the  eleventh. 

*  Including  sixteen  of  those  collected  by  Simpson  ('  Edin.  Med.  Journ.,'  1854). 
In  several  cases  it  has.  followed  the  Caesarean  section,  but  these  are  not  included. 


ETIOLOGY.  679 

Of  the  cases  after  labour,  the  particulars  of  the  labour  are  recorded 
in  twenty-six,  and  in  only  three  was  there  no  abnormal  condition 
during  or  after  parturition.  The  most  frequent  accident  was  adhesion 
of  the  placenta,  which  existed  in  nearly  half  the  cases  (twelve). 
Metritis  occurred  alone  in  two,  and  in  association  with  pharyngeal 
diphtheria  in  one.  In  only  one  case  was  the  forceps  used ;  in  one 
there  was  placenta  prsevia,  and  turning  was  necessary.  In  four  cases 
the  disease  followed  a  subsequent  exposure  to  cold ;  and  in  one  it 
succeeded  a  secondary  haemorrhage,  two  weeks  after  delivery,  for 
which  the  vagina  was  plugged.  The  interval  before  the  appearance 
of  the  symptoms  (noted  in  twenty-seven  cases)  varied  more  than  in 
the  cases  after  abortion,  but  in  nearly  half  (twelve  cases)  it  was  from 
five  to  seven  days  (inclusive).  In  one  third  (nine  cases)  it  came  on 
during  the  second  week. 

In  three  cases,  which  occurred  after  fourteen  days,  a  secondary 
influence  could  be  traced  (diphtheria  and  metritis,  cold,  secondary 
haemorrhage).  On  the  other  hand,  the  interval  was  once  only  three 
days,  and  once  four  days,  and  in  one  exceptional  case  (without  albu- 
minuria) symptoms  of  tetanus  came  on  during  labour,  ceased  for 
three  hours  after  delivery,  then  recurred  with  such  severity  as  to 
cause  death  in  an  hour.*  In  spite  of  the  apparent  influence  of  ex- 
ternal causes,  it  is  the  general  opinion  that  the  disease  is  related  to 
the  presence  of  decomposing  substances  in  the  uterus,  to  which,  in 
some  way,  the  tetanus  bacilli  gain  access,  or  in  which  some  toxic 
material  is  formed,  which  has  an  action  on  the  nervous  system  similar 
to  that  produced  by  the  organism.  The  inhalation  of  the  spores  of 
the  bacillus,  and  their  passage  to  the  decomposing  substance  of  the 
blood,  is  possible. 

Tetanus  neonatorum  is  fortunately  a  rare  disease  in  this  country, 
but,  like  other  forms,  it  is  exceedingly  common  in  certain  tropical 
countries,  especially  among  the  coloured  races.  In  Demerara,  at  one 
period,  one  half  of  the  negro  children  died  from  this  cause.  But  it  is 
endemic  also  in  some  localities  far  removed  from  the  tropics,  as  in 
the  notorious  instance  of  Heimaey,  an  island  near  Iceland,  where  the 
population  at  one  time  was  kept  up  only  by  immigration,  almost  all 
the  children  dying  from  this  cause.  This  fact  is  rendered  intelligible 
by  the  discovery  that  the  specific  bacillus,  infecting  the  umbilical 
wound,  is  the  cause  of  this  form  also.  Its  presence  is  doubtless 
favoured  by  insanitary  conditions,  since  the  employment  of  well- 
arranged  lying-in  hospitals  has  caused  the  affection,  formerly  pre- 
valent, to  disappear.f  It  usually  begins  between  the  third  and 
seventh  day,  occasionally  not  till  the  second  week,  very  rarely  later.J 

*  Curtis  Smith,  '  Philadelphia  Med.  Reports,'  1873. 

f  Of  three  successive  children  of  the  same  mother,  the  first  two,  horn  in  one 
house,  died  of  tetanus ;  the  third,  horn  in  a  different  house,  did  not  suffer  (Salzmann, 
'  Wurt.  Cor.-bl./  1885).  This  fact  agrees  perfectly  with  the  causation  of  the  disease 
by  bacilli.     (See  Pathology.) 

%  Tetanoid  spasms,  commencing  within  twenty  four  hours  of  birth,  are  probably 


680  TETANUS. 

The  liability  to  tetanus  of  newly -bom  children  seems  to  be  unin- 
fluenced by  sex;  boys  suffer  only  a  little  more  frequently  than  girls.* 
Tbe  umbilical  wound  is  frequently  inflamed ;  sometimes  arteritis 
extends  from  it  along  tbe  cord,f  but  it  maybe  healthy  in  appearance. 
In  hot  climates  (e.  g.  India,  according  to  Wallace)  tetanus  often  results 
from  circumcision,  and  bence  is  far  more  common,  during  tbe  second 
and  tbird  week  of  life,  among  Jews  and  Mobammedans  tban  among 
Cbristians.J  Occasionally  (as  in  otber  traumatic  cases)  an  exposure 
to  cold  precedes  tbe  onset. 

Symptoms.  — Tbe  symptoms  of  tetanus  present  little  variation  in 
tbe  majority  of  cases.  Rarely,  vague  pains  in  tbe  bead,  tbe  epigas- 
trium, or,  in  traumatic  cases,  at  tbe  seat  of  tbe  wound,  bave  preceded 
tbe  onset.  Tbe  first  symptom  is  usually  some  sense  of  stiffness  on 
movemeut  of  tbe  neck  or  jaw,  sometimes  difficulty  in  swallowing,  or 
stiffness  in  tbe  tongue.  Tbe  patient  tbinks  tbat  be  bas  got  a  stiff 
neck  from  sitting  in  a  draugbt,  and  if,  as  is  often  tbe  case,  tbe  sym- 
ptoms bave  actually  followed  an  exposure  to  cold,  tbe  patient's  im- 
pression may  be  shared  by  bis  medical  attendant.  But  in  tbe  course 
of  a  few  hours,  or  at  most  of  a  day  or  two,  the  difficulty  in  separating 
the  jaws  becomes  greatei*,  and  is  clearly  due  to  increasing  rigidity  of 
the  masseters.  "With  this  there  is  also  more  stiffness  in  the  neck,  and 
the  head  is  slightly  bent  backwards  from  tbe  preponderance  of  tbe 
spasm  in  the  extensor  muscles.  As  tbe  rigidity  in  the  neck  increases 
it  passes  down  tbe  spinal  muscles,  until  tbe  vertebral  column  becomes 
over-extended  in  what  is  called  "  opisthotonos."  Tbe  legs  may  also 
become  extended  and  rigid,  but  tbe  arms  are  little  affected.  Some- 
times opistbotonos  comes  on  at  the  same  time  as  the  rigidity  in  the 
muscles  of  the  jaw. 

due  to  meningeal  haemorrhage  (see  p.  413).  Marion  Sims  maintained  that  tetanus 
may  be  produced  by  displacement  forwards  of  the  occipital  bone,  irritating  the 
medulla.  This  displacement,  he  said,  is  physiological  during  birth,  and  is  maintained 
afterwards,  in  these  cases,  by  the  child  lying  on  its  back,  with  the  head  resting  on 
the  arm  of  the  nurse;  the  symptoms  may  be  removed  by  keeping  it  on  its  side,  first 
one,  then  tbe  other,  for  a  few  hours  ('American  Journal  of  Medical  Science/  April, 
1846;  July  and  October,  1818).  Evidence  in  favour  of  this  opinion  has  been 
brought  forward  by  Wilhite  (ibid.,  1875,  p.  375),  and  by  Hartigan  (ibid.,  Jan., 
1884);  but  these  authors  are  manifestly  in  error  in  believing  all  cases  of  tetanus 
neonatorum  to  be  thus  produced  and  thus  remediable.  Indeed,  the  correct  state- 
ment of  the  facts,  if  their  view  is  correct,  is  not  that  tetanus  is  thus  produced,  but 
that  tetanus  neonatorum  is  less  common  than  is  supposed,  and  is  simulated  by  the 
effects  of  compression  of  the  brain. 

*  In  Ireland,  of  371  deaths  from  tetanus  under  five  years  between  1841  and  1851, 
219  were  of  boys  and  152  of  girls.  It  is  probable  that  all  these  cases  were  of  tetanus 
neonatorum,  since,  as  already  stated,  the  disease  is  otherwise  practically  unknown 
under  five  years. 

t  Two  cases,  due  apparently  to  umbilical  ulceration,  one  in  a  child  three  weeks 
old,  are  described  by  Godlee  and  'Williams,  '  Med.  Times  and  Gaz.,'  Dec.  27th,  1884. 

f  Wallaie,  '  Lancet,'  18S2,  Aug.  12th. 


SYMPTOMS.  681 

As  the  rigidity  increases  it  involves  the  facial  muscles.  Apparently 
all  the  facial  muscles  are  affected,  but  those  which  are  strongest  over- 
come the  others,  and  impress  on  the  countenance  the  effects  of  their 
contraction.  Thus  the  eyebrows  are  raised  by  the  frontales,  while  the 
ocular  fissure  is  narrowed  by  the  orbicularis.  The  angles  of  the  mouth 
are  drawn  outwards  and  a  little  downwards,  and  the  upper  lip  is 
pressed  against  the  teeth",  in  what  has  been  termed  the  "  risus  sar- 
donicus."* 

The  tonic  spasm  or  rigidity  occasions  at  first  little  discomfort 
beyond  a  feeling  of  stiffness,  but  as  it  increases  a  pain  is  felt  in  the 
rigid  muscles.  Soon,  however,  it  occurs  in  paroxysms,  at  first  slight, 
but  gradually  increasing  in  severity,  and  causing  distressing  cramp- 
like pain.  The  paroxysms  are  usually  brief,  lasting  from  five  to  fifteen 
seconds,  and  the  spasm  is  greatest  in  those  muscles  which  are  the  seat 
of  the  persistent  rigidity.  Thus  the  posture  produced  by  the  latter 
is  increased  during  the  attacks.  The  head  is  drawn  back,  the  spine 
is  arched,  the  legs  rigid,  and  the  feet  extended,  so  that  the  patient,  in 
a  severe  paroxysm,  may  rest  on  the  head  and  heels.  The  peculiar 
expression  of  the  face  is  exaggerated  during  the  attacks  ;  the  jaw  is 
firmly  closed,  and  sometimes  the  tongue  is  bitten  from  being  caught 
between  the  teeth  when  the  paroxysm  comes  on.  Other  muscles, 
however,  are  involved,  although  in  less  degree.  The  thorax  may  be 
fixed  and  the  glottis  closed,  while  the  face  becomes  livid,  in  conse- 
quence of  the  interference  with  respiration.  The  abdominal  muscles 
are  also  contracted  and  hard  like  boards,  while  the  arms,  though  free 
from  rigidity  at  the  elbow  and  hand,  may  be  fixed  to  the  thorax.  In 
addition  to  the  cramp-like  pain  in  the  muscles,  severe  and  very  dis- 
tressing pain  is  frequently  felt  in  the  epigastric  region,  darting 
through  to  the  back.  It  may  be  an  early  symptom,  and  is  supposed 
to  be  due  to  spasm  in  the  diaphragm.  From  the  violence  of  the 
muscular  action  the  surface  is  covered  with  sweat,  and  during  the 
paroxysms  perspiration  may  pour  in  streams  from  the  body. 

Among  the  variations  in  the  symptoms  it  may  be  noted  that  in  rare 
cases  the  spasm  commences  in  the  limb  injured,  or  movement  of 
the  limb  may  excite  a  paroxysm  in  which  the  spasm  commences  there 
and  spreads  gradually.  Occasionally  the  stiffness  in  the  throat  pre- 
cedes that  in  the  jaw,  and  may  be  described  as  "  sore  throat."  It  has 
been  known  to  continue  for  a  week  before  the  rigidity  of  the  masse- 
ters  was  sufficient  to  prevent  inspection  of  the  throat.  Usually  the 
spasm  is  equal  in  the  two  masseters,  but  in  one  recorded  case  it 
commenced  on  the  side  that  had  been  exposed  to  a  draught  (Harris 
and  Doran).  The  spasm  is  always  more  extensive  than  the  posture 
suggests  ;  the  muscles  which  are  most  powerful  determine  the  attitude, 
but  their  weaker  opponents  also  contract,  perhaps  equally.  Thus  the 
muscles  that  depress  the  jaw  become  rigid,  as  well  as  those  that  raise 
it.  The  jaw  is  sometimes  fixed  by  both  sets  of  muscles  without  beincr 
*  From  a  plant  Sardonia,  so  called  because  it  grows  in  Sardinia. 


682  TETANUS. 

quite  closed,  and  in  one  case  the  jaw  remained  widely  open  during  a 
paroxysm. 

Opisthotonus  spasm  is  the  rule,  to  which  the  exceptions  are  few. 
Rarely  the  trunk  is  bent  forwards,  from  predominant  cramp  in  the 
abdominal  muscles  and  other  flexors  of  the  spine — "  emprosthotonos." 
Still  more  rarely  there  is  slight  lateral  flexion,  "  pleurothotonos,"  or 
the  trunk  and  neck  are  rigid  in  a  straight  line,  "  orthotonos."  These 
irregular  forms  seem  to  be  rather  more  frequent  in  cases  of  idiopathic 
tetanus  than  in  the  traumatic  form.  In  a  case  recorded  by  Treves 
considei*able  pain  in  the  abdomen  accompanied  the  emprosthotonos, 
and  shifted  to  one  side  as  the  spasm  became  pleurothotonic. 

The  tonic  spasm,  although  constant,  usually  varies  in  degree,  and 
is  occasionally,  usually  in  slight  cases,  intermittent.  Rarely  there  are 
no  paroxysmal  exacerbations.  The  paroxysms  are  sometimes  brief 
and  frequent,  so  as  to  resemble  a  slow  clonic  spasm.  The  tonic  has 
been  known  to  commence  by  clonic  spasm. 

When  the  muscles  of  respiration  share  the  tonic  spasm,  the  respi- 
ratory movements  are  limited  in  range,  and  the  breathing  is  short  and 
hurried.  During  severe  paroxysms  it  is  arrested,  and  death  from 
asphyxia  sometimes  results.  It  is  said  that  the  spasm  is  inspiratory 
in  some  cases,  in  others  expiratory.  The  former  is  probably  the  more 
frequent.* 

During  sleep,  whether  spontaneous  or  induced  by  chloroform,  the 
spasm  usually  ceases,  but  it  returns  in  undiminished  force  when  the 
patient  awakes.  It  has  been  thought,  indeed,  that  after  prolonged 
sleep  from  chloroform  the  violence  of  the  spasms  is  increased  in  pro- 
portion to  the  length  of  time  they  have  been  kept  in  abeyance.  Con- 
sciousness is  unaffected,  even  to  the  last. 

The  pulse  is  increased  in  frequency,  especially  during  the  par- 
oxysms, and  is  often  very  small.  There  is  some  reason  to  believe  that 
the  small  size  of  the  pulse  is  due  to  general  vaso-motor  spasm.  The 
temperature  varies  much  in  different  cases.  It  is  often  normal,  or 
nearly  so,  during  the  whole  course  of  the  disease,  although  in  fatal 
cases  there  is  usually  a  moderate  rise  (2°  or  3°)  towards  the  end.  In 
other  cases  there  is  a  continuous  elevation  of  3°  to  5°,  without  evening 
remission,  although  frequent  measurements  may  show  a  slight  rise  at 
each  paroxysm,  and  a  slight  fall  at  each  interval,  so  that  the  chart 
presents  a  serrated  tracing  (H.  C.  Wood).  In  other  cases  irregular 
variations  occur,  without  corresponding  variations  in  the  symptoms. 
Lastly,  in  some  instances  the  temperature  rises  towards  the  end  to 
an  extreme  degree,  108°  or  110°,  and,  as  Wunderlich  first  showed,  the 

*  According:  to  Richet  ('  Societe  de  Biologie,'  March  4th,  1876),  in  the  inspiratory 
spasm  the  glottis  is  open,  in  the  expiratory  spasm  it  is  closed,  and  the  latter  entails 
more  interference  with  circulation,  and  more  danger  of  death  from  asphyxia,  than 
the  former.  But  in  the  case  recorded  hy  Harris  and  Doran  ('  Path.  Trans.,'  vol 
xxxi)  there  were  severe  paroxysms  of  inspiratory  spasm,  and  the  patient  died 
asphyxiated  at  the  end  of  the  second  day. 


VARIETIES.  683 

elevation  may  continue  for  a  few  hours  after  death,  and  even  reach 
114°.  Some  of  the  increase  in  body-heat  may  be  due  to  the  increased 
muscular  work,  but  this  cannot  be  regarded  as  the  chief  source  of  the 
pyrexia.  Yerneuil  has  pointed  out  that  the  cases  in  which  the  mus- 
cular spasm  is  greatest  are  rarely  those  in  which  the  temperature  is 
highest.  Mos't  of  the  fever  is  apparently  of  nervous  origin.  The 
hyperpyrexia  is  comparable  to  that  met  with  in  some  cases  of  disease 
of  the  pons  Varolii  and  upper  part  of  the  spinal  cord,  and  may  be 
associated  with  the  fact  that  the  earliest  symptoms  of  tetanus  proceed 
from  this  region. 

The  urine  is  usually  scanty  and  high-coloured,  perhaps  partly  in 
consequence  of  the  loss  of  water  by  the  skin.  The  amount  of  nitro- 
genous matter  excreted  (urea,  kreatinin,  &c.)  is  not  increased,  even  in 
pyrexial  cases — a  striking  difference  from  most  febrile  diseases 
(Senator).  Micturition  may  be  interfered  with  by  the  spasm  ;  some- 
times there  may  be  actual  retention.  The  bowels  also  are  usually 
confined,  in  some  cases  in  very  obstinate  degree. 

Varieties. — In  their  developed  symptoms,  cases  of  tetanus  present 
little  variety,  but  the  early  aspect  of  the  case  differs  according  to  the 
seat  of  the  spasm.  There  is,  however,  one  form  that  presents  con- 
siderable variation  from  the  ordinary  type,  on  account  of  the  dis- 
tribution and  character  of  the  symptoms,  and  also  on  account  of  its 
cause ;  it  has  been  termed  by  Rose  "  cephalic  tetanus  "  (Kopf tetanus) . 
It  results  from  wounds  on  the  head,  chiefly  in  the  region  of  the  fifth 
nerve,  and  especially  on  the  face.  In  many  cases  the  wound  has  been 
due  to  a  fall  on  the  ground,  or  has  been  inflicted  by  an  object 
recently  in  contact  with  the  earth.*  The  chief  peculiarity  is  that 
initial  trismus  is  associated  with  paralysis  of  the  face  on  the  same 
side  as  the  injury,  and  often  with  some  tonic  spasm  on  the  other  side. 
In  many  cases  there  is  also  a  peculiar  pharyngeal  spasm  on 
swallowing,  often  accompanied  by  respiratory  spasm,  or  by  a  violent 
general  tetanic  paroxysm.  This  symptom  resembles  the  spasm  that 
occurs  in  hydrophobia,  and  hence  the  variety  has  also  been  termed 
"tetanus  bydrophobicus."  In  severe  paroxysms  there  may  be  turgiditv 
of  the  veins  of  the  head  and  neck,  prominence  of  the  eyeballs, 
and  loss  of  consciousness.  Such  attacks,  at  first  produced  only  by 
the  attempt  to  swallow,  may  afterwards  become  spontaneous.  The 
facial  palsy  usually  involves  all  parts,  as  in  disease  of  the  facial 
nerve,  but  its  mechanism  is  unknown.  It  may  be  preceded  by  a  slight 
sense  of  "  numbness  "  or  tingling  in  some  parts  of  the  face,  sometimes 
on  both  sides.     There  is  no  degenerative  reaction  during  life,f  and  no 

*  A  few  instances  have  been  recorded  in  this  country,  as  by  C.  J.  Bond  ('  Brit. 
Med.  Journ.,'  Nov.  10th,  1883),  Nankivell  ('Lancet/  July  14th,  1883),  and  Roberts 
and  Williamson  ('  Lancet,'  1891). 

t  Bernhardt,  Remak.  Increased  irritability  of  nerve  and  muscle,  to  both  currents 
and  to  mechanical  stimulation,  was  found  by  Nerlich,  but  a  lowered  irritability  in 
the  nerve  by  Von  Spenje. 


684  TETANUS. 

disease  of  the  nerve  lias  been  found  after  death  ;  hence  the  paralysis 
is  presumed  to  be  of  reflex  origin.  We  have  seen  (p.  200)  that 
irritation  of  the  fifth  nerve  may  cause  paralytic  ptosis,  and  it  is 
worthy  of  note  that  in  one  recorded  case  ptosis  formed  part  of  the 
symptoms  of  this  disease  ;*  while  in  the  remarkable  case  recorded  by 
Boberts  and  Williamson  there  was  complete  palsy  of  all  the  muscles 
of  the  eye  on  the  injured  side,  with  motionless  pupil,  and  on  the  other 
side,  paralysis  of  the  upper  part  of  the  face,  and  of  the  third  and 
fourth  nerves,  with  a  sort  of  cataleptoid  state  of  the  upper  lid.  A 
few  recorded  cases  have  recovered,  between  the  ages  of  2-|  and  25,  but 
those  over  25  (which  have  occurred  at  various  ages  up  to  52)  have 
been  fatal.  In  the  cases  that  have  recovered,  the  tetanic  spasm  and 
facial  palsy  have  very  slowly  passed  away,  the  symptoms  continuing 
altogether  several  weeks.  Death  has  usually  occurred  in  the  course 
of  the  second  or  third  week. 

Other  varieties  depend  on  differences  in  the  course  of  the  disease 
and  in  the  distribution  of  the  early  symptoms.  In  the  most  severe 
•cases  the  spasm  in  the  trunk  may  come  on  with  that  in  the  jaw ; 
paroxysms  occur  almost  from  the  first,  and  the  patient  may  die  in  two 
or  three  days,  sometimes  in  a  few  hours,  and  a  still  shorter  duration 
has  been  known  (see  p.  677).  On  the  other  hand,  the  rigidity  in  the 
jaAv  and  neck  may  exist  alone  for  several  days,  even  for  a  week,  and 
the  tetanic  spasms  on  the  trunk  slowly  supervene.  In  extremely  rare 
cases  transient  spasm  of  the  neck  and  jaw  may  be  the  only  manifesta- 
tion of  the  disease — the  abortive  form  of  Kussmaul. 

In  cases  that  recover,  the  disease  always  ends  gradually,  passing 
into  a  chronic  stage.  The  paroxysms  of  spasm,  at  the  end  of  one, 
two,  or  three  weeks,  become  slighter  and  less  frequent,  and  ultimately 
cease,  while  the  tonic  rigidity  continues,  slowly  lessening  in  degree. 
It  disappears  first  in  the  parts  affected  last,  and  endures  longest 
where  it  commenced,  in  the  neck  and  jaw,  becoming  occasional,  and 
finally  ceasing.  Very  rarely  the  tonic  spasm  passes  off  while  the 
paroxysms  continue.  There  is  no  special  tendency  to  recurrence,  for 
second  attacks  are  at  present  unknown. f  Nor  have  sequelae 
(paralysis,  &c.)  been  hitherto  observed. 

The  duration,  in  fatal  cases  is,  as  a  rule,  less  than  a  fortnight,  and 
as  already  stated,  frequently  only  a  few  days.  After  two  weeks  the 
patient's  chance  of  recovery  is  fairly  good. 

The  mortality  of  tetanus  is  extremely  high,  rivalled  by  few  acute 
diseases,  and  excelled  among  its  congeners  only  by  hydrophobia.  In 
traumatic  tetanus  the  mortality  is  nearly  90  per  cent.,  and  seems  to 
be  rather  greater  in  women  than  in  men. J     The  influence  of  age  on 

*  Sereins,  '  L'Un.  med.,'  No.  173,  1886.  The  case  is  evidently  an  instance  of  this 
disease  although  it  is  not  described  as  such. 

t  The  case  recorded  by  Ogle  ('  British  and  Foreign  Med.-Chir.  Kev.,'  1868,  Oct., 
p.  488)  is  inconclusive. 

X  It  has  been  strangely  understated  by  those  who,  disregarding  the  caution  given 


MORTALITY.  685 

mortality  is  uncertain.  Adequate  statistics  for  its  determination  do 
not  at  present  exist.  It  is  greater  after  severe  injuries  than  after 
those  that  were  slight.  When  the  symptoms  do  not  commence  until 
after  ten  days  from  the  receipt  of  the  injury,  the  proportion  of 
recoveries  is  much  greater  than  in  those  that  commence  during  the 
first  ten  days,  and  seems  to  increase,  the  longer  the  interval.  When 
the  disease  begins  within  ten  days,  recoveries  are  extremely  rare,  and 
the  mortality  seems  not  to  be  influenced  by  the  date  of  onset.  Still, 
cases  have  been  known  to  recover  in  which  the  disease  commenced, 
within  three  days  from  the  time  of  the  injury.  The  variations  are 
doubtless  related  chiefly  to  the  quantity  of  the  toxic  agent  that  has 
been  inoculated,  and  perhaps  in  part  to  its  state.  Traumatic  tetanus, 
although  more  common,  does  not  appear  to  be  more  fatal  in  hot 
climates.     At  Calcutta  it  is  said  to  be  about  83  per  cent.  (Wallace). 

In  the  recorded  cases  of  idiopathic  tetanus  which  I  have  compared 
the  mortality  has  been  50  per  cent.,  and  this  is  probably  not  far  from 
the  actual  fact.*  In  hot  climates,  idiopathic  tetanus  is  usually  stated 
to  be  more  fatal  than  the  traumatic  variety,  but  the  statistics  of 
Wallace  give  a  mortality  among  males  of  56  per  cent.f 

The  mortality  in  tetanus  neonatorum  is  extremely  high,  probably  at 
least  as  high  as  in  traumatic  tetanus.  Of  all  forms,  however,  puer- 
peral tetanus  is  that  which  is  most  frequently  fatal.  When  it  occurs 
after  abortion,  recovery  is  practically  unkuown.  The  only  recorded, 
case  which  had  not  ended  in  death  was  still  in  progress  at  the  time  of 
the  report. £  After  labour,  all  the  cases  in  which  the  disease  could  be 
referred  only  to  the  process  of  parturition  have  been  fatal.  Of  three 
cases  that  recovered,  in  one  eclampsia  occurred  before  childbirth, 
and  in  the  other  two  the  tetanus  was  apparently  excited  by  exposure 
to  cold,  in  one  four  days,  in  the  other  three  weeks  after  parturition. 

Causes  of  Death. — In  about  two  thirds  of  the  fatal  cases  of  tetanus 
death  occurs  during  a  paroxysm,  either  from  failure  of  the  heart,  or 
from  asphyxia  in  consequence  of  the  prolonged  arrest  of  respiration. 
The  cause  of  cardiac  failure  is  supposed  to  be  the  increase  of  the 
intra-vascular  pressure  (partly  by  the  compression  of  vessels  by  the 
contracted  muscles,  partly  by  vaso-motor  spasm)  to  such  a  point  that 
the  enfeebled  heart  is  unable  to  contract.  The  severity  of  the  strain 
long  ago  by  Lawrie,  have  estimated  the  mortality  from  collections  of  cases  which 
have  been  separately  published,  most  of  them  because  the  patients  recovered.  For 
instance,  the  total  mortality  was  estimated  by  Yandell  ('Brain/  1879)  from  a  collec- 
tion of  449  cases  to  be  46  per  cent. !  The  164  cases  of  traumatic  tetanus  contained 
in  the  consecutive  series  of  Lawrie,  and  of  Poland  and  Taylor,  comprise  140  males, 
of  whom  122  died  (87  per  cent.),  and  24  females,  of  whom  22  died  (91  per  cent.). 

*  This  conclusion  agrees  with  that  of  the  idiopathic  cases  in  the  series  of  Lawrie,. 
Poland,  and  Taylor.     Of  these,  11  in  number,  6  died. 

f  "Wallace,  "Statistics  of  Tetanus  in  the  College  Hospital,  Calcutta"  ('Indian 
Med.  Gazette,'  Jan.  1st,  1881).  Of  93  males,  53  died.  The  statistics  regarding 
females  are  not  available,  because  puerperal  cases  are  included  in  the  idiopathic  form. 

J  A  case  described  by  Lawrie  in  a  letter  to  Simpson,  and  published  by  the  latter, 
loc.  cit. 


686  TETANUS. 

to  which  the  heart  is  exposed  is  shown  by  one  case  in  which  a  degene- 
rated wall  gave  way  during  a  violent  paroxysm.*  In  the  remaining 
cases  death  occurs  from  exhaustion,  or  from  some  accidental  compli- 
cation, f 

Pathological  Anatomy. — Rigor  mortis  usually  sets  in  early,  and 
is  well  marked.  It  is,  indeed,  said  that  the  spasm  during  life  may 
pass  into  the  rigidity  of  death,  but  in  most  cases  brief  relaxation 
occurs. 

The  lungs  are  usually  congested,  and  there  may  be  oedema,  hypostatic 
pneumonia,  local  emphysema,  and  subpleural  extravasations — direct  or 
indirect  results  of  the  interference  with  the  pulmonary  circulation  by 
the  frequent  and  violent  spasm.  The  heart  is  sometimes  relaxed ;  more 
frequently  it  is  firmly  contracted,  probably  only  from  rigor  mortis. 
The  liver  and  spleen  are  usually  anemic.  The  kidneys  may  be  pale 
or  congested ;  sometimes  they  contain  extravasations.  The  difference 
in  the  amount  of  congestion  depends  chiefly  on  the  mode  of  death, 
whether  from  exhaustion  or  during  a  spasm  which  arrests  the  move- 
ment of  the  blood. 

The  muscles  often  contain  small  extravasations.  Rupture  of  indi- 
vidual fibres  may  be  found  on  microscopical  examination,  and  occa- 
sionally a  lai'ge  muscle  may  be  torn  across  by  the  violence  of  the 
spasm.  Such  rupture  has  only  been  seen  in  the  flexors  of  the  trunk 
and  hip  (rectus  abdominis  frequently,  psoas  rarely  J),  which  are  con- 
tracted, and  at  the  same  time  are  stretched  by  the  more  powerful  spasm 
in  the  extensors.  The  fibres,  under  the  microscope,  usually  present  a 
normal  appearance,  but  occasionally  granular  degeneration  is  seen,  or 
there  is  a  tendency  to  split  up  longitudinally  (Bowman).  Chemical 
analysis  has  shown  that  they  contain  more  water  than  normal,  and 
less  albuminous  material,  but  in  the  alcoholic  extract  there  is  more 
nitrogenous  matter  and  a  substance  containing  phosphorus — lecithin 
(Danilewsky). 

In  traumatic  cases  the  wound  may  be  in  almost  any  condition, 
healthy  or  unhealthy,  in  process  of  normal  cicatrisation,  or  even 
actually  healed.  Perfect  cicatrisation  is  necessarily  rare,  on  account 
of  the  period  at  which  tetanus  usually  commences.  Otherwise  no  state 
of  wound  is  sufficiently  frequent  to  be  of  significance.  The  nerves  of 
the  part  injured  have  presented,  in  the  majority  of  cases,  no  abnormal 
condition  that  could  be  recognised  even  by  the  microscope.  In  some 
cases,  however,  distinct  evidence  of  inflammation  has  been  found,  the 
nerve  being  swollen  and  reddened,  and,  in  a  few  instances,  ascending 
neuritis  has  been  traced  up  the  nerve,  even  as  high  as  the  cord%— red- 
dened nodular  swellings,  usually  separated  by  normal   interspaces. 

*  Duclaux,  *  Bull,  de  Therapeutique/  1877,  Sept.  30th. 

t  E.  g.  in  a  case  recorded  by  Pitraui  ('  Wien.  rned.  Presse,'  Nov.  1st,  1886)  death 
was  due  to  pulmonary  embolism  from  a  clot  in  the  hypogastric  vein,  the  formation  of 
which  was  supposed  to  be  due  to  the  compression  of  the  vein  by  the  muscular  spasm. 

J  Wynne  Foote,  Earle. 


PATHOLOGY.  687 

Increase  of  interstitial  tissue,  with  degenerative  changes  in  the  nerve- 
fibres,  is  found  in  such  cases.  It  is  certain,  however,  that  local 
neuritis  is  no  constant  part  of  the  morbid  appearances  in  tetanus. 
The  facts  relating  to  the  micro-organisms  will  be  described  in  the 
section  on  the  Pathology  of  the  disease.    . 

In  puerperal  tetanus  there  is  no  constant  abnormal  appearance  in 
the  uterus,  but  in  some  cases  metritis,  and  decomposing  remnants  of 
the  placenta,  have  been  discovered. 

In  newly-born  children,  as  we  have  seen,  the  umbilicus  may  be 
inflamed,  and  an  arteritis  umbilicalis  may  be  traced  along  the  cord 
within  the  abdomen.  The  adjacent  peritoneum  is  often  also  inflamed. 
In  some  cases,  however,  these  parts  are  normal. 

In  the  brain  and  spinal  cord  the  only  common  changes  in  tetanus 
are  distension  of  vessels,  large  and  small,  and  the  presence  of  minute 
haemorrhages,  such  as  are  met  with  in  all  cases  of  death  from  convul- 
sion, and  are  perhaps  produced  chiefly  during  the  process  of  death. 
In  many  cases,  no  morbid  appearance  has  been  discovered  on  micro- 
scropical  examination.*  In  some,  slight  changes  have  been  found, 
but  these  have  varied  much.  Many  are  of  no  significance,  such 
as  an  unusual  amount  of  interstitial  tissue  in  the  white  columns, 
spaces  around  the  vessels,  yellow  pigmentation  of  the  ganglion-cells, 
amorphous  exudation  at  the  bottom  of  the  fissures,  and  an  increase  of 
nuclei  around  the  central  canal,  sometimes  obliterating  it  or  extending 
laterally  in  the  posterior  commissure. 

The  microscopical  changes  which  have  been  observed  in  the  cord,f 
and  are  possibly  or  probably  connected  with  the  disease  (besides  the 
vascular  distension  and  minute  extravasations),  are — increase  of  the 
corpuscles  in  the  interstitial  tissue  and  around  the  vessels,  chiefly  in 
the  grey  substance  ;  areas  of  "  granular  disintegration,"  sometimes 
amounting  to  actual  cavities  containing  amorphous  or  finely  granular 
material,  also  chiefly  found  in  the  grey  matter  ;  irregular  areas  of 
carmine-staining  amorphous  "  exudation "  in  the  grey  matter  and 
posterior  columns,  and  various  changes  in  the  large  ganglion-cells, 
swelling,  with  indistinctness  of  the  outline  of  the  cell  and  of  the 
nucleus ;  shrinking  of  the  cells  ;  apparent  destruction  of  the  processes. 
Similar  alterations  have  been  found  in  a  few  cases  in  the  medulla 
oblongata,  but  slighter  in  degree.  These  changes,  when  found,  have 
presented  no  uniformity  in  character  or  distribution,  nor  can  any 
relation  be  traced  between  their  position  and  the  seat  of  the  wound. 

Pathology. — The  chief  fact  of  the  pathology  of  tetanus  is  its  rela- 
tion to  the  specific  organisms,  which  has  been  mentioned  in  the  section 
on  Etiology.     The  discovery  is  an  event  of  the  last  six  years,  and,  as 

*  As  in  four  cases  examined  by  F.  Schultze  ('  Neurologiscb.es  Centralblatt,'  1882, 
No.  6),  two  by  Hadden  ('Brain,'  Oct.,  1885),  and  five  by  Bowlby  ('St.  Bart.  Hosp. 
Rep.,'  1884). 

t  Cbiefly  by  Lockbart  Clarke,  Clifford  Allbutt,  Ross,  Doran,  Harris,  Dickinson, 
and  Auf  recbt. 


688  TETANUS. 

regards  the  traumatic  and  infantile  forms,  is  established  by  over^ 
whelming  evidence.  It  places  tetanus  distinctly  in  the  rank  of  "  acute 
infective  diseases ;  "  infective,  however,  chiefly,  perhaps  exclusively,  by 
inoculation.  The  discovery  has  been  facilitated  by  the  special  sus- 
ceptibility to  tetanus  possessed  by  certain  animals,  especially  mice,  rats, 
guinea-pigs,  and  rabbits.  As  long  ago  as  1884  it  was  found  (by  Carle 
and  Eattone)  that  the  disease  could  be  produced  in  rabbits  by  inocu- 
lation with  the  pus  of  the  wound  of  a  person  suffering  from  tetanus  ;  * 
and,  independently,  Nicolaier  found  that  the  disease  was  produced  in 
the  animals  mentioned  above  by  inoculation  with  different  kinds  of 
earth,  and  that  a  peculiar  bacillus  was  always  to  be  found  in  the  active 
earth,  and  also  in  the  wound  in  which  it  had.  been  inoculated.  In  1885 
Eosenbach  found  that  the  same  bacillus  was  always  present  in  the 
secretion  and  tissues  of  the  wound  which  had  given  rise  to  traumatic 
tetanus  in  man ;  when  the  wound  was  due  to  a  fall  on  the  earth,  he 
found  the  same  organisms  in  the  soil  at  the  place,'  and  he  confirmed  the 
observation  that  inoculation  with  the  pus  and  tissues  of  the  wound  in 
man  gave  rise  to  the  disease  in  animals.  He  cultivated  the  bacillus, 
and  proved  that  it  was  then  equally  effective.  These  facts  have  been 
since  confirmed  by  many  investigators,  and  may  be  accepted  as  invari- 
ably true.  The  disease  has  also  been  produced  in  horses,  sheep,  and 
sometimes  in  dogs,  but  the  last  are  not  prone  to  tetanus,  and  require 
a  large  dose. 

The  bacillus  is  met  with  in  two  forms, — fine  needle-shaped  rods,  and 
similar  rods  with  a  much  wider  oval  "  head  "  at  one  extremity,  con- 
taining spores.  The  former  are  4  to  6  ju  f  in  length,  the  latter  6  to  8. 
The  "  head"  is  15  /*  in  width,  the  rod  only  half  as  wide.  They  are 
always  found  in  the  tissues  of  the  wound,  and  have  sometimes  been 
met  with  sparingly  in  the  blood  and  spinal  cord,  but  not  in  other 
organs.  They  possess  remarkable  power  of  resisting  heat,  even  expo- 
sure to  175°  F.  for  an  hour,|  and  their  spores  for  six  hours  ;  §  by  this 
they  may  be  sepai'ated  from  other  organisms  which  are  killed.*  But 
they  cease  to  form  spores  at  108°  F.  They  are  "  anaerobic,"  growing 
in  an  atmosphere  of  hydrogen  or  in  vacuo,  and  are  slowly  weakened 
and  at  last  killed  by  free  access  of  air,  and  especially  of  light.  They 
are  destroyed  by  nascent  chlorine,  and  by  a  5  per  cent,  solution 
of  carbolic  acid,  but  not  by  weaker  solutions.  The  chief  habitat 
of  the  organism  is  the  soil,  in  which  they  have  been  found  so  widely  dis- 
tributed as  to  be  found  in  earth  taken,  for  instance,  from  various  parts 
of  Warsaw,  and  in  sixteen  out  of  twenty-three  specimens  from  various 
parts  of  Copenhagen.  The  vital  endurance  of  the  organisms,  and  espe- 
cially of  their  spores,  under  favorable  conditions  is  great.  The  dried 
pus  from  the  wound  of  a  tetanic  horse  has  been  found  active  after 

*  Buchanan,  '  Glasgow  Med.  Journ.,'  1890. 
t  Or  ^  to  ^Vo  in. 
J  Kitasato,  '  Zeitsch.  f.  Hyg.,'  Bd.  vii. 
§  Schwarz,  E,.,  'Arch.  Sc.  Med./  1891. 


PATHOLOGY.  689 

sixteen  months,*  and  earth  in  which  tetanus  spores  had  been  placed 
was  virulent  at  the  end  of  three  years. f 

On  account  of  the  small  number  of  bacilli  found  within  the  body 
it  was  suggested,  first  by  Nicolaier,  that  the  symptoms  are  due,  not  to 
the  organisms  themselves,  but  to  a  strychnia-like  toxine  produced  by 
them ;  and  this  opinion  has  been  generally  accepted,  and  it  has  been 
shown  to  be  correct.  Vaillard  and  VincentJ  succeeded,  by  a  special 
process  of  filtration,  in  separating  the  bacilli  from  the  material 
they  had  formed,  and  found  that  the  former  were  inert,  while  the 
latter  at  once  caused  the  disease.  Brieger,§  indeed,  had  previously 
described  four  distinct  forms  of  toxic  material  as  produced  by  the 
bacilli,  of  which  three  cause  symptoms  of  tetanus,  and  for  the  most 
active  of  these  he  proposed  the  name  of  "  tetanin."  It  has  been 
thought  that  the  symptoms  of  traumatic  tetanus  are  due  to  the  toxine 
which  is  inoculated  with  the  bacilli ;  this  is  probably  true  when  the 
affection  begins  in  a  few  hours,  but  the  interval  which  usually  elapses 
suggests  that  the  virus  is  formed  by  the  organisms  either  in  the 
wound  or  in  the  blood. 

These  discoveries  have  naturally  suggested  attempts  to  produce 
immunity  by  methods  analogous  to  those  employed  by  Pasteur  in  the 
case  of  hydrophobia,  but  hitherto  with  only  limited  success.  Tizzoni 
succeeded  in  the  case  of  dogs,  who  are  little  prone  to  tetanus,  by  a 
series  of  inoculations  with  the  cultivated  virus,  at  first  minute,  and 
gradually  increasing  in  strength  ;  and  he  found  that  their  blood-serum 
destroyed  the  activity  of  the  virus — in  consequence,  he  believes,  of  the 
presence  of  a  peculiar  albuminoid  body  which  he  terms  "  tetanus 
antitoxine :"  its  power  is  destroyed  by  lactic  and  hydrochloric  acids, 
and  by  a  temperature  of  150°  F.  He  failed  to  produce  immunity  in 
rabbits  and  guinea-pigs,  or  to  arrest  the  developed  disease  except  in  rats. 
Arrest  was  also  obtained  by  Behring  and  Kitasato,  who  found  that 
simple  blood- serum,  without  the  corpuscles,  produced  immunity,  and 
that  the  serum  of  the  animals  rendered  immune  was  even  more  potent. 

We  have  seen  that  the  intensity  of  the  cause  of  tetanus  can  be 
varied  experimentally,  and  probably  similar  variations  exist  in  that 
which  enters  accidental  wounds.  That  which  is  found  in  soil  manured 
and  decomposing,  is  said  to  be  especially  intense.  The  presence  of  the 
organisms  of  decomposition  has  been  found  to  favour  the  growth  of 
the  tetanus  bacilli,  which  ultimately  persist  while  the  others  perish. 
These  variations,  and  differences  in  the  quantity  of  the  virus  that 
enters  the  wound,  probably  cause  the  variations  in  the  intensity  of 
the  disease,  and  the  corresponding  differences  in  the  period  of 
incubation.  "What  part  is  played  by  individual  predisposition  is 
unknown  (see  Etiology). 

*  Kitt,  '  Cent,  f .  Bact.,'  1889. 

f  Raume,  '  Zeitschr.  f .  Hygiene,'  Bd.  vii. 

X  'Coniptes  Kend./  1891. 

§  '  Deut.  ined.  Wochenschr.,'  1887. 

vol.  ii.  44 


690  TETANUS. 

To  what  part  of  the  central  nervous  system  is  the  disturbance  to  be 
referred  which  is  produced  by  the  poison  ?  The  early  symptoms  are 
in  the  region  supplied  by  nerves  that  arise  from  the  highest  part  of  the 
spinal  cord,  the  medulla  oblongata,  and  the  pons,  and  must  be  referred 
to  centres  in  this  region.  The  same  indication  is  afforded  by  the  co- 
ordinated respiratory  spasm  that  forms  so  conspicuous  a  feature  in  the 
attacks,  by  the  vaso- motor  spasm,  by  the  occasional  hyperpyrexia,  by 
the  phenomena  of  cephalic  tetanus,  and  by  such  cases  as  one  recorded 
by  Silbermann,  in  which  a  fall  on  the  back  of  the  head  was  followed 
in  a  few  hours  by  symptoms  of  tetanus,  accompanied  by  striking 
cyanosis  and  dyspnoea.  Permanent  trismus  sometimes  results  from 
organic  disease  of  the  pons  Varolii,  and  general  tonic  spasm,  especially 
marked  in  the  legs,  is  not  uncommon  from  haemorrhage  in  this  situation. 
It  is  only  in  the  later  stage  of  tetanus  that  there  is  evidence  (in  in- 
creased reflex  excitability)  of  a  morbid  state  of  the  lower  spinal  centres, 
which,  secondary  in  point  of  time,  is  doubtless  secondary  in  its  pro- 
duction. The  symptoms  point,  therefore,  to  the  pons  and  medulla  as 
the  seat  of  the  chief  disturbance  of  nerve-function  in  the  disease. 

The  facts  that  the  injury  causing  tetanus  often  involves  the  nerves, 
and  that  these  are  sometimes  inflamed,  and  even  the  seat  of  an  ascend- 
ing neuritis,  must  not  be  overlooked  in  the  light  of  the  new  pathology. 
The  tetanic  spasms  sometimes  stai'tfrom  the  seat  of  the  injury,  and  in 
cephalic  tetanus  the  injury  in  the  region  of  the  fifth  nerve  causes  para- 
lysis of  motor  nerves  related  to  it  in  reflex  action,  although  the  specific 
virus  is  present  in  the  wound  in  this  as  in  other  forms.  These  facts 
suggest  that  the  toxine,  which  acts  so  powerfully  on  the  central 
nervous  system,  has  also  a  local  action  on  peripheral  nerves  to  which 
it  can  gain  access. 

In  connection  with  the  theory  of  uerve  irritation  a  case  recorded  by 
Terrier*  deserves  especial  note.  An  injured  toe  had  become  gangre- 
nous, and  was  amputated.  Trismus,  absent  before,  was  present  a 
quarter  of  an  hour  afterwards,  and  the  patient  averred  that  the  pain 
of  the  operation  distinctly  made  his  jaw  muscles  contract  while  the 
amputation  was  being  performed.  He  died  from  the  tetanus  in  two 
days.  Here  it  would  seem  that  the  toxic  irritation  brought  the  centre 
into  a  condition  so  unstable  that  its  discharge  was  produced  by  the  addi- 
tional stimulus.  Verneuil  has  also  noted  that  surgical  interference  with 
a  wound  may  apparently  excite  tetanus.  It  may  be  that  a  similar  in- 
fluence is  exerted  by  exposure  to  cold.  In  the  unstable  condition  of  the 
centres,  a  slight  degree  of  surface  chill  may  cause  discharge  of  the  nerve- 
cells.  For  instance,  in  the  case  of  tetanus  after  ovariotomy,  recorded 
by  Harris  and  Doran,  the  contraction  commenced  in  the  masseter  on 
the  side  turned  towards  a  window,  the  weather  being  very  cold  at  the 
time.  That  the  surface  chill  causes  a  peculiar  nervous  stimulation  is  the 
more  probable,  since  we  know  that  it  causes  other  effects  through  the 
agency  of  the  neiwous  system,  stimulating,  for  instance,  the  vaso-motor 
*  Terrier, '  Gaz.  des  Hop./  1874. 


DIAGNOSIS.  691 

centre  to  constrict  the  vessels  of  the  skin,  and  even  the  motor  centres 
to  produce  the  muscular  spasm  of  "  shivering,"  in  which  the  muscles 
of  mastication  always  take  a  conspicuous  part.  It  is  noteworthy, 
however,  that,  whether  acting  alone  or  conjointly,  the  effect  of  cold  is 
always  rapidly  produced.  Rarely  more  than  twenty-four  hours  pass 
before  the  appearance  of  the  first  symptoms.  Lastly,  it  may  be 
observed  that  in  tetany  we  have  a  disease  consisting  of  tonic  spasm, 
and  sometimes  caused  by  cold. 

In  true  tetanus  neonatorum,  the  pathology  of  the  disease  is  the 
same  as  in  the  traumatic  form,  the  bacilli  having  been  invariably 
found  in  the  umbilical  wound.  The  precise  nature  of  puerperal 
tetanus  and  of  the  idiopathic  form  has  still  to  be  ascertained.  If,  as 
previously  suggested,  they  are  produced  by  the  specific  organisms,  it 
is  probably  by  the  inhalation  of  spores  from  the  air.  The  organisms 
seem  to  have  no  effect  when  taken  into  the  stomach. 

Diagnosis. — The  symptoms  of  tetanus  are  so  peculiar  and  so  pro- 
nounced, that  the  diagnosis  rarely  presents  any  difficulty,  except  in 
the  earliest  stage  of  cases  that  commence  insidiously.  Under  such 
circumstances  the  stiffness  of  the  neck  may  be  mistaken  for  muscular 
rheumatism,  the  more  readily  if  the  symptom  has  followed  exposure 
to  cold.  But  the  existence  of  rigidity  in  the  muscles  of  the  jaw, 
never  present  in  simple  rheumatism  and  rarely  absent  in  tetanus, 
should  at  once  arouse  suspicion.  In  the  rare  cases  in  which  difficulty 
in  swallowing  precedes  trismus,  the  nature  of  the  case  can  only  be 
suspected  from  the  facts  that  there  is  no  local  affection  to  account  for 
the  symptom,  no  evidence  elsewhere  of  paralysis,  and  no  history  of 
any  cause  of  hydrophobia,  while  trismus  and  tetanic  spasms  usually 
follow  within  twenty-four  hours. 

The  characters  of  the  developed  disease  resemble  those  of  strychnine 
poisoning  more  than  any  other  condition.  A  mistake  is  rare,  but  has 
probably  been  made  in  one  or  two  recorded  instances.  In  strychnine 
poisoning  the  symptoms  never  commence  by  trismus  ;  they  come  on 
and  develop  in  a  more  rapid  manner  than  has  ever  been  seen  in  tetanus 
except  in  traumatic  cases,  in  which  the  wound  assists  the  diagnosis. 
The  reflex  excitability  is  an  early  symptom  in  strychnia  poisoning, 
but  is  late  in  tetanus,  and  the  severe  epigastric  pain  of  the  latter  is' 
absent  in  the  former,  in  which  there  are  often  collateral  circumstances 
to  suggest  poisoning. 

In  hydrophobia  there  is  no  initial  rigidity  in  the  jaw  or  elsewhere. 
The  first  paroxysms  are  of  respiratory  spasm,  excited  by  attempts  to 
swallow.  These  may  be  present,  however,  in  the  "  hydrophobic " 
form  of  tetanus,  and  in  it  swallowing  is  difficult,  but  a  wound  on  the 
head  and  facial  palsy  are  conspicuous.  Cases  of  hydrophobia  in  which 
there  are  tetanoid  spasms  in  the  later  stage  of  the  disease  have  been 
confused  with  tetanus,  but  attention  to  the  initial  symptoms  will 
prevent  error.     These  spasms  are  merely  an  excessive  development  of 


692  TETANUS. 

those  that  are  frequently  met  with  in  hydrophobia,  and  do  not 
indicate  that  the  two  diseases  co-exist,  as  has  sometimes  been 
erroneously  imagined. 

In  hysteria,  tetanoid  spasm  is  extremely  rare  except  as  part  of  a 
convulsive  attack,  and  then  its  nature  is  sufficiently  conspicuous. 
But  trismus,  causing  persistent  closure  of  the  jaws,  occurs  in  hysteria. 
It  may  succeed  a  convulsion,  and  last  until  another,  or  it  may  come 
on  without  obvious  cause,  continue  for  a  few  hours  or  days,  and  then 
suddenly  vanish.  It  is  prone  to  recur,  and  this  character,  the 
suddenness  of  onset,  its  complete  degree,  the  absence  of  rigidity  in 
the  neck,  and  the  presence  of  other  symptoms  of  hysteria  will  rarely 
leave  any  doubt  as  to  its  nature.  It  should  be  remarked  that  the 
symptoms  of  tetanus,  coming  on  after  an  injury  or  exposure  to  cold, 
must  not  be  treated  lightly  because  they  occur  in  an  hysterical  person, 
or  follow  fear  of  the  disease. 

In  tetany  there  is  widely  spread  tonic  spasm  with  paroxysmal 
exacerbations,  but  its  distribution  is  characteristically  different.  The 
limbs  are  most  affected  towards  the  extremities,  the  arms  more  than 
the  legs,  the  hands  most  of  all,  and  trismus  is  a  late,  and  not  an  early 
symptom.  In  each  of  these  respects,  the  condition  in  tetanus  is  the 
reverse.  Even  in  the  most  acute  and  violent  cases  of  tetany  a  mistake 
can  hardly  be  made,  especially  if  attention  is  paid  to  the  peculiar 
posture  of  the  hands. 

In  many  case3  of  tetanus  there  is  considerable  difficulty  in  deter- 
mining whether  it  is  to  be  regarded  as  traumatic  or  idiopathic.  They 
are  the  cases  in  which  tetauus  is  apparently  excited  by  cold  in  a 
person  who  has  had  a  trifling  injury,  perhaps  some  time  before.  The 
question  is  fortunately  not  of  any  great  practical  importance,  and 
each  case  must  be  judged  on  its  own  merits.  For  scientific  purposes 
■we  must  include  such  cases  in  the  traumatic  variety.* 

Prognosis. — The  statistics  of  the  mortality  in  tetanus  show  how 
grave  the  prognosis  is  in  every  case,  and  it  is  still  grave,  however  slight 
the  initial  symptoms  may  be,  or  however  trifling  the  injury  which  has 
produced  it.  But  it  is  distinctly  worse  if  the  injury  is  severe  than  if 
slight.  After  a  lacerated  wound,  the  compound  fracture  of  a  limb,  or 
distinct  contamination  of  the  wound  with  earth,  and  also  after  labour, 
recovery  is  extremely  rare.  The  chance  of  recovery  is  less  if  the  first 
symptoms  occur  before  the  tenth  day  from  the  receipt  of  the  injury. 
Most  recoveries  occur  in  cases  which  begin  after  the  first  ten  days, 
and  the  prognosis  is  better  the  longer  the  interval.  It  is  worse  when 
the  spasm  quickly  extends  to  the  trunk,  better  if  trismus  exists  alone 
for  several  days.  After  the  first  four  or  five  days  the  prognosis 
improves  with  the  duration  of  the  disease,  although  it  does  not  become 

*  By  this  means  we  run  least  risk  of  error.  It  is  certain,  however,  that  soine 
proportion  of  cases  of  idiopathic  tetanus  will  have  a  recent  scratch  or  cut  or  bruise, 
without  this  being  concerned  in  the  production  of  the  disease. 


TREATMENT.  693 

decidedly  hopeful  unless  the  symptoms  have  lasted  for  a  fortnight, 
or  present  a  distinct  and  persistent  diminution.  It  is  doubtful  whether 
the  prospect  of  recovery  is  materially  influenced  by  sex  or  age.* 
Adequate  statistics  to  determine  this  point  are  not  at  present  forth- 
coming. Previous  intemperance  lessens  the  chance  of  recovery,  and 
so  also  does  inability  to  swallow  and  considerable  elevation  of  tem- 
perature, but  its  subsequent  fall  is  not  of  significance  if  the  symptoms 
continue.  The  concurrence  of  cold  with  injury  as  a  cause  does  not 
influence  the  prognosis.  Under  the  most  favorable  circumstances — in 
cases,  for  instance,  which  occur  a  fortnight  after  the  receipt  of  a 
trifling  injury — the  probability  of  recovery  is  not  more  than  equal  to 
that  of  death.  On  the  other  hand,  hardly  any  case  of  traumatic 
tetanus  is  absolutely  hopeless.  Cases  occasionally  recover  under  all 
■conditions  of  cause  and  character. 

The  prognosis  in  idiopathic  tetanus  is,  intemperate  climates,  a  little 
better  than  in  the  traumatic  form.  In  hot  climates  it  is  regarded  as 
even  more  grave.  In  tetanus  neonatorum  the  prognosis  is  nearly  the 
same  as  in  the  traumatic  form  in  adults  (provided  the  children  are 
not  exposed  to  powerful  insanitary  conditions),  and  here  also  the  pro- 
gnosis is  better  the  longer  the  interval  after  birth  before  the  symptoms 
appear.  After  abortion  and  labour,  the  chance  of  recovery  is  only 
appreciable  when  the  disease  is  distinctly  excited  by  cold. 

Treatment. — For  tetanus,  as  for  most  acute  diseases,  no  specific 
remedy  is  known,  although  the  recent  discoveries  give  distinct  promise 
that  it  may  not  be  long  before  some  method  of  counteracting  the 
action  of  the  bacilli  is  discovered.  It  will  probably  be  possible 
to  foresee  the  malady  by  microscopical  examination  of  the  pus  in  any 
wound  contaminated  with  earth,  and  then  prophylaxis,  as  in  hydro- 
phobia, may  become  possible.     But  for  this  we  have  yet  to  wait. 

Tetanus  is  a  disease  of  limited,  though  variable  duration,  and  if  the 
patient  can  be  kept  alive  until  it  is  over,  he  recovers.  Moreover, 
there  is  reason  to  believe  that  the  intensity  of  the  disease  can  often  be 
lessened  by  treatment,  but  the  variable  severity  of  the  affection 
renders  it  very  difficult  to  assess  the  influence  of  the  remedies 
employed.  Three  elements  in  treatment  have  hitherto  chiefly  re- 
ceived attention — general  management,  operative  treatment  in  trau- 
matic cases,  and  the  endeavour  to  relieve  the  symptoms  by  the  use  of 
drugs. 

In  general  management,  rest  and  food  are  the  two  essential  measures. 
All  possible  sources  of  peripheral  irritation  should  be  avoided.  The 
patient  should  be  kept  absolutely  still,  and  the  room  darkened.  Liquid 
nourishment  should  alone  be  given,  even  if  the  trismus  is  not  complete. 
In  most  cases,  by  patience,  a  fair  quantity  can  be  taken  through  the 
closed  teeth  ;  sometimes  there  is  a  space  between  the  teeth,  and  a  tube 
can  be  introduced  through  which  the  food  may  be  sucked.  When 
*  Regarding  sex,  compare  the  mortality  given  on  p.  684. 


694  TETANUS. 

this  is  impossible,  sufficient  relaxation  of  the  spasm  to  permit  of  food 
being  given  may  be  obtained  by  the  inhalation  of  chloroform,  or 
liquids  may  be  injected  into  the  oesophagus  by  a  long  catheter  passed 
through  the  nose.  If  this  brings  on  spasm,  it  is  better  to  employ 
peptonised  injections  into  the  rectum.  A  tooth  has  been  extracted  to 
permit  feeding  through  a  tube,  but  it  is  better,  if  possible,  to  avoid 
any  fresh  irritation  of  peripheral  nerves.  .In  infants  the  catheter 
passed  through  the  nose  has  usually  been  employed. 

The  surgical  measures  which  have  been  adopted  in  traumatic  cases 
comprehend  amputation,  excision  of  the  cicatrix  or  wound,  neurotomy, 
and  nerve-stretching.  Of  all  these  it  may  be  said  that  in  most  cases 
in  which  they  have  been  employed  they  have  apparently  exerted  no 
beneficial  influence  on  the  course  of  the  disease.  Indian  experience 
of  these  measures  is  at  least  as  unfavorable  as  that  in  England.*  A 
curious  case  has  indeed  been  described  by  Reichertf  in  which  stretch- 
ing of  both  sciatic  nerves  was  followed  by  improvement  and  ultimate 
recovery;  the  cause  of  the  tetanus  was  a  bite  on  the  back  by  a  horse, 
but  the  patient  was  an  epileptic.  The  modus  operandi  of  the  operation 
is  difficult  to  understand.  The  common  failure  of  these  proceedings  is 
rendered  intelligible  by  what  we  now  know  of  the  pathology  of  the 
disease.  A  more  promising  measure  would  be  the  early  excision  of 
the  wound  in  any  case  in  which  the  bacilli  can  be  found  in  it  or  in  the 
soil  of  the  place  at  which  it  was  inflicted.  In  such  a  case,  amputation 
may  even  prove  justifiable.  The  late  excision  of  the  cicatrix  has  appar- 
ently been  effective,!  although  it  usually  fails,  no  doubt  because  the 
toxine  has  invaded  the  whole  system.  Perhaps,  also,  division  of  the 
nerve  is  justifiable  when  tetanic  spasms  start  from  the  injured  part. 
Most  of  the  cases  in  which  local  surgical  treatment  has  had  a  distinct 
and  immediate  effect  have  been  of  this  character.  In  one  case,  for 
instance,  a  small  nerve  in  a  wound  was  tender,  and  pressure  upon  it 
brought  on  severe  tetanic  spasms.  The  nerve  was  excised,  and  the 
spasms  ceased.  In  another  case,  tetanus  came  on  after  a  wound  was 
healed  ;  the  cicatrix  was  tender,  and  pressure  on  it  excited  the  spasm, 
which  ceased  after  the  cicatrix  had  been  excised. 

There  are  few  diseases  for  which  so  many  and  such  varied  drugs  have 
been  employed  as  in  the  treatment  of  tetanus,  but  hitherto  not  one  has 
been  found  to  exert  a  powerful  influence  on  the  disease,  not  one  that 
does  not  usually  fail  when  the  disease  is  severe,  and  frequently  when 
it  is  moderate  in  intensity,  and  few  that  have  not  been  credited  with 
cures,  chiefly  in  slight  cases.  Recovery  has,  indeed,  in  most  cases 
been  obviously  due  much  more  to  the  character  of  the  attack  than  to 
the  treatment  employed.  Still,  there  is  reason  to  believe  that  drugs 
have,  in  many  instances,  helped  recovery,  and  in  some  cases  have 
actually  turned  the  scale  and  saved  the  patient's  life. 

*  Wallace,  loc.  cit. 

t  'Bayer.  Aerztl.  Intell.-bl.,'  1885,  No.  5. 

%  Cotteril,  '  Lancet/  1888. 


TEEATMEXT.  695 

Of  the  agents  employed  there  are  some  that  give  temporary  relief  to 
the  spasm,  and  are  used  to  afford  rest  or  avert  death,  but  which  do  not 
influence  the  course  of  the  disease.  The  most  efficient  is  the  inhala- 
tion of  chloroform.  With  complete  narcosis,  the  spasm  passes  off,  but 
it  returns  when  the  influence  of  the  chloroform  is  over.  Ether  has  a 
similar  action,  but  is  less  convenient.  Nitrite  of  amyl  has  been  said 
to  relieve  spasm  more  speedily  than  chloroform,  and  H.  C.  Wood  has 
recommended  it  as  a  most  valuable  agent  for  averting  death  during  a 
paroxysm ;  at  Guy's  Hospital,  -when  employed  in  quantities  of  tl^iij 
to  tn_v,  it  was  found  that  the  spasm  became  more  intense  at  first, 
although  slighter  afterwards.  The  continuous  inhalation  of  chloroform 
does  not  seem  to  modify  the  course  of  the  disease,  nor  has  any  benefit 
resulted  from  attempts  to  charge  the  air  of  the  room  with  the  vapour 
of  chloroform.* 

Sedative  drugs  have  been  employed  in  the  treatment  of  tetanus  in 
two  ways,  occasionally,  to  procure  sleep,  and  continuously,  to  lessen  the 
severity  of  the  spasm.  In  severe  cases,  it  is  rare  that  a  marked  effect 
is .  produced  by  any  drug,  but  in  cases  of  moderate  severity,  distinct 
amelioration  has  been  obtained  by  many  agents.  Bromide  of  potassium 
has  been  given  at  frequent  intervals  in  large  doses,  four  to  six  drachms 
daily,  and  the  spasm  has  been  observed  to  increase  when  it  is  discon- 
tinued, and  to  lessen  when  it  is  r-esunied  (Southey).  It  may,  perhaps, 
with  advantage  be  injected  into  the  rectum  with  food ;  ISTothnagel 
has  found  that  it  tends  to  cause  ascending  contractions  in  the  bowel, 
and  thus  an  injection  is  carried  higher  up,  and  is  rapidly  and  more 
completely  absorbed. 

Chloral  hydrate  has  been  largely  substituted  for  the  administration  of 
chloroform  by  the  mouth,  although  it  does  not  remove  severe  spasm 
so  completely  as  the  inhalation  of  chloroform.  It  may  be  given  at 
night  to  procure  sleep,  and  frequently  succeeds,  or  it  may  be  given 
continuously,  and  has  thus,  in  many  cases,  appeared  distinctly  bene- 
ficial. Indeed,  it  has  been  held  to  have  more  influence  on  the  disease 
than  any  other  drug,  by  a  very  large  number  of  observers. f  Larg*e 
doses  must  be  employed.  Yerneuil,  for  instance,  who  is  a  strong 
advocate  of  its  use,  would  never  give,  to  an  adult,  a  smaller  dose  than 
5j,  or  less,  in  the  day,  than  3iv,  and  he  has  sometimes  given  3iij  at 
a  dose  and  5vij  in  the  day.  It  needs  to  be  continued  for  a  consider- 
able time.  In  two  cases  which  recovered,  gviij  were  given  in  the 
course  of  a  month.  Antipyrine  was  used  in  conjunction  with  chloral 
in  one  idiopathic  case  which  recovered.  Chloral  has  been  injected 
into  the  veins  by  Ore,  but  this  is  a  dangerous  proceeding,  since  it  has 
caused  extensive  thrombosis  in  several  cases  (Lannelongue  and  others). 
In  tetanus  neonatorum  it  has  usually  been  given  in  doses  of  one  grain, 

*   Simonin  used  in  this  way  22  kilogrammes  of  chloroform  without  effect. 

t  Schmidt  ('Bayer.  Intell.-bl.,5  1SS5,  p.  329)  records  the  recovery  of  four  out  of 
five  cases  treated  with  chloral,  hut  so  favorable  an  experience  must  be  regarded  as 
altogether  exceptional,  and  perhaps  open  to  suspicion. 


696  TETANUS. 

but  this  is  probably  too  small.  Opium  and  morphia  have  been  largely 
used,  the  latter  by  subcutaneous  injection ;  it  is  useful  for  the  purpose 
of  procuring  sleep,  in  doses  of  a  quarter  or  half  a  grain, which  maybe 
employed  in  addition  to  the  continuous  administration  of  bromide  and 
chloral.  The  continuous  use  of  morphia  has  not,  on  the  whole,  been 
so  often  effective  as  that  of  other  sedatives,  but  it  has  seemed  to  cure 
some  cases,  one  of  idiopathic  tetanus,*  and  others  of  the  traumatic 
foim.f 

Belladonna,  atropine,  Indian  hemp,  and  aconite  have  also  been  fre- 
quently employed.  Under  their  use  (as  under  that  of  all  other  drugs) 
recoveries  have  been  occasionally  observed,  but  on  the  whole  their 
utility  has  been  even  less  frequently  recognisable  that  that  of  other 
sedatives.  The  same  may  be  said  of  conium,  lobelia,  nicotine,  and 
tobacco,  veratrum  viride  and  gelsemium.J 

Next  to  bromide  and  chloral,  Calabar  bean  has  received  most  praise. 
The  extractum  physostigmatis  has  been  usually  employed  subcuta- 
neously,  in  doses  of  from  one  third  of  a  grain  to  one  or  two  grains,  or 
by  the  mouth,  one  to  four  grains.  Still  larger  doses  have  been  some- 
times given  by  the  mouth,  e.  g.  seventy-two  grains  in  twenty-four 
hours,  and  1026  grains  in  forty-three  days,  in  a  case  that  recovered. § 
Toxic  effects  are  not  easily  produced,  and  the  pupil  does  not  contract 
as  it  does  in  health,  even  when  nausea  and  feebleness  of  pulse  have 
been  produced.  Eilert  has  suggested  that  local  effects  may  be  lessened 
by  the  simultaneous  injection  of  atropine.  In  infants,  from  one 
thirtieth  to  one  third  of  a  grain  has  been  given  under  the  skin.  The 
salicylate  of  eserine  had  a  marked  influence  on  the  spasms,  injected 
in  doses  of  I^-g  grain, in  a  case  in  which  chloral  and  bromide  hadj>re- 
viously  been  used.  The  tetanus  began  on  the  fifth  day  alter  the 
removal  of  a  tumour  of  the  leg,  and  the  patient  recovered.  ||  Jaborandi 
and  pilocarpine  have  been  used,  generally  without  success,  although 
three  recoveries  have  been  described  by  Casati.1^ 

The  alleged  success  of  curara  in  hydrophobia  has  led  to  its  use  in 
tetanus,  but  seldom  with  effect.  Small  doses,  y^  grain,  do  not 
influence  the  disease.  With  large  doses  up  to  half  a  grain  every  hour, 
the  muscular  spasms  become  slighter,  but  life  has  rarely  been  saved. 
In  one  case  it  was  pushed  until  the  patient  passed  into  a  state  of 
collapse  and  respiration  ceased.  Prolonged  artificial  respiration,  with 
faradisation  of  the  phrenic  nerve,  revived  the  patient ;  the  spasms  re- 
mained absent  for  several  hours,  and  then  returned  in  slighter  form, 
and  the  patient  recovered.     Spasm  is  probably  lessened  by  the  influ- 

*  F.  J.  Smith,  •  Lancet,'  1889. 

f  C.  Dukes,  'Lancet,'  1888;  Morrison,  ib. 

J  Four  cases  are  said  to  have  been  successfully  treated  by  veratrum  viride  and 
gelsemiuni  by  R.  B.  Harris  ('New  York  Med.  Record,'  1884,  July  12th). 

§  Watson,  '  Practitioner,'  April,  1870.  For  another  successful  case  see  Dougall, 
'  Glasgow  Med.  Journ.,'  March,  1885. 

||  Rees  and  Raywood,  '  Lancet,'  18S9,  ii. 

%  See  'Brit.  Med.  Journ.,'  18S9,  quoted  from  '  Raccoglitore  Medico.' 


TREATMENT.  697 

•eneeof  eurara  on  the  intra- muscular  nerve- endings,  as  it  is  not  known 
to  have  any  influence  on  the  spinal  cord.  It  appears  only  to  avert 
death  from  spasm  by  bringing  the  patient  equally  near  to  death  from 
paralysis.*  Among  other  drugs  which  have  been  used  are  iodide  of 
potassium,  carbonate  of  iron,  arsenic,  antimony,  mercury,  urethane,  and 
strychnine.  Cases  have  recovered  in  which  each  has  been  used,  even, 
strange  to  say,  the  last,  which  distinctly  increases  the  spasm.f 

External  applications,  chloroform,  aconite,  &c,  to  the  affected  part 
appear  useless,  but  applied  to  the  epigastrium  they  sometimes  give 
relief  to  the  severe  pain  often  felt  there.  Cold  to  the  spine  (ice,  ether 
spray)  has  been  employed  without  distinct  influence  on  the  spasm. 
Electricity  (the  voltaic  current  from  the  spine  to  the  muscles)  has 
been  observed  to  lessen  the  spasm  in  trifling  cases,  but  probably  did  not 
influence  the  course  of  the  disease.  Continuous  warm  baths  have  been 
occasionally  employed,  since  the  time  of  Ambrose  Pare.  Zechmeister 
kept  one  patient  in  a  bath  for  a  fortnight,  but  the  treatment,  used  in 
eight  cases,  did  not  influence  the  mortality,  since  seven  of  the  patients 
died.  It  seemed,  however,  to  moderate  a  little  the  intensity  of  the 
spasm.  Bleeding  was  formerly  largely  used,  and,  opposed  as  the 
measure  is  to  the  therapeutic  principles  of  the  present  day,  it  may 
remove  some  of  the  toxine  from  the  system ;  at  any  rate,  cases  have 
recovered,  and  the  flow  of  blood  has  appeared,  in  some  instances,  to 
lessen  the  spasm.  Transfusion  of  blood  has  been  once  employed,  but 
without  success  (Sakler).  No  case  has  yet  been  influenced  by  the 
injection  of  the  serum  of  immune  rabbits,  supposed  to  contain  the 
antitoxine.  It  was  tried  in  a  case  of  tetanus  neonatorum,  but  four 
injections  had  no  effect.  J 

On  the  whole,  the  drugs  that  seem  to  deserve  most  confidence  in  the 
treatment  of  tetanus  are  bromide  of  potassium  and  chloral,  morphia, 
and  perhaps  eserine.  The  first  two  may  with  advantage  be  combined, 
the  influence  of  both  being  kept  up  continuously,  or  bromide  may  be 

*  Karg  ('  Arch,  f .  klin.  Chirurg.,'  xxix,  p.  338)  relates  four  cases  in  which  the 
transient  amelioration  of  the  symptoms  did  not  prevent  death.  He  advises  the 
simultaneous  use  of  morphia.  One  noteworthy  lesson  from  his  cases  is  that  if  arti- 
ficial respiration  hecomes  necessary  it  is  not  facilitated  by  tracheotomy.  Cases 
successfully  treated  have  been  recorded  by  Berckham  ('  Berl.  kl.  Wochenschr.,'  1884, 
No.  48)  and  Gontermann  (ib.,  1883,  No.  44).  In  the  latter  case,  the  tetanus  followed 
an  injury  to  the  head.  Nine  injections  were  given  in  the  course  of  a  few  days,  each 
consisting  of  i — |  grain  of  eurara,  dissolved  in  40  parts  of  water  and  2  of  spirit. 
He  makes  the  reasonable  suggestion  that  the  activity  of  the  specimen  employed 
should  always  be  proved  by  an  injection  in  an  animal. 

t  A  collection  of  937  reported  cases,  beginning  before  the  fifteenth  day,  has  been 
made  by  Melden,  to  compare  the  apparent  effect  of  different  drugs,  but  it  is  doubtful 
what  value  can  be  attached  to  the  statistics  of  so  very  large  a  number  of  cases. 
Chloral  and  eurara  are  each  credited  with  the  cure  of  a  quarter  of  the  cases  in 
which  they  were  used;  opium  with  one  twenty-fifth ;  conium  one  seventh;  Indian 
hemp  a  sixth  ;  bromide  a  fourteenth ;  alcohol  a  quarter ;  and  a  third  of  those  treated 
by  other  agents  are  said  to  have  recovered  ('  Lancet,'  1887). 

%  Babinsky,  'Berl.  kl.  Wochensch.,'  1891. 


698  TETANY. 

given  frequently,  and  chloral  in  occasional  hypnotic  doses.  If  the 
violence  of  the  spasm  threatens  death  during  a  paroxysm,  this  should  be, 
if  possible,  averted  by  the  inhalation  of  chloroform  or  nitrite  of  amyl, 
but  on  the  value  of  the  latter  for  this  purpose  further  observations 
are  necessary.  Lastly,  it  is  of  great  importance,  in  the  event  of  appa- 
rent death  during  a  paroxysm,  that  an  attempt  should  be  made  to 
restore  the  patient  by  artificial  respiration.  It  is  surprising  that  this 
measure  has  been  so  rarely  adopted.  Its  importance  is  illustrated  by 
a  case  recorded  by  Farrage.*  During  a  severe  paroxysm,  heart  and 
respiration  stopped,  the  patient  was  apparently  dead.  Artificial  re- 
spiration was  employed,  and  in  five  minutes  the  heart's  pulsations  could 
be  again  perceived.  For  two  days  the  spasm  was  extremely  slight; 
a  most  violent  paroxysm  then  occurred,  during  which  the  patient  died, 
no  medical  assistance  being  at  hand.  The  remarkable  freedom  from 
spasm  in  this  case,  and  one  or  two  others  on  record,  after  revival  by 
artificial  respiration  from  apparent  death,  can  only  be  ascribed  to  the 
influence  of  the  arrest  of  the  circulation  on  the  morbid  condition  of 
the  centre.  This  fact,  and  the  evidence  that  the  primary  disturbance 
is  in.  the  medulla  oblongata,  suggest  the  desirability  of  trying  the 
effect  of  ligature  of  the  vertebral  arteries,  which  Alexander  has  intro- 
duced for  the  treatment  of  epilepsy.  The  operation  is  severe  when 
both  vertebrals  are  simultaneously  tied,  but  in  a  case  in  which  the 
danger  was  extreme  it  might  be  justifiable. 


TETANY. 

The  condition  designated  "  tetany  "  is  characterised  by  tonic  mus- 
cular spasm  or  "  contracture,"  affecting  especially  the  extremities, 
symmetrical  in  distribution,  and  either  paroxysmal  or  continuous. 
The  spasm  is  often  preceded  and  accompanied  by  sensory  symptoms, 
tingling,  formication,  or  pain. 

The  affection  was  first  described  more  than  fifty  years  ago  by 
Steinheim  in  Germany,  and  Dance  in  France,  but,  like  so  many  other 
maladies,  it  was  through  the  study  and  description  of  the  disease  by 
Trousseau  that  it  became  generally  known.  Trousseau  called  it 
"  tetanilla,"  but  the  name  "  tetany,"  by  which  it  is  now  universally 
known,  was  suggested  by  Lucien  Corvisart  in  1852. f 

*  '  Lancet,'  1860,  Sept.  18th. 

t  Trousseau's  account  of  the  disease  is  accessible  to  English  readers  in  the  volume 
of  lectures  translated  by  Bazire.  Other  descriptions  have  been  given  by  Riegel 
('Deut.  Arch.  f.  kl.  Med.,'  xii,  1863,  405);  Weiss  ('  Volkmann's  klin.  Vort./ 
No.  169) ;  Buzzard  ('  Clin.  Lect./  p.  411)  ;  and  Abercrornbie  ('  On  Tetany  in  Young 
Children,'  London,  1880). 


CAUSES.  699 

Causes. — Tetany  is  rather  more  frequent  in  males  than  in  females, 
the  proportion  being  as  seven  to  six,  but  this  relation  does  not  obtain 
at  all  ages.  It  occurs  at  all  periods  of  life,  from  infancy  to  old  age, 
but  is  most  frequent  in  early  childhood  and  in  early  adult  life.  Of 
150  cases  that  I  have  collected  from  various  sources  or  observed 
myself,  142  are  available  for  comparison  on  these  points. 

Aires  .     .     1-4     5-9 


Males      .       26  ...  5 
Females.         8  ...  3 


1-9 

10-19 

20-29 

30-39 

40-49 

50-61 

31 

..  23 

..     9     . 

..     4     . 

..     5     . 

..     4=   76  Males. 

11  . 

..   13 

..   15     . 

..  19     . 

..     8     . 

0=   66  Females 

Total.     .       34...  8      42  ...  36     ...  24     ...   23     ...  13     ...     4=142 

Thus  the  disease  is  most  frequent  in  infancy  and  in  the  second 
decade  of  life.  More  than  half  the  cases  occur  during  the  first 
twenty  years.  In  early  childhood  the  disease  is  far  more  frequent  in 
males  than  in  females,  but  between  the  ages  of  twenty  and  fifty  the 
liability  of  the  sexes  is  reversed,  and  females  suffer  twice  as  frequently 
as  males.  Over  fifty,  on  the  other  hand,  the  only  recorded  cases  have 
been  in  males.  These  figures  correspond,  on  the  whole,  with  those 
supplied  by  smaller  series  of  cases  lately  published,  but  some  varia- 
tions exist,  owing  to  special  features  that  have  marked  periods  of 
special  prevalence.  Young  children,  for  instance,  have  sometimes 
been  the  only  sufferers,  and  in  a  number  of  such  cases  at  Prague,  the 
proportion  of  males  to  females  was  only  as  2  to  1,  while  of  a  series  of 
41  cases  in  adults,  36  were  males  and  5  females. 

A  neuropathic  heredity  can  be  traced  in  only  a  small  proportion  of 
cases,  but  that  a  family  predisposition  sometimes  exists  is  shown  by 
instances  recorded  by  Abercrombie,  in  which  there  occurred,  at 
different  times,  in  each  of  two  families  four  cases,  and  in  another 
family  three  cases.  It  has  often  been  observed  to  be  more  frequent 
in  winter  or  in  spring  than  in  summer  or  autumn,  in  the  case  both  of 
outbreaks  and  of  recurrences. 

Most  of  the  male  cases  have  occurred  in  the  lower  classes,  and  occu- 
pation is  influential  partly  as  involving  exposure  to  cold  and  fatigue  ; 
but  the  affection,  especially  in  Germany,  is  common  in  shoemakers 
and  tailors,  perhaps  from  some  influence  exerted  by  posture  combined 
with  that  of  a  sedentary  life. 

A  direct  exciting  cause  of  tetany  can  be  traced  in  at  least  three 
quarters  of  the  cases.  The  most  frequent  is  diarrhoea,  usually  long 
continued  and  exhausting,  but  sometimes  acute  and  brief.  Epidemic 
diarrhoea  has  been  the  cause  of  some  local  outbreaks  of  tetany  in 
young  children.  It  often  co-exists  with  other  causes.  Next  in  fre- 
quency is  exposure  to  cold,  which  may  produce  also  catarrhal 
disturbance.  A  lady  a  month  after  confinement  caught  cold  in 
driving ;  an  attack  of  tonsillitis  came  on,  and,  in  a  few  days,  a  sharp 
attack  of  tetany,  quickly  yielding,  however,  to  treatment.  Cold  is 
effective,  especially  when  conjoined  with  fatigue,   acute  disease,   and 


700  TETANY. 

lactation  A  series  of  cases  in  women  who  were  suckling  led 
Trousseau  at  first  to  propose  for  the  disease  the  name  of  "  nurse's 
contracture."  The  comparative  frequency  of  the  disease  in  adult 
■women  is  almost  entirely  due  to  the  various  influences  of  maternity. 
The  tetany  may  also  come  on  during  pregnancy,  usually  during  the 
second  half,  but  sometimes  early  ;  it  almost  always  continues  until 
delivery  and  then  ceases,  at  once,  or  in  a  week  or  two.  In  those  who 
have  suffered  before  marriage  it  is  especially  apt  to  occur  during  preg- 
nancy, often  more  than  once,  but  not  always  in  successive  pregnancies. 
It  may  also  develop,  in  rare  instances,  after  confinement.  Other 
occasional  causes  are  simple  ausemia,  prolonged  muscular  effort  of 
various  kinds,  alcoholism,  and  sexual  excess,  especially  masturbation. 
Many  cases  have  been  observed  in  the  subjects  of  dilatation  of  the 
stomach,*  sometimes  with  ulceration  or  with  the  cicatrix  of  an  ulcer, 
which  in  some  has  been  at  the  middle  of  the  organ,  associated  with 
external  adhesions,  an  hour-glass  form  of  the  organ,  and  even  with 
rotation  of  the  pyloric  end. 

In  young  children  the  indications  of  rickets  are  rarely  absent,  and 
in  them  tetany  is  evidently  allied  to  the  carpo-pedal  contractions  so 
common  in  that  disease,  and  it  is  often  associated  with  laryngismus 
stridulus  and  convulsions.  In  three  recorded  instances  the  disease 
was  apparently  due  to  intestinal  worms  (taenia?),  and  ceased  when 
■these  were  expelled.  It  very  rarely  follows  a  fright,  and  seldom 
an  injury,  but  there  is  one  operation  after  which  it  is  singularly  fre- 
quent,— excision  of  the  thyroid.  When  the  whole  thyroid  is  removed, 
tetany  supervenes  in  about  one  sixth  of  the  cases ;  this  is  the  average 
of  a  series  of  cases  reported  by  various  surgeons,  which  have  varied 
from  7  in  70  (Wolfler)  to  12  in  53  (Billroth).  All  the  patients  have 
been  young  females,  still  in  the  developmental  period  of  life.  The 
svmptoms  of  tetany  set  in  during  the  first  ten  days  after  the  opera 
tion.  It  does  not  follow  partial  extirpation.  It  has  been  observed 
in  association  with  atrophy  of  the  thyroid  and  myxcedema.  This 
remarkable  relation  to  thyroidectomy  will  be  considered  further  in 
connection  with  the  pathology  of  th£  disease. 

In  well-marked  forms,  tetany  is  less  frequently  associated  with 
hvsteria  than  might  be  expected,  but  hysterical  contracture  sometimes 
assumes  a  similar  form,  and  it  may  indeed  be  difficult  to  say  whether 
a  given  case  is  to  be  regarded  as  tetanoid  hysterical  contracture,  or  as 
true  tetany  in  an  hysterical  subject.  The  acute  diseases,  during  or 
after  which  tetany  has  been  known  to  come  on,  are  typhoid  fever, 
scarlet  fever,  cholera,  smallpox,  rheumatic  fever,  measles,  febricula, 
catarrh,  and  pneumonia.  It  has  been  met  with  very  frequently  in  some 
epidemics  of  typhoid,  usually  during  the  latter  part  of  the  disease, 
after  the  sixteenth  day,  or  during  convalescence— in  rare  cases  during 
the  first  week.  It  has  also  been  met  with  in  Bright's  disease,  and  I 
have  seen  one  case  apparently  due  to  lead-poisoning.  Symptoms 
*  Cases  described  bv  Collie,  Xason,  Muller,  Lob,  and  otbers. 


SYMPTOMS.  701 

resembling  those  of  tetany  lastiug  a  week  have  followed  a  fall  on  the 
head  in  a  young  child,  which  caused  loss  of  consciousness  and 
vomiting  for  two  days.* 

Lastly,  singular  epidemics  of  tetany  have  been  met  with  on  the 
Continent.  Some  of  these  are  apparently  analogous  to  the  occasional 
epidemics  of  hysterical  convulsion.  For  instance,  in  a  girls'  school  in 
France,  in  1876,  an  epidemic  occurred  in  which  no  less  than  thirty 
girls  were  attacked. f  A  still  more  singular  epidemic  occurred  in  1846 
in  certain  Belgian  prisons.  The  local  prevalence  of  the  typical 
disease  is  apparently  secondary  to  that  of  one  of  its  causes,  as  diar- 
rhoea in  children,  or  typhoid  fever,  in  which  there  has  been,  probably, 
some  special  element  in  the  cause  of  the  primary  disease. 

Symptoms. — As  a  rule,  the  peculiar  symptoms  in  the  limbs  come 
on  without  premonitory  nervous  disturbance,  but  in  rare  cases  they 
have  been  preceded  by  headache,  pain  in  the  spine,  and  malaise,  and 
even  vomiting  not  due  to  gastric  derangement.  The  muscular  spasm 
may  be  the  first  symptom,  but  is  usually  preceded  for  a  few  hours  or 
days  by  sensory  disturbance  in  the  extremities,  as  "tingling"  or 
"burning"  sensations.  The  spasm  almost  always  sets  in  suddenly 
in  the  hands,  occasionally  in  both  hands  and  feet  at  the  same  time, 
rarely  in  the  hands  only,  and  still  more  rarely  in  the  trunk.  The 
hands  feel  stiff  and  -cramped,  and  then  become  fixed.  The  usual 
posture  is  with  the  fingers  flexed  at  the  metacarpo-phalangeal  joints, 
extended  at  the  others  ;  the  thumb  is  adducted  and  in  contact  with 
the  index  finger,  or  is  flexed  beneath  it,  while  the  spasm  in  the  thenar 
and  hypotbenar  muscles  renders  the  palm  hollow.  The  fingers  are 
sometimes  pressed  together,  sometimes  inclined  towards  the  ulnar 
side.  The  position  of  the  fingers  is  mainly  due  to  spasm  in  the 
interossei  muscles.  The  wrist  is  usually  slightly  flexed.  The  elbow 
may  be  free,  but  is  more  often  in  slight  flexion.  The  shoulder  muscles 
are  rarely  involved,  but  occasionally  there  is  spasm  in  them  adducting 
the  arm.  In  a  few  cases  the  spasm  in  the  hand  muscles  has  been  chiefly 
in  the  long  flexor  of  the  fingers,  which  are  then  flexed  at  all  joints, 
and  the  fist  thus  closed.  Still  more  rarely  the  wrist  has  been  extended, 
and  in  two  recorded  cases  the  fingers  were  extended  at  all  joints. 

The  feet  are  extended  at  the  ankle-joint,  and  are  inverted,  being  in 
the  position  of  talipes  equino-varus.  The  toes  are  strongly  flexed ; 
the  knees  are  usually  extended,  rarely  flexed.  The  thighs  are  some- 
times adducted,  rarely  flexed. 

In  cases  of  slight  or  moderate  severity  the  contracture  is  limited  to 
the  hands  and  feet,  not  unfrequently  to  the  hands.  It  is  very  rarely 
unilateral.  In  severe  cases  the  muscles  of  the  trunk  and  head  share  in 
the  spasm.  The  abdominal  muscles  become  rigid,  and  there  may  be 
spasmodic  retention  of  urine.     Those  of  the  back  are  less  affected, 

*  Demme,  1889. 

f  Simon ;  Mattraits,  '  These  de  Paris,'  1877. 


702         i  TETANY. 

but  occasionally  there  is  a  slight  degree  of  opisthotonos.  The  thorax ! 
may  be  fixed  by  spasm,  which  may  even  involve  the  diaphragm,  and 
cause  some  difficulty  in  breathing,  cyanosis,  and  even  transient  loss  of 
consciousness.  Sometimes  the  sterno-mastoids  are  rigid,  and  the  head 
may  be  bent  forwards.  More  frequently  the  jaws  are  closed  by  spasm 
in  the  masseters,  the  angles  of  the  mouth  ai-e  drawn  out,  and  the  eye- 
lids are  half  closed.  Even  the  eyeball  muscles  may  be  involved,  caus- 
ing strabismus,  convergent  or  divergent,  and  immobility  of  the  pupils 
has  been  observed.  The  tongue  is  sometimes  stiff,  and  articulation 
may  be  rendered  difficult  by  this  or  by  the  involvement  of  the  larynx, 
and  swallowing  by  spasm  in  the  pharynx.  The  affection  of  the 
muscles  of  the  face  is  usually  only  seen  in  severe  attacks,  but  has 
been  occasionally  met  with  in  attacks  which  were  very  slight. 

The  tonic  spasm  may  render  the  muscles  firm  and  hard,  and  fibril- 
lary contractions  are  sometimes  visible  in  them.  Rarely,  paroxysms 
have  begun  by  brief  clonic  spasm.  Attempts  to  extend  the  muscles 
usually  cause  much  pain.  Movement  is  interfered  with  by  the  spasm 
and  in  proportion  to  it,  but  there  is  no  actual  paralysis.  "When  the 
contracture  is  slight,  movements  are  merely  rendered  difficult  and 
awkward ;  when  it  is  considerable,  all  voluntary  movement  may  be, 
for  the  time,  impossible. 

Slight  contracture  may  be  painless,  but  when  the  spasm  is  con- 
siderable there  is  severe  cramp-like  pain  in  the  muscles,  and  sharp 
pains  pass  up  the  limbs,  especially  in  the  course  of  the  nerves.  When 
the  spasm  is  continuous,  the  pain  may  be  paroxysmal,  probably  in 
consequence  of  slight  exacerbations  of  the  spasm.  The  subjective 
sensations  (tingling,  &c.)  which  precede  the  spasm  may  persist  during 
the  intervals,  and  may  be  accompanied  by  actual  diminution  of  sensi- 
bility to  touch  or  pain,  or  to  both. 

The  spasm  is  usually  paroxysmal.  After  continuing  for  a  time, 
which  varies  from  a  few  minutes  to  a  few  hours,  and  rarely  to  a  few 
days,  the  contracture  gradually  passes  off,  to  recur  after  a  variable 
interval  of  hours  or  days.  A  feeling  of  stiffness  often  succeeds 
it.  In  some  cases  the  spasm  continues  in  slighter  degree  in  the 
arms,  rarely  in  the  legs  only,  in  the  intervals  between  the  paroxysms. 
In  other  cases,  again,  in  both  children  and  adults,  the  spasm  may 
continue  in  moderate  degree  for  several  days,  without  exacerbations 
or  with  merely  an  occasional  trifling  increase.  Attacks  of  spasm  may 
occur  and  even  commence  during  sleep,  and  if  there  is  continuous 
contracture  this  may  persist  during  sleep,  although  usually  in  less 
degree.  Abercrombie  observed  no  change  in  the  continuous  spasm 
during  an  attack  of  measles  which  ended  fatally.  Attacks  are  some- 
times excited  by  muscular  exertion.  When  due  to  dilatation  of  the 
stomach,  percussion  of  the  abdomen  has  excited  attacks,  and  this  was 
also  observed  in  a  case  apparently  due  to  perforation-peritonitis. 

In  the  intervals  between  the  attacks  of  spasm  there  is  usually  a  re- 
markable increase  in  the  excitability  of  the  nerves  and  muscles  in  the 


SYMPTOMS.  703 

parts  in  which  the  spasm  occurs  or  is  most  intense.  Percussion  of  the 
muscles,  and  especially  of  the  nerves,  causes  a  conspicuous  contraction. 
This  phenomenon  may  be  well  observed  in  the  face,  where  a  tap  on  the 
nerve  will  often  cause  a  momentary  contraction  in  all  the  muscles 
supplied  by  it  (the  "  facial  phenomenon  ").  It  is  also  marked  in  the 
limbs,  in  which  an  attack  of  characteristic  local  spasm  may  usually  be 
induced  by  compression  of  the  artery  and  nerves  of  the  limb, 
sometimes  called,  from  its  discoverer,  "  Trousseau's  phenomenon."  The 
spasm  comes  on  a  few  minutes  after  the  commencement  of  the 
pressure.  It  is  probable  that  the  effect  is  chiefly  produced  through  the 
nerves,  although  it  is  said  that  sometimes  compression  of  the  artery  is 
effective  when  that  of  the  nerve  is  not ;  but  slighter  pressure  on  the 
nerve  has  sometimes  been  the  most  effective,  and  can  hardly  be  avoided 
when  the  artery  is  compressed.  Sometimes  this  phenomenon  cannot 
be  obtained.  Abercrombie  found  the  increased  irritability  invariably 
present  in  the  face,  and  not  in  the  limbs,  in  cases  of  continuous 
tetany  of  young  children.  Cutaneous  reflex  action  is  also  greater 
than  normal,  especially  on  the  trunk.  The  knee-jerk  may  be  normal, 
but  sometimes  it  cannot  be  obtained,  probably  by  reason  of  slight 
persistent  muscular  contraction,  and  not  beeause  it  is  really  absent. 

There  is  also  a  greatly  increased  electrical  excitability  of  the  nerves 
of  the  most  affected  parts  to  both  faradism  and  voltaism.  I  have 
obtained  contraction  in  the  muscles  of  the  face  by  applying  to  the 
nerve  the  voltaic  current  from  a  single  cell.  The  mode  of  reaction  to 
voltaism  is  changed,  as  Erb  has  pointed  out.  The  earliest  contraction 
occurs  with  the  positive  pole  when  the  circuit  is  closed,  and  sometimes 
when  it  is  opened,  instead  of  at  the  negative  pole  when  the  circuit  is 
closed.  Moreover,  the  closing  and  opening  of  the  circuit  causes  not 
only  a  momentary  contraction,  as  in  health,  but  a  prolonged  contrac- 
tion, "  tetanus,"  and  this  with  the  positive  pole  (anode)  as  well  as  with 
the  negative  (kathode).  It  is  the  only  condition  in  which  anodal 
opening  tetanus  has  been  observed  in  man.  Thus,  instead  of  the 
normal  reaction  (see  vol.  i,  p.  54)  1,  KC1C  ;  2,  AC1C,  KOC  ;  3,  AOC, 
we  have  1,  AC1C ;  2,  AOC  ;  3,  KC1C,  or  1,  AOC  ;  2,  AC1C,  KC1C, 
AOTe.*  A  similar  increased  irritability  has  been  found  in  the  sensory 
nerves  ;f  a  sensation  has  also  been  produced  more  readily  by  the  anode. 
It  is  said  also  to  exist  to  mechanical  stimulation.  The  increased  irri- 
tability, electrical  and  mechanical,  is  greatest  at  the  height  of  the 
disease,  lessens  with  it,  but  usually  persists  for  two  or  three  weeks 
after  the  spasms  have  ceased  and  after  pressure  has  ceased  to  be 
effective.  J 

*  It  is  said  that  excitability  of  the  nerve  sometimes  exists  to  voltaism  only,  but 
it  is  probable  that  in  such  cases  it  would  have  been  found  equally  distinct  to  the 
separate  faradic  shocks,  had  these  been  used  instead  of  the  serial  "  current "  (see 
vol.  i,  p.  376). 

t  Hoffmann,  1888  ;  Chovstek,  1890. 

J  It  is  said  that  the  increased  irritability  may  be  sometimes  found  in  rickety 
children  and  in  weakly  nervous  adults,  who  have  no  attacks  of  spasm. 


704 


TETANY . 


During  severe  paroxysms  there  is  often  copious  perspiration,  and 
sometimes  local  vaso-motor  disturbance,  redness,  and  even  slight  oedema 
in  the  affected  parts ;  the  pulse  is  quickened,  and  in  some  cases  and 
in  some  outbreaks  a  rise  in  temperature  has  been  observed,  rarely 
exceeding  101°  F.  In  other  cases  the  temperature  has  been  normal. 
The  urine  is  usually  unchanged,  but  transient  albuminuria  has  been 
twice  observed  (Kussmaul,  Nonchen),  and  in  one  case  glycosuria  coin- 
cided with  the  attack  (Stich).  Tetany  has  been  followed  by  general 
muscular  atrophy,  and  also  by  local  atrophy  of  the  thenar  muscles 
spreading  to  the  forearm,  and  accompanied  by  slight  atrophy  in  one 
leg ;  the  electrical  irritability  was  lowered  in  the  atrophied  muscles.* 
Other  trophic  changes  have  been  occasionally  observed,  chiefly  in  the 
growth  of  the  nails  of  the  feet  and  hands  ;  thus  necrosis  has  even  been 
met  with.     Bi'ownish  pigmentation  of  the  hands  and  face  has  been  seen. 

Varieties. — We  may  distinguish  three  varieties  of  tetany,  according 
as  the  spasm  is  intermittent,  remittent,  or  continuous,  but  cases 
are  met  with  that  present  every  gradation  between  these  varieties. 
Although  the  spasm  is  almost  always  symmetrical,  I  have  once  seen 
it  so  much  greater  on  one  hand  than  on  the  other,  that  when  slight  in 
degree,  it  was  one-sided.  There  is  little  relation  between  the  course 
and  severity  of  the  spasm  except  that  in  the  continuous  form  the  spasm 
is  never  so  violent  as  it  sometimes  is  in  the  paroxysmal  varieties.  In 
young  children  tetany  is  usually  continuous,  but  the  intermittent  form 
is  not  unknown.  In  older  children  and  adults,  the  continuous  form  is 
less  common  than  that  in  which  the  spasms  remit  or  intermit. 

It  has  been  said  that  not  only  does  continuous  tetany  persist  during 
sleep,  but  that  attacks  of  spasm  may  occur  even  for  the  first  time 
during  sleep.  The  continuous  form  usually,  however,  lessens  or  ceases 
during  sleep,  to  return  or  increase  on  waking.  It  is  removed  for  the 
time  by  chloroform  narcosis. 

Slight  tetanoid  symptoms  are,  indeed,  not  rare  during  sleep,  espe- 
cially in  adult  women  who  are  in  somewhat  feeble  general  health.  The 
patient  is  waked  up  by  tingling  in  both  hands,  accompanied  by  a  feeling 
of  stiffness,  and  sometimes  by  actual  rigidity,  which  may  prevent  all 
movement  and  last  for  a  few  minutes  or  longer,  even  for  an  hour  or 
more.  The  fingers  may  be  in  the  position  characteristic  of  tetany,  or 
may  be  flexed  at  all  joints,  but  never  strongly.  The  tingling  usually 
lasts  longer  tha.n  the  spasm.  The  condition  is  bilateral,  and  comes  on 
irrespective  of  posture. f  It  seems  to  be  a  slight  "  sleep  tetany."  Occa- 
sionally the  patients  who  suffer  from  this  nocturnal  tetany  have  similar 
attacks  in  the  daytime.  Now  and  then  the  attack  is  accompanied  by 
some  pain  in  the  head. 

Course. — In  both  the  continuous  and  intermitting  form  of  tetany  > 

*  Weiss,  '  Wien.  Allg.  med.  Zeit.,'  1885,  No.  31. 

t  It  must  not  be  confounded  with  the  tingling  in  the  region  of  the  ulnar  nerve 
that  is  due  to  long  flexion  of  the  elbow,  or  in  all  the  fingers  that  is  caused  by  pres- 
sure on  the  braucbial  plexus ;  in  these  cases  the  tingling  is  always  one-sided. 


PATHOLOGICAL   ANATOMY.  705 

the  total  duration  of  tlie  disease  varies  much.  Cases  of  either  variety, 
may  last  only  a  few  days ;  but  the  continuous  form  very  seldom  pre- 
sents the  prolonged  duration  which  is  not  uncommon  when  the  spasm 
is  intermittent.  If  the  spasm  presents  no  considerable  remission  it  is 
rare  for  the  disease  to  last  more  than  a  few  weeks,  whereas  in  the  cases 
of  intermittent  tetany  the  disease  often  lasts  for  several  months.  In 
the  severe  cases  after  excision  of  the  thyroid,  which  are  not.  fatal,  the 
duration  is.  sometimes  prolonged ;  the  symptoms  may  even  continue 
for  two  or  three  years  after  the  operation. 

Tetany  is  an  affection  prone  to  return  on  a  recurrence  of  its  exciting 
cause,  and  sometimes  without  appreciable  cause.  A  mother  suffered 
frorn  it  while  suckling  each  of  five  successive  children  (Maccall),anda 
woman  had  an  attack  in  each  of  ten  successive  winters  (Lussana). 
I  have  also  seen  a  case  in  which  a  woman  became  subject  to  attacks  at 
the  age  of  twenty-two,  and  was  still  liable  to  them  at  thirty-four ;  each 
winter,  as  the  cold  weather  came  on,  she  suffered  from  rheumatic 
pains  in  the  limbs,  and  these  were  followed  by  attacks  of  tetany,  each 
lasting  from  half  an  hour  to  one  or  even  two  days,  and  recurring  about 
twice  a  week,  until  the  late  spring,  and  then  they  ceased  until  the  winter. 
Another  patient  had  frecjuent  attacks,  each  lasting  about  six  hours, 
during  six  weeks  every  spring,  from  the  age  of  fourteen  to  twenty 
years. 

Termination. — Most  cases  of  tetany  end  in  recovery.  Very  rarely 
some  weakness  of  the  legs  Iras  persisted  for  a  time.  When  death  has 
occurred,  it  has  been  usually  due  to  the  cause  of  the  tetany,  e.  g.  to 
diarrhoea.  In  a  few  instances,  the  spasms  have  caused  death,  either 
directly,  by  their  violence  producing  fatal  exhaustion  (Trousseau),  or 
indirectly,  by  the  repeated  interference  with  respiration  causing  con- 
gestion of  the  lungs,  and  a  low  form  of  pneumonia.  The  disease,  when 
it  follows  excision  of  the  thyroid,  is  much  more  fatal  than  it  is  under 
other  circumstances,  except  when  due  to  dilatation  of  the  stomach 
which  lessens  the  strength  of  the  patient.  Tetany  has  been  known  to 
be  immediately  followed  by  chorea  (Salomonsen)  ;  I  have  met  with 
chorea  a  year  after  tetany.  As  might  be  expected,  an  affection  which 
sometimes  occurs  in  hysteria,  is  occasionally  associated  with  other 
symptoms  of  the  latter  disease.  In  one  patient  attacks  of  tetany 
were  preceded  by  hysterical  trismus.  We  have  seen  that  muscular 
atrophy  may  supervene,  either  slight  and  confined  to  the  hands,  or 
general  and  severe.  Epileptic  attacks  have  been  observed  in  asso- 
ciation with  tetany,  and  very  rarely  mental  disturbance  has  accom- 
panied it.* 

Pathological  Anatomy. — In  the  few  cases  in  which  a  post-mortem 
examination  has  been  made,  no  change  has  been  found  which  we  can 
regard  as  the  cause  of  the  disease.     The  minute  alterations  that  have 

*  Frankl-Hochwart,  '  Jahrbuch  f.  Psych.,'  ix  (three  cases). 
VOL.   II.  45 


706  TETANY. 

been  detected  in  the  spinal  cord  in  some  cases*  are  probably  secondary 
to  its  functional  over-action.  Such,  for  instance,  are  capillary  haemor- 
rhages, accumulation  of  lymphoid  cells  around  blood-vessels,  and  even 
minute  foci  of  myelitis.  The  ganglion-cells  have  been  found  somewhat 
shrunken  in  aspect,  and  to  contain  vacuoles.!  Hyperemia  of  the 
upper  part  of  the  cord  has  been  observed  in  some  cases,  but  was  absent 
in  others.  Softening  in  the  cervical  region,  met  with  by  Trousseau, 
probably  indicated  organic  disease  causing  symptoms  that,  simulated 
tetany,  such  as  may  be  produced  by  a  concussion  of  the  head. 

Pathology. — The  great  increase  in  the  excitability  of  the  motor 
nerves  shows  that  there  is  an  alteration  in  the  function  (and  doubt- 
less also  in  the  nutrition)  of  the  motor  nerve-fibres.  We  know  that 
changes  in  the  nutrition  of  these  fibres  are  usually  dependent  on,  and 
secondary  to,  a  similar  change  in  motor  cells  of  the  spinal  cord,  of 
which  the  axis-cylinders  of  these  nerves  are  the  prolonged  pro- 
cesses. The  discovery  of  slight  changes  in  the  cells  in  severe  cases, 
and  the  fact  that  slight  spinal  weakness  may  follow  tetany,  also 
suggest  a  disturbance  of  function  of  the  cord,  while  the  bilateral  sym- 
metry of  the  disease,  and  the  peculiar  and  uniform  character  of  the 
spasm,  constitute  strong  evidence  of  its  ceutral  origin.  The  sensory  sym- 
ptoms indicate  that  the  disturbance  of  function  is  not  confined  to  motor 
structures.  Beyond  this  we  are  not  at  present  justified  in  going. 
There  is  in  this  (as  "Weiss  has  pointed  out)  nothing  inconsistent  with 
the  possibility  that  the  primary  disturbance  may  be  still  higher  up  in 
the  brain,  and  that  the  derangement  of  the  cord  and  nerves  may  be 
secondary,  although,  at  present,  the  only  evidence  of  implication  of  the 
cerebrum  is  afforded  by  the  associated  symptoms  of  insanity,  hysteria, 
and  epilepsy.  These  do  not,  however,  show  that  the  special  symptoms 
have  a  cerebral  origin,  although  it  may  be  noted  that  the  peculiar  form 
of  spasm  ("  interosseal  "  flexion  of  the  fingers)  is  seen  in  some  forms 
of  spasm  of  brain  origin  as  in  many  cases  of  epilepsy. 

Whatever  the  seat  of  the  disease,  the  morbid  process  must,  as  a 
rule,  be  limited  to  disturbance  of  function  aod  nutrition,  and  the 
occasional  origin  of  the  disease  in  reflex  irritation  suggests  that  the 
disturbance  of  function  may  be,  in  such  cases  at  least,  the  primary 
change.  The  resemblance  of  the  spasni  to  that  seen  in  ergotism 
has  struck  many  observers. J  and  has  suggested  its  dependence  on 
some  toxic  influence,  possibly  in  dilatation  of  the  stomach,  an 
"  auto-toxic  "  process,  by  some  product  of  imperfect  digestion  or  of 
altered  secretion.  The  search  for  such  an  agent  in  the  contents  of 
the  stomach  has  hitherto  been  unsuccessful.     The  effect  of  cold  may 

*  By  Weiss,  Langhans,  Ferrario,  6cc. 

f  The  significance  of  the  vacuoles  in  nerve-cells  has  been  much  discussed.  I 
believe  that  they  form  during  the  process  of  hardening,  but  only  when  the  cells  are 
in  an  abnormal  state. 

J  Imbert-Goubeyre  (1844),  Hasse,  Moson,  Eulenburg. 


DIAGNOSIS.  707 

possibly  be  due  to  a  blood  change,  such  as  causes  rheumatic  fever ; 
its  action  on  the  nerves  of  the  skin  may  co-operate  with  a  predisposi- 
tion. Some  etiological  facts  are  scarcely  compatible  with  a  toxic 
cause.  Infantile  tetany  has  doubtless  the  same  cause  as  infantile 
convulsions  (q.  v.). 

The  frequent  occurrence  of  the  disease  after  excision  of  the  thyroid 
is  a  pathological  fact  of  great  importance,  but  not  yet  of  clear 
significance,  although  most  observers  consider  that  a  toxic  mechanism 
is  the  probable  explanation.  It  can  be  produced  also  in  animals,  and 
follows  ligature  of  all  the  blood-vessels  of  the  organ,  as  well  as  its 
excision.  The  remarkable  fact  has  been  ascertained  that  if  one  half  of 
the  thyroid  is  first  removed  (a  proceeding  that  does  not  cause  tetany), 
and  is  placed  in  some  other  part,  as  the  peritoneum,  the  second 
half  can  be  afterwards  removed,  in  some  cases,  without  the  result  that 
would  follow  the  simultaneous  excision  of  both  halves.*  The  malady 
has  been  thought  to  be  the  first  result  of  the  process  which  leads  to 
myxcedema  and  the  "  cachexia  strumipriva,"  and  to  be  due  to  the 
accumulation  in  the  blood  of  some  material,  as  mucin,  which  it  is  the 
function  of  the  thyroid  to  change.  "With  the  admission  of  the  possi- 
bility of  this  we  must,  at  present,  be  content. 

On  the  whole,  our  knowledge  of  the  pathology  of  the  disease 
points  to  the  nerve-cells  of  the  spinal  cord  and  medulla  as  the  parts 
immediately  deranged ;  whether  these  structures  are  affected  pri- 
marily, or  in  consequence  of  a  deranged  action  of  the  motor-cells  of 
the  cortex,  we  have  yet  to  ascertain.  The  nerve-fibres  seem  to  share 
the  disturbance,  almost  from  the  first.  Its  definite  and  uniform 
features  suggest  that  the  derangement  is  a  primary  one  of  the  cells 
themselves,  and  is  not  pi-oduced  by  the  agency  of  any  vaso-motor 
mechanism. 

Diagnosis. — The  peculiar  character  of  the  spasm,  its  limitation  to 
certain  groups  of  muscles,  its  commencement  in  the  extremities,  and 
its  bilateral  symmetry,  are  usually  sufficient  indications  of  the  nature 
of  the  case.  If  present,  the  intermissions  in  the  spasm,  the  increased 
irritability  of  the  nerves,  and  the  excitation  of  the  spasm  by  their 
compression,  corroborate  the  diagnosis,  but  these  symptoms  may  be 
absent  in  early  cases.  The  presence  of  one  of  the  most  common 
etiological  conditions  (exposure  to  cold,  diarrhoea,  lactation  or  preg- 
nancy), is  also,  in  some  cases,  of  diagnostic  value.  It  is  important, 
however,  to  remember  that  in  slight  cases  the  sensory  symptoms  may 
attract  more  attention  than  the  motor  spasm.  Whenever  chronic 
tingling  in  the  hands  and  feet  is  complained  of,  careful  inquiry  should 
be  made  for  attacks  of  spasm. 

Prom  tetanus  the  disease  is  distinguished  by  the  commonly  inter- 

*  Eiselsberg, '  Wien  klin.  Wochensch.,'  1890.  Tetany  was  sometimes  prevented  by 
placing  the  whole  organ  in  the  peritoneum,  and  occurred  when  this  was  afterwards 
removed  ('  Neur.  Cent.,'  1892). 


708  TETANY. 

mitting  character  of  the  spasm,  by  its  commencement  in  the  extremi- 
ties, by  the  peculiar  posture  of  the  hands,  and  by  the  fact  that  the 
earliest  symptom  in  tetanus,  spasm  in  the  masseters,  is  the  latest  in. 
tetany.  In  organic  brain  disease,  contracture  is  usually  permanent 
and  often  unilateral ;  there  is  paralysis  in  addition  to  spasm,  and 
cerebral  symptoms  are  usually  present.  Hysterical  contracture  may 
closely  resemble  tetany,  so  far  as  the  form  of  spasm  is  concerned, 
but  is  almost  invariably  unilateral,  while  tetany  never  is.  When 
such  contracture  is  bilateral,  the  case  should  be  regarded  as  one  of 
hystei-ical  tetany.  In  the  tonic  form  of  epilepsy,  bilateral  spasm  may 
exist,  almost  identical  with  tetany  in  its  character,  but  distinguished 
by  the  extreme  brevity  of  the  paroxysms,  and  by  the  occurrence  of 
loss  of  consciousness. 

Prognosis. — Tetany  involves  little  danger  to  life  except  in  the  cases 
after  excision  of  the  thyroid,  and  those  due  to  dilatation  of  the 
stomach.  The  chief  danger  is  from  the  cause  of  the  tetany,  such  as 
severe  diarrhoea.  It  is  only  when  the  paroxysms  are  very  violent, 
causing  considerable  and  repeated  interference  with  respiration,  with 
signs  of  cedema  of  the  lungs,  that  there  is  any  ground  for  apprehen- 
sion. The  duration  of  the  disease  is  difficult  to  foretell.  When  the 
attacks  are  prolonged,  lasting  several  days,  the  affection  is  not  likely  to 
be  of  long  duration,  and  continuous  tetany,  of  slight  intensity,  will 
certainly  soon  be  over.  Prompt  treatment  of  a  commencing  case  will 
frequently  cut  it  short.  As  long  as  the  irritability  of  the  nerves  is 
increased,  the  paroxysms  are  likely  to  recur.  It  must  not  be  forgotten 
that  the  subjects  of  tetany  are  very  liable  to  future  attacks,  if  exposed 
to  an  adequate  cause.  The  tetany  of  pregnancy,  it  must  also  be 
remembered,  usually  continues  until  delivery. 

Treatment. — Whenever  the  cause  of  the  disease  can  be  traced,  the 
removal  of  this  or  the  mitigation  of  its  general  effect,  is  the  first  and 
most  important  element  in  treatment.  If  resulting  from  exposure  to 
cold,  and  seen  early,  warm  baths,  or  free  diaphoresis,  should  be  em- 
ployed. Pilocarpine  has  been  used  with  advantage,  but  is  seldom 
necessary.  The  state  of  the  bowels  must  be  carefully  regulated. 
Lactation  should  be  stopped,  and  strength  restored  by  tonics,  espe- 
cially by  iron  and  quinine. 

In  most  cases  the  spasm  may  be  relieved  most  effectually  by  full 
doses  of  bromide  of  potassium,  5ss  three  times  a  day.  Chloral,  Indian 
hemp,  and  hypodermic  injections  of  morphia  have  also  been  found 
useful  for  the  same  purpose.  The  inhalation  of  chloroform  at  first 
increases  the  spasm,  but  all  contracture  usually  disappears  when  the 
patient  is  fully  under  its  influence  ;  at  the  same  time  chloroform  has 
little  influence  in  preventing  a  recurrence.  Two  cases,  however  (re- 
corded by  Hauber),  which  had  resisted  other  treatment  were  quickly 


TETANOID    CHOBEA,  709 

cured  by  a  course  of  chloroform  inhalation,  "with  energetic  massage 
during  the  narcosis.  The  local  application  of  stimulating  liniments 
(especially  chloroform)  and  of  cold  to  the  extremities,  also  sometimes 
arrests  the  spasm.  Trousseau  observed  benefit  from  the  application 
of  ice  to  the  spine.  Electrical  treatment  has  been  followed  by  improve- 
ment in  some  cases,  and  has  failed  in  others.  The  best  results  have 
been  obtained  -with  the  voltaic  current,  the  negative  pole  to  the  spine, 
the  positive  on  the  irritable  nerves.     Faradism  is  contra-indicated. 

In  France,  tetany  was  once  invariably  treated  by  bleeding ;  the 
symptoms  rapidly  disappeared  in  some  cases,  especially  in  men,  occa- 
sionally also  in  weakly  women.  The  procedure  often  failed,  however, 
when  tonics  quickly  cured  the  patient.  As  a  rule,  when  the  spasm 
has  ceased,  nervine  tonics  are  desirable,  as  strychnia,  quinine,  arsenic, 
iron,  or  valerianate  of  zinc.  I  have  found  the  two  last,  with  bromide, 
of  great  service  in  chronic  paroxysmal  tetany. 

The  treatment  of  tetany  in  children  is,  in  the  main,  similar  to  tbat  of 
their  convulsions.  Attention  to  the  underlying  diathesis  is  of  para- 
mount importance.  In  yours  children,  symptoms  of  i*ickets  are  rarely 
absent,  and  cod-liver  oil  and  iron  are  the  most  effectual  remedies,  the 
continuous  tetany  of  early  life  being  less  amenable  to  sedatives  than 
the  intermittent  tetany  of  older  children  and  adults.  Cheadle  found 
bromide  and  chloral  useless  in  one  case,  in  which  the  extract  of  Cala- 
bar bean  succeeded,  in  doses  of  one  thirty-sixth  of  a  grain  increased 
gradually  to  a  third,  but  cod-liver  oil  and  iron  were  given  at  the 
same  time.  In  addition  to  the  latter,  the  administration  of  bromide 
should  never  be  omitted. 

For  nocturnal  tetany  I  have  found  no  remedy  so  useful  as  a  dose 
of  digitalis  given  at  bedtime.  Bromide  often  removes  the  symptom, 
but  occasionally  fails.  Tonics  may  also  be  given  with  advantage 
during  the  day. 

Tetanoid  Chorea. 

A  case  was  recently  under  my  care  that  presented  symptoms  inter- 
mediate between  those  of  chorea  and  of  tetany.  The  disease  was  fatal 
and  no  lesion  was  found  after  death.  The  patient  was  a  boy  aged  ten. 
A  brother  was  said  to  have  died  from  some  affection  similar  to  that 
from  which  this  child  was  suffei-ing.  There  was  a  history  of  three 
other  relations  having  suffered  from  maladies  resembling  chorea.  In 
the  patient  the  symptoms  commenced  gradually,  seven  months  before 
death.  They  consisted  of  tonic  spasm,  which  was  continuous,  acd 
varied  by  paroxysmal  attacks  of  similar,  but  more  intense,  spasm. 
The  face  was  involved  on  both  sides,  so  as  to  cause  a  constant  peculiar 
smile.  The  tongue  was  pressed  back  against  the  palate  in  such  a 
manner  as  to  impede  swallowing  and  prevent  speech.  The  arms 
were  extended,  pronated,  and  rotated  inwards,  so  as  to  bring  the  back 
of  the  forearm  outwards,  while  the  fingers  were   generally  slightly 


710  OCCUPATION   NEUROSES. 

flexed  at  all  joints,  "but  at  times  were  extended,  and  slowly  moved  in 
the  irregular  way  characteristic  of  athetosis.  The  legs  were  extended 
at  all  the  joints,  the  feet  being  over-extended  in  talipes  equino- 
varus,  and  the  toes  were  flexed.  At  times  the  spasm  at  the  hip 
became  flexor,  so  that  the  extended  legs  were  raised  off  the  bed.  The 
muscles  of  the  trunk  were  also  involved  in  the  spasm.  At  first  the 
left  side  was  the  more  severely  affected,  but  afterwards  the  spasm 
became  equal  on  the  two  sides.  The  electric  irritability  of  the  muscles 
was  normal,  and  there  was  no  mechanical  excitability  of  the  nerves. 
There  was  considerable  pyrexia  during  the  more  severe  stage  of  the 
disease.  The  boy  steadily  emaciated,  and  died  from  exhaustion. 
The  whole  central  nervous  system  appeared  normal  to  the  naked  eye, 
and  no  distinct  morbid  appearances  could  be  discovered  on  micro- 
scopical examination.  I  have  not  been  able  to  find  a  description  of 
any  quite  similar  case. 


OCCUPATION  LEUKOSES. 

The  term  "  occupation  neuroses,"  adopted  from  the  German  ("  Be- 
schaftigungs-neurosen"),  is  a  convenient  designation  for  a  group 
of  maladies  in  which  certain  symptoms  are  excited  by  the  attempt  to 
perform  some  often-repeated  muscular  action,  commonly  one  that  is 
involved  in  the  occupation  of  the  sufferer.  The  symptoms  occur  in 
the  part  by  which  the  action  is  effected,  and  the  action  is  interfered 
with  by  them.  Other  acts  (at  least  in  the  early  stage  of  the  affection) 
do  not  excite  the  symptoms,  and  are  not  interfered  with.  The  most 
frequent  symptom  is  spasm  in  the  part,  which  disturbs  or  prevents 
the  due  performance  of  the  intended  action,  and  hence  the  word 
"cramp"  is  commonly  applied  to  it,  qualified  by  the  name  of 
the  action,  or  occupation,  that  excites  the  disorder,  as  "  writers' 
cramp,"  "pianoforte-players'  cramp,"  "telegraphists'  cramp,"  "  semp- 
stresses' cramp."  The  term  "cramp"  sets  forth  the  muscular  spasm 
which,  in  most  cases,  is  the  chief,  but  rarely  the  sole  symptom.  There 
is  usually  not  only  spasm  but  pain,  which  is  not  the  direct  result  of 
the  spasm,  and  may  be  the  only  obtrusive  symptom.  It  may  be  re- 
ferred to  the  muscles,  or  to  the  bones  or  joints,  or  to  the  position  of 
certain  nerves.  In  the  latter  case,  it  resembles  neuralgia,  and  the 
more  closely,  since  certain  foci  of  pain  and  tender  points  may  be 
developed,  as  in  ordinary  neuralgia,  from  which  it  differs  in  being  at 
first  not  spontaneous,  but  excited  only  by  the  special  action.  Hence 
we  must  distinguish  a  motor  and  a  sensory  form,  a  spasmodic  and  a 
neuralgic  variety  of  occupation-neurosis,  but  the  two  forms  are  very 
often  combined.  Although  the  disturbance  is  in  the  first  instance 
confined  to  the  special  action,  and  may  remain  limited  to  this,  it  often 
extends,  after  a  time,  to  other  actions  in  varying  degree,  and  in  pro- 


WEITEES     CEAMP.  711 

portion  as  the  muscular  contractions  correspond,  in  combination  and 
character,  to  those  of  the  movement  first  disordered.  The  extension 
may  ultimately  be  so  wide,  that  spasm,  and  still  more  often  pain, 
occurs  on  any  movement.  I  have  even  met  with  cases  in  which  a 
spasm,  at  first  excited  only  by  a  special  act,  ultimately  extended  not 
only  to  all  acts,  but  occurred  spontaneously.  Thus,  in  their  ultimate 
extension,  the  occupation-neuroses  are  not  so  well  defined  as  in  their 
earlier  stages.  Moreover,  they  are  not  always  well  defined  in  their 
causation.  Local  disease  or  injury,  or  some  affection  of  the  central 
nervous  system,  weakening  the  limb,  may  distinctly  co-operate  in 
developing  the  morbid  state.  In  such  cases,  extreme  care  is  necessary 
in  determining  the  nature  of  the  case,  because  a  local  affection  is 
often  first  revealed  by  the  interference  with  a  delicate  action,  per- 
formed frequently  and  for  a  long  time.  Many  forms  of  disease  are  thus 
erroneously  supposed  to  be  of  the  nature  of  occupation  neuroses,  when 
the  occupation  merely  manifests  and  does  not  cause  the  symptoms. 

The  most  common  form  of  occupation-neurosis  is  that  of  writing:, 
and  since  this  is  not  only  the  most  common  but  is  typical  of  the  class, 
it  will  be  most  convenient  to  describe  it  at  length,  the  conclusions 
regarding  it  being  applicable  to  all  other  forms. 


Writing  Neurosis;  Writers'  Cramp. 

Writers'  cramp  was  first  described  by  Sir  Charles  Bell  in  the  year 
1830.  It  was  called  "  Scriveners'  Palsy  "  by  Solly,  a  term  still  some- 
times applied  to  it.* 

Etiology. — The  affection  is  very  much  more  common  in  males  than 
in  females,  especially  in  its  motor  form,  doubtless  because  fewer 
women  are  engaged  in  occupations  that  involve  a  large  amount 
of  writing.  If  all  forms  are  included,  males  constitute  two  thirds  of 
the  sufferers,  but  a  still  larger  proportion,  at  least  five  sixths,  of 
those  who  present  the  motor  form.  It  is  a  disease  of  the  active 
period  of  adult  life,  rarely  commencing  under  twenty,  not  often  after 
fifty,  while  about  five  sixths  of  the  cases  begin  during  the  intervening 
thirty  years.     The  distribution  of  153  cases  f  is  as  follows  : 

10-  20-  30-  40-  50-  60- 

*  Cases        .         .     2       ...       52       ...       50       ...       32       ...       12       ...      5 

*  The  most  important  writings  on  the  disease  are  those  of  Berger  ('  Eulenburg's 
Real-Encyclopsedie/  art.  "Beschaftigungs-ueurosen  ")  and  of  Poore  ('  Practitioner/ 
1872-3;  'Text-Book  of  Electricity/  and  'Med.-Chir.  Trans.,'  vol.  lxi).  The  last 
ariicle  contains  a  large  number  of  carefully  observed  facts. 

f  33  cases  described  by  Poore  ('  Practitioner/  1878),  64  collected  by  Berger 
(loc.  cit.),  and  54  cases  of  my  own;  all  being  rejected  in  which,  from  the  character 
of  the  symptoms,  there  was  any  room  for  doubt  as  to  the  nature  of  the  case. 


712  writers'  cramp. 

Thus  about  one  third  of  the  cases  commence  in  each  of  the  third 
and  fourth  decades  of  life,  and  only  a  fifth  in  the  following  ten  years. 

An  hereditary  tendency  to  nervous  affections  can  often  be  traced. 
One  of  my  patients  had  an  epileptic  uncle;  another  lost  a  brother 
from  general  paralysis  of  the  insane  ;  three  others  had  each  an  insane 
parent,  and  one  an  epileptic  father.  In  some  instances,  more  than 
one  member  of  a  family  has  suffered  from  the  special  affection. 
Vance  relates  the  case  of  a  patient  who,  to  rest  his  hand,  went  on  a 
visit  to  a  distant  brother,  and  was  surprised  to  find  that  he  also 
had  given  up  writing  from  the  same  cause.  I  have  met  with  a  very 
characteristic  case  in  a  lady  whose  father  also  suffered  from  writers' 
cramp.  In  estimating  a  family  tendency,  it  must  be  remembered  that 
writers'  cramp  is  a  disease  that  is  easily  imagined,  especially  by  those 
who  have  witnessed  the  disorder.  The  malady  is  sometimes  met  with 
in  those  who  exhibit  no  other  symptom  or  tendency  to  nervous  derange- 
ment, but  more  frequently  the  subjects  of  it  are  of  distinctly  "  nervous  " 
temperament,  irritable,  sensitive,  bearing  over- work  and  anxiety  badly, 
and  occasionally  the  neuropathic  tendency  shows  itself  in  other  inde- 
pendent disease.  For  instauce,  one  patient  with  characteristic  writers' 
cramp  (spasm  absolutely  confined  to  the  act  of  writing)  subsequently 
presented  the  early  stage  of  tabes  ;  others  had  previously  suffered  from 
migraine,  epilepsy,  and  melancholia ;  and  many  of  those  who  suffer 
from  pain  in  writing,  alone  or  with  spasm,  have  been  liable  to  neu- 
ralgia elsewhere,  or  have  presented  various  manifestations  of  nervous 
weakness.  Two  of  Berger's  patients  were  epileptic,  and  one  of  my 
own  had  some  fits  in  early  adult  life.  Another  had  suffered  from 
infantile  paralysis  in  one  leg.  We  must  distinguish,  however,  be- 
tween such  cases,  in  which  an  independent  disease  shows  the  existence 
of  a  neuropathic  tendency,  and  the  cases  already  referred  to,  in  which 
a  nervous  affection  of  the  part  employed  in  writing,  is  one  of  the  causes 
of  the  special  disease. 

Whatever  lowers  the  general  tone  of  the  nervous  system  may  doubt- 
less act  as  a  predisposing  cause,  but  no  influence  is  met  with  so  fre- 
quently as  to  deserve  special  mention,  except  anxiety.  It  is  remarkable 
how  many  patients,  at  the  time  of  the  onset  of  the  affection,  were 
enduring  anxiety  from  family  trouble,  business  worry,  or  weighty 
responsibilities.  As  an  instance  of  the  potent  influence  of  anxiety  I 
may  mention  the  case  of  a  clerk  in  a  Government  office  who  had  done 
only  a  moderate  amount  of  writing,  but  became  affected  with  writers' 
cramp  during  an  anxious  lawsuit  about  his  wife's  property.  He  took 
six  months'  rest,  and  at  the  end  of  two  months  his  handwriting  was 
as  good  and  free  as  ever.  Towards  the  close  of  his  holiday  his  Avife 
became  seriously  ill ;  while  nursing  her,  and  before  resuming  his  work, 
the  writing  cramp  returned. 

An  example  of  the  influence  of  local  disease  or  injury  was  a  naval 
officer  who  sprained  his  thumb,  and  before  it  had  recovered  had  to  do  a 
considerable  amount  of  writing  in  preparing  a  report  of  a  surveying 


ETIOLOGY.  713 

•exppflition  ;  characteristic  writing  spasm  came  on.  In  many  re- 
corded instances  some  painful  affection  of  a  finger  has  preceded  the 
onset,  and  in  one  case,  periostitis  of  the  external  condyle  of  the 
humerus  (from  which  some  of  the  forearm  muscles  arise),  distinctly 
co-operated  in  causing  the  cramp  ;  pressure  on  the  tender  part  excited 
reflex  spasm  (Eunge).  In  two  patients,  characteristic  writers'  cramp 
followed  recovery  from  a  slight  attack  of  right  hemiplegia  (Vance, 
Eunge).  Primary  neuralgia  and  neuritis  in  the  arm  may  also  aid  in 
the  causation  of  the  disease,  but  nerve-tenderness,  which  is  common, 
is  probably,  in  most  instances,  part  of  the  affection  and  not  its  cause, 
and  does  not  show  that  there  is  a  primary  disease  of  the  nerves. 

The  chief  agent  in  the  production  of  the  malady  is  the  act  of 
writing,  which  has  usually  been  excessive  in  degree.  Hence  the 
affection  occurs  chiefly  among  those  who  earn  their  living  by  writing, 
and  clerks  furnish  the  majority  of  the  cases.  But  it  now  and  then 
occurs  in  persons  who  have  not  done  an  excessive  amount  of  writing ; 
and  in  such  cases  a  powerful  predisposing  cause,  such  as  anxiety 
or  neuralgia,  may  commonly  be  traced.  The  occurrence  of  the 
disease  is  influenced  less  by  the  amount  than  by  the  manner  of 
"writing.  There  are,  in  writing,  two  chief  elements — the  way  in  which 
the  pen  is  held,  and  the  way  -in  which  the  movements  are  effected. 
The  mode  in  which  the  pen  is  held  is  comparatively  unimportant ;  it 
is  the  mode  in  which  the  pen  is  moved  that  chiefly  determines  the 
occurrence  of  the  disease.  The  movement  may  be  effected  either  by  the 
muscles  moving  the  fingers  and  hand,  or  by  the  muscles  of  the  upper 
arm,  and  according  to  the  mode  adopted  does  the  necessary  degree 
of  muscular  contraction  vary.  The  smaller  the  muscles  employed,  the 
greater  must  be  the  relative  degree  of  contraction  to  produce  a  given 
movement  of  the  pen,  the  greater  is  the  amount  of  fatigue  produced, 
and  the  more  readily  does  cramp  occur.  Writers'  cramp  is  almost 
entirely  confined  to  those  who  write  in  the  first  two  of  the  following 
four  modes  : — (1)  The  worst  mode  of  writing  is  with  the  little  finger 
as  a  fixed  point  of  support.  The  pen  is  then  moved  up  and  down  by 
the  muscles  of  the  thumb  and  first  two  fingers,  which  are  constantly 
contracted  almost  to  their  maximum  ;  the  lateral  movement  is  effected 
by  a  slight  supination  of  the  hand  ;  only  a  few  letters  can  be  written 
■without  the  movement  of  the  little  finger,  and  before  it  is  moved  a 
considerable  strain  is  necessary  to  prevent  the  pen  being  raised  from 
the  paper  by  the  process  of  supination.  Of  all  modes  of  writing, 
this  is  the  worst  and  most  common.  (2)  Another  mode  is  to 
write  from  the  wrist  as  a  fixed  point.  In  this  method,  the  up-  and 
down- strokes  are  made  chiefly  by  the  flexion  and  extension  of  the 
fingers  and  thumb  in  the  manner  above  described,  but  the  lateral 
movement  of  the  hand  is  effected  chiefly  by  the  ulnar  abductors  of 
the  wrist ;  as  these  are  also  flexors  and  extensors,  considerable  effort  is 
necessary  to  keep  the  pen  on  the  paper  during  the  left-to-right 
movement.     (3)  A  far  better  way  is  to  write  from  the  middle  of  the 


714  (     WRITERS'   CRAMP. 

forearm,  the  wrist  moving  with  the  hand,  and  the  lateral  movement 
being  effected  by  adduction  of  the  humerus,  the  forearm  rotating  on 
its  point  of  support  as  on  a  pivot.  Even  in  this  method,  however, 
since  the  tendency  of  the  hand  is  to  move  in  a  curve,  effort  is 
necessary  to  keep  the  writing  in  a  straight  line,  and  this  has  to  be 
effected  by  increasing  flexion  of  the  wrist,  which  interferes  with  the 
action  of  the  flexors  of  the  fingers  in  moving  the  phalanges.  (4)  The 
best  and  only  free  method  is  to  write  from  the  upper  arm  and  shoulder, 
with  no  fixation  of  the  arm  ;  the  forearm,  wrist,  and  little  finger  rest 
on  the  table  so  as  to  take  off  some  of  the  weight  of  the  limb  from  the 
shoulder-muscles,  but  both  wrist  and  forearm  move  along  the  table 
as  the  writing  progresses  from  left  to  right.*  In  this  way  the  pen  can 
be  held  Tery  lightly;  very  little  of  the  movement  is  effected  by  the 
small  muscles  of  the  hand  ;  the  fingers  scarcely  alter  their  position, 
except  when  a  stroke  is  carried  far  above  or  below  the  line ;  and  even 
for  this  a  movement  of  the  fingers  is  not  always  necessary.  No  style 
can  be  considered  free  unless  it  is  easy  to  write  a  whole  line  across  a 
page  of  foolscap  without  once  breaking  contact  between  the  pen  and 
the  paper. 

It  is  probable  that  the  practice  of  thickening  the  down-strokes 
conduces  to  the  occurrence  of  the  affection,  as  it  necessitates  frequent 
increased  pressure  on  the  pen.  Many  writers  have  suggested  that 
the  use  of  steel  pens  is  one  element  in  the  causation  of  the  disease, 
and  it  seems  probable  that  this  is  true,  since  steel  pens  have  to  be 
grasped  more  firmly,  and  adjusted  more  exactly,  than  a  quill,  and  also 
because  the  disease  seems  to  have  become  more  frequent  since  the  use 
of  steel  pens  has  become  almost  universal.  But  writers'  cramp 
occurred  when  quills  were  the  invariable  instruments  of  writing,  and 
is  still  seen  occasionally  in  those  who  never  use  a  steel  pen. 

Among  clerks  who  suffer,  lawyers'  clerks  constitute  an  undue 
proportion.  This  is  no  doubt  due  to  the  cramped  style  in  which  they 
commonly  write.  On  the  other  hand,  writers'  cramp  is  practically 
unknown  among  those  who  write  more,  and  under  higher  pressure, 
than  any  other  class, — shorthand  writers.  The  speed  required,  and  the 
style  needed,  for  forming  shorthand  characters,  compels  a  very  free 
style  of  writing,  generally  from  the  shoulder,  and  this  is  also  adopted 
by  them  in  longhand  writing,  and  the  result  is  that  they  have  an 
almost  complete  immunity  from  the  disease.f  I  have  it  is  true  known 
the  cramp  to  occur  when  the  patient  was  writing  longhand,  and  not 
when  he  was  writing  shorthand.     It  ultimately  involved  the  latter, 

*  To  some  who  are  accustomed  to  write  with  the  fingers  chiefly,  the  statement  in 
the  text  may  seem  incredible,  but  I  have  verified  it  by  a  pencil  fixed  to  the  forearm, 
which  produced  the  same  characters  as  were  traced  by  the  pen  held  in  the  hand. 

f  I  have  indeed  seen  one  case  in  a  shorthand  writer,  but  it  was  not  quite  a  pure 
case,  and  at  the  meeting  of  the  Shorthand  Congress  I  could  not  hear  of  any 
stenographer  who  had  known  of  a  case  of  writers'  cramp  in  a  member  of  his  pro« 
fession. 


SYMPTOMS.  715 

but  he  was  not  a  professional  shorthand  writer,  and  his  longhand 
method  of  writing  was  bad. 

Symptoms.— The  precise  mode  in  which  the  act  of  writing  is 
deranged  varies  much  in  different  cases.  The  chief  disturbance  is 
usually  from  spasm,  but  sometimes  it  is  from  pain.  Occasionally  there 
is  tremor  without  other  spasm,  ceasing  when  the  attempt  to  write  is 
relinquished.  More  rarely  still  there  is  simple  inability  to  write, 
apparently  from  weakness,  without  spasm,  although  there  is  no  loss  of 
power  for  other  movements.  Four  forms  may  thus  be  distin- 
guished, the  spastic,  tremulous,  neuralgic,  and  paralytic  forms,  but 
the  last  is  extremely  rare,  and  I  have  never  met  with  a  distinct 
example  of  it. 

Motor  symptoms. — The  spasmodic  form  is  the  most  frequent  and 
the  most  characteristic,  but  it  presents  considerable  variety  in  its 
features,  dependent  partly  on  the  mode  in  which  the  patient  is  accus- 
tomed to  write,  and  the  muscles  which  he  accordingly  calls  into  chief 
action.  The  commencement  is  almost  always  gradual  (some  instances 
of  sudden  onset  will  be  mentioned  presently).  After  writing  for  some 
time  the  patient  finds  something  unusual  about  his  writing ;  the  pen 
does  not  move  quite  as  he  intended  it  to  do  ;  a  stroke  now  and  again 
is  irregular,  extends  too  high  or  too  low  ;  a  slight  involuntary  move- 
ment causes  an  unintended  mark.  He  finds  that  he  is  grasping  the 
pen  too  tightly,  and  cannot  help  doing  so ;  that  the  fingers  do  not 
keep  in  their  accustomed  place  ;  and  the  first  finger  has  a  tendency  to 
slip  off  the  pen,  so  that  this  gets  between  the  first  and  second  finger. 
He  endeavours  to  mend  matters  by  taking  a  firmer  hold,  but  this 
seems  to  increase  the  difficulty,  and  he  finds  that  he  writes  slowly,  as 
if  a  weight  were  attached  to  the  hand.  The  hand  feels  strangely 
tired,  and  an  aching  pain  in  the  finger  or  thumb  or  first  metacarpal 
bone,  or  in  the  wrist  or  forearm,  makes  it  still  more  difficult  for  him 
to  go  on  writing.  These  symptoms  may  continue,  with  only  slight 
impairment  of  the  power  of  writing,  for  weeks  or  months,  but  they 
occur  after  writing  for  a  shorter  time ;  they  increase  in  degree,  and 
now  and  then  there  is  distinct  spasm,  which  cannot  be  controlled. 
The  first  finger  or  the  thumb  tends  to  become  flexed  at  the  middle 
joint,  so  that  its  tip  moves  up  the  pen,  or,  less  commonly,  the  fingers 
become  extended,  so  that  the  pen  is  not  pressed  against  the  paper 
with  sufficient  force,  and  may  even  drop  from  the  hand,  or  the  thumb 
may  become  extended  across  the  pen.  The  characters  of  the  writing 
become  still  more  irregular,  the  down-strokes  are  too  thick,  the  point 
of  the  pen  may  be  driven  through  the  paper,  and  in  its  irregularity  of 
form  and  force  the  writing  "  resembles  that  done  in  a  jolting  carriage.'' 
Rarely  the  chief  spasm  is  in  the  fourth  finger,  or  in  the  third  and 
fourth  fingers,  and  pain  may  be  felt  in  the  long  flexor  of  these  fingers, 
and  the  ulnar  flexor  of  the  wrist.  Sometimes  the  whole  hand 
seems  to   get   stiff,  and  its  movements  slow ;    in    such   cases   there 


716 


WRITERS     CRAMP. 


is  a  tendency  for  the  letters 
and  smaller  as  the  writing 
As    the    spasm    increases    in 

Fig.  155. 


that  are  formed  to  become  smaller 
proceeds,  until  they  are  illegible, 
degree,  it  extends  in  range,  and 
involves  more  of  the  muscles  of 
the  forearm.  There  is  a  ten- 
dency for  the  wrist  to  become 
flexed,  or  extended,  or  supinated, 
and  in  the  effort  to  prevent  the 
disturbing  movement,  the  oppo- 
nents contract  strongly,  until  at 
last  all  the  muscles  of  the  fore- 
arm may  be  in  such  enei'getic 
spasm  as  to  render  movement  of 
the  pen  impossible.  Various 
devices  are  at  first  employed  to 
counteract  the  spasm.  The 
mode  of  holding  the  pen  is 
changed  ;  it  is  held  between  the 
first  two  fingers,  or  fixed  in  a 
piece  of  cork,  which  is  grasped 
by  the  hand,  and  the  move- 
ments  in   writing   are   effected 

Fig.  155.-Cramped  method  of  holding  by  the  upper  arm  ;  or  the  pa- 
pen,  habitual  to  a  patient  who  suffered  tient  fixes  the  right  hand  by 
from  writers'  cramp.  the  h  j       f   th        ^  placicg 

Fig.  156. — Pen  held  between  first  and  .     r  '  r  =>' 

second  fingers,  by  a  patient  suffering  from   for    instance,    some    fingers    of 
difficulty  in  writing.  the  left  hand  between  the  two 

last  fingers  of  the  right.  Tor  a  time  these  devices  give  a  little  help, 
but  the  spasm  gradually  increases  in  degree,  and  overcomes  the  fixing 
help,  or  it  spreads  to  the  muscles  of  the  upper  arm. 


<&&- 


Fig.  156. 


Fis.  157. — Handwriting  of  n  ]>atient  suffering  from  writers'  cramp, 
and  alter  recovery. 


SYMPTOMS.  717 

Although  the  onset  is  gradual  in  almost  all  cases,  in  very  rare 
instances  the  affection  comes  on  in  an  acute  manner.  In  the  cases  of 
this  character,  pain  has  generally  been  a  permanent  symptom,  and 
some  slight  symptoms  have  usually  preceded  the  acute  onset.  One 
patient,  who  had  noticed  a  slight  "  crampy  "  feeling  in  his  fingers  after 
writing  for  a  long  time,  one  day  wrote  rapidly  for  several  hours,  arid 
then  the  hand  suddenly  became  so  stiff  that  be  could  scarcely  move 
it.  He  gave  up,  but  next  day  was  no  better,  and  when  I  saw  him,  ten 
days  later,  he  could  only  write  two  words,  and  that  with  extreme  slow- 
ness and  effort,  and  the  attempt  caused  much  pain.  Another  patient,, 
who  had  been  conscious  for  some  time  of  a  little  more  fatigue  in 
writing  than  was  usual,  sat  down  one  clay  to  write  a  number  of  letters 
on  a  subject  that  vexed  her  much.  After  writing  for  about  two  hours 
she  felt  a  sudden  pain  around  the  wrist,  passing  down  to  the  knuckles, 
and  up  the  forearm  to  the  elbow.  The  hand  then  slowly  closed  in 
spasm.  She  forced  the  fingers  back,  and  went  on  writing  for  a  short 
time  with  much  pain  and  difficulty.  Subsequently  for  some  years,  as 
soon  as  she  attempted  to  write,  the  same  pain  came  on,  followed  by 
spasm.  Other  acts,  after  a  time,  also  excited  the  pain,  although  much 
less  readily  than  writing. 

The  spasm  is  almost  always  tonic  in  character ;  and  although  it  may 
now  and  then  be  varied  by  a  slight  start  or  jerk,  there  is  very  seldom 
actual  clonic  spasm.  Clonic  spasm  is,  however,  sometimes  met  with ;  in 
one  instance,  as  soon  as  the  patient  attempted  to  write,  the  first  finger 
and  thumb  became  flexed  at  all  joints  by  clonic  spasm,  and  slipped  off 
the  pen;  in  another,  as  soon  as  the  pen  was  adjusted  inits  proper  position 
by  the  help  of  the  left  hand,  the  fingers  and  thumb  began  to  jerk,  and 
when  the  pen  was  put  against  the  paper,  the  thumb  displaced  the  pen 
over  or  under  the  forefinger.  A  sudden  jerk  in  one  of  the  fingers,  ex- 
tending for  instance  the  first,  second,  or  little  finger,  is  not  uncommon, 
nor  is  a  sudden  jerk  of  the  whole  hand,  causing  an  unintended  stroke 
on  the  paper.  Tonic  spasm  is  often  accompanied  by  some  tremor,  and 
occasionally  the  tremor  is  a  conspicuous  symptom.  The  letters  are 
"  shaky,' '  and  the  lines  are  varied  here  and  there  by  angular  zigzags.  As 
soon  as  the  attempt  to  write  is  relinquished,  the  tremor  usually  ceases. 
When  confined  to  the  act  of  writing  it  is  sometimes  limited,  as  to  the 
thumb.  It  is  rare  to  meet  with  tremor  only ;  in  most  cases  spasm  is  asso- 
ciated with  it;  there  may  be  at  first  simple  spasm  and  afterwards  some 
tremor  in  addition,  or  tremor  may  at  first  occur  alone  and  afterwards 
tonic  spasm  as  well  as  tremor.  Occasionally,  in  old-standing  cases, 
there  is  slight  tremor  in  the  hand  when  the  patient  is  not  writing,  and 
when  this  is  the  case  there  is  often  some  tremor  in  the  left  hand  as  well 
as  in  the  right. 

The  spasm  may  be  limited  to  the  act  of  writing,  and  other  actions, 
even  such  as  involve  delicate  muscular  co-ordination,  may  be  performed 
without  the  slightest  difficulty.  It  is  not  uncommon,  for  instance,  for 
the  patient  to  be  able  to  shave  himself,  or  to  play  the  piano,  with  perfect 


718  writers'  cramp. 

facility.  In  slight  cases  the  spasm  may  be  limited  even  to  the  act  of 
■writing  with  a  pen,  and  the  patient  can  write  with  a  pencil  without 
difficulty.*  I  have  known  a  patient  to  be  able  to  paint  without  diffi- 
culty, although  he  could  scarcely  write.  A  still  more  curious  limita- 
tion has  been  observed ;  printed  characters  could  be  traced  with  a 
pen,  although  an  attempt  to  write  in  the  ordinary  manner  at  once 
brought  on  spasm. 

But  absolute  limitation  to  the  act  of  writing  is  seldom  met  with  in 
severe  cases  of  long  duration;  there  is  generally  some  difficulty  in  actions 
requiring  delicate  co-ordination  of  the  same  muscles.  One  patient  had 
no  difficulty  in  any  other  action  except  in  shaving  himself.  Another, 
at  the  end  of  twelve  years,  could  do  everything  except  draw  and  scratch 
out  with  a  penknife.  The  extent  to  which  the  spasm  spreads  to  other 
actions  varies  very  much  in  different  cases.  It  is  greatest  in  cases  in 
which  flexor  spasm  predominates.  Occasionally,  in  such  cases,  the 
spasm  comes  on  when  any  action  is  attempted,  and  I  have  known 
one  case  in  which  spasm,  at  first  confined  to  the  act  of  writing,  ulti- 
mately not  only  extended  to  all  other  actions,  but  became  spontaneous, 
so  that  when  the  hand  was  at  rest  the  fingers  and  wrist  gradually 
became  flexed. 

Power  in  the  hand  may  be  quite  unimpaired.  Sometimes  the  grasp 
is  a  little  weaker  than  it  should  be,  and  it  is  not  uncommon,  as  Poore 
has  pointed  out,  to  find  definite  slight  weakness  of  certain  muscles  of 
the  hand.  Occasionally  there  is  considerable  loss  of  power,  and  in- 
ability to  sustain  effort.  There  may,  in  rare  cases,  be  slight  wasting  of 
certain  muscles,  but  this  is  altogether  exceptional  in  cases  of  true 
writers'  cramp. 

The  electric  irritability  of  the  nerves  and  muscles  may  be  perfectly 
normal,  or  may  present  a  slight  change,  increase  or  diminution,  chiefly 
in  cases  that  have  lasted  for  some  time.  The  change  is  usually  the 
same  to  faradism  and  voltaism,  and  the  degree  of  irritability  is  similar 
in  both  muscles  and  nerves.  It  is  often  found  in  all  the  nerves  which 
are  accessible  to  examination.  It  is  thus  to  be  regarded  as  primarily 
a  change  in  nerve  irritability,  not  of  muscle  irritability ;  the  change  in 
the  irritability  of  the  muscles  depends  on  the  motor  nerve-endings 
they  contain. f  It  may  be  remembered  that  all  three  nerves  of  the  arm, 
radial  (musculo-spiral),  ulnar,  and  median,  supply  muscles  employed  in 
writing.  Several  cases  that  I  have  seen,  show  that  increased  irritability 
is  the  earlier  change  of  the  two,  and  that  diminution  of  irritability 
succeeds  it. 

*  Partly  because  he  can  press  more  firmly  on  the  pencil,  and  thus  steady  the 
hand  (see  Poore,  'Med.-Chir.  Trans.,'  vol.  lxi,  p.  127). 

f  At  the  same  time  it  would  be  wrong  to  lay  much  weight  on  this  consideration, 
because  it  is  possible  that  an  abnormal  irritability  of  the  muscular  fibres  may  cause 
them  to  respond  more  readily  to  a  given  stimulation  of  the  nerve-fibres.  We  can 
only  judge  of  the  stimulation  of  the  motor  nerves  by  the  effect  on  the  muscular 
fibres.  It  is,  however,  customary  to  regard  a  change  in  the  muscular  effect  of  stimu- 
lation of  the  nerves,  as  evidence  of  a  change  in  the  nerve-fibres  themselves. 


SYMPTOMS.  719 

Sensory  symptoms  are  seldom,  entirely  absent,  and  are  often  very 
prominent.  They  may  exist  alone  ("sensory  form"),  or  may  be 
combined  with,  motor  symptoms.  Often,  at  first,  there  is  only  a 
general  sense  of  distressing  fatigue  in  the  hand,  to  which  spasm  may 
be  afterwards  added.  Definite  dull  pain  is  often  referred  to  the 
bones  or  joints,  very  often  to  the  metacarpal  bones  or  to  the  wrist, 
soon  ceasing  when  the  effort  to  write  is  relinquished.  In  one  case  it 
was  felt  on]y  in  the  middle  and  fourth  finger,  passing  from  the  latter 
up  the  outer  edge  of  the  hand  which  rested  on  the  paper.  Sometimes 
it  is  accompanied  by  local  tenderness.  Occasionally,  though  not 
often,  a  tingling  sensation,  "pins  and  needles,"  is  felt  in  certain 
fingers  during  the  attempt  to  write.  Now  and  then  the  pain  is 
more  severe,  and  may  be  referred  to  the  course  of  the  nerves,  so 
as  to  be  distinctly  neuralgic  in  character.  At  first  it  occurs  only 
during  the  act  of  writing,  but  after  a  time  it  may  be  produced  by  any 
muscular  effort  in  the  part.  It  may  be  chiefly  localised  in  certain  foci 
along  the  course  of  tbe  nerve,  and  after  a  time  the  nerves  are  found 
to  be  tender,  and  the  tenderness  is  greatest  at  the  foci  of  pain,  these 
tender  points  thus  completing  the  resemblance  to  ordinary  neuralgia. 
In  many  cases  some  muscular  spasm  accompanies  the  pain  during  the 
act  of  writing,  and  often  has  preceded  the  pain  in  time.  I  may  briefly 
relate  a  most  instructive  case  of  this  character.  The  patient  was  a  young 
woman,  a  lithographic  writer,  producing  exquisite  copper-plate  writing, 
which  could  only  be  executed  in  a  cramped  manner,  with  fixation  by 
the  little  finger.  She  found  that  her  hand  grasped  the  pen  with  undue 
force,  and  now  and  then  a  stroke  did  not  go  quite  in  the  intended  direc- 
tion. The  spasmodic  symptoms  slowly  increased,  without  the  slightest 
pain,  for  three  months,  the  pen  tending  to  slip  between  the  first  and 
second  finger  until  she  was  obliged  to  hold  it  thus.  Then  slight  pain 
was  felt  in  the  thumb  and  fingers,  at  the  places  where  they  were  in 
contact  with  the  pen.  This  pain  gradually  extended  to  the  wrist,  and 
then  up  the  arm  to  the  axilla,  and  continued  until  she  came  under 
my  care  two  years  after  the  onset.  The  spasm  remained  about 
the  same,  but  the  pain  was  so  great  as  alone  to  prevent  her  from 
writing.  It  still  commenced  where  the  pen  was  in  contact  with  the 
thumb  and  with  the  contiguous  sides  of  the  first  two  fingers,  being 
felt  in  all  three,  and  darting  up  the  arm.  A  focus  of  greater  pain  was 
situated  in  front  of  the  wrist  over  the  median  nerve,  and  another  a  little 
below  the  elbow  ;  these  points  were  very  tender  to  pressure.  There 
was  also  some  general  tenderness  of  the  median  and  ulnar  nerves,  and 
another  tender  point  on  the  musculo-spiral.  The  pain  never  occurred 
spontaneously,  but  was  now  excited  by  any  muscular  effort.  The 
nerves  presented  a  distinct  increase  of  electrical  excitability.  Thus  the 
prominent  trouble  at  the  time  the  patient  came  under  observation  was 
neuralgic  pain,  but  both  the  history  and  the  character  of  the  pain 
showed  that  it  was  secondary  to  writing  and  a  true  "  occupation 
neuralgia."  In  some  cases  the  pain  may  become  altogether  independent 


720  writers'  cramp. 

of  the  act  of  writing.  In  one  patient  it  was  associated  at  the  ons'.'t 
with  well-marked  spasm  ;  writing  was  entirely  given  up,  and  the 
spasm  ceased,  but  the  pain  continued  and  was  produced  by  any 
movement,  and  ultimately  it  was  felt  chiefly  in  the  upper  part  of  the 
arm  and  then  in  both  shoulders,  and  was  brought  on  by  emotion 
at  well  as  by  movement.  The  sensory  symptoms,  when  they  once 
become  pixnninent,  often  exhibit  a  strong  tendency  to  spread,  and 
sometimes  acquire  a  relative  independence,  as  in  the  case  just  men- 
tioned. The  feeling  -of  "tingling"  or  "  pins  and  needles"  already 
mentioned  as  an  occasional  symptom,  may  also  spread,  like  the  treinor, 
to  the  other  arm. 

Course. — The  symptoms  continue,  and  usually  increase  as  long  as 
the  patient  perseveres  in  the  attempt  to  write,  and  only  become 
stationary  when  prudence  or  sheer  inability  prevents  the  effort.  The 
rate  of  increase  varies  much  in  different  cases,  and  is  generally  rapid 
in  proportion  to  the  badness  of  the  original  method  of  writing.  The 
tendency  for  the  affection  to  spread  to  other  actions  also  varies  much, 
and  is  generally  proportioned  to  the  general  weakness  of  the  nervous 
system.  As  we  have  seen,  the  sensory  symptoms  of  neuralgic  type 
exhibit  a  greater  tendency  to  extension  than  do  the  motor  symptoms. 
The  anxiety  caused  by  the  affection,  in  those  who  depend  for  their 
living  on  the  action  deranged,  often  causes  general  nervous  weakness, 
which,  in  its  turn,  tends  to  increase  the  malady.  It  is  not  common 
to  have  actual  recovery  and  later  recurrence ;  one  patient  had  typical 
cramp  for  eighteen  months  at  thirty-three,  which  passed  away  with 
rest,  to  return  at  forty-one. 

The  sufferer  who  finds  himself  unable  to  write  with  one  hand  often 
learns  to  write  with  the  other.  After  he  has  acquired  the  needful 
facility,  and  has  written  with  the  left  hand  for  a  time,  similar  sym- 
ptoms may  develop  in  this  hand,  and  they  then  usually  progress  more 
quickly  than  in  the  arm  first  affected.  Sometimes,  even  when  the 
left  hand  does  not  suffer,  the  action  of  writing  with  it  causes  synergic 
movements  of  the  right  hand.  When  sensory  symptoms  are  prominent, 
the  left  hand  is  especially  apt  to  suffer  early.  Fortunately  the  inva- 
sion of  the  left  hand  is  not  invariable ;  I  have  known  it  to  do  good 
work  for  twelve  years,  although  the  affection  continued  unchanged 
in  the  right  hand.  Indeed,  if  we  exclude  the  cases  of  neuralgic  type, 
I  think  that  the  chances  are  nearly  equal  whether  the  left  hand  will 
suffer  or  not.  If  perfect  rest  is  given  to  the  right  hand,  either  by 
abstinence  from  writing  or  by  the  exclusive  use  of  the  left  hand,  the 
symptoms  may  slowly  lessen,  and  ultimately  pass  away,  so  that 
writing  may  be  resumed,  without  any  return  of  the  affection.  This 
was  the  case  with  the  patient  whose  handwriting  is  shown  in  Fig.  157. 
A  more  typical  case  of  writers'  cramp  could  not  be,  and  yet  the 
recovery,  during  two  years'  use  of  the  left  hand,  was  so  complete  that 
he  has  now  written,  and  written  much,  with  the  right  hand  for 
thirteen  years,  without  any  recurrence  of  the  disease.     In  some  cases, 


PATHOLOGY.  721 

however,  tbe  symptoms  that  have  been  removed  by  rest  return  soon 
after  the  attempt  to  write  is  made,  especially  if  the  period  of  rest 
then  given  to  the  right  hand  is  too  short ;  in  others,  even  rest  fails  to 
effect  much  improvement,  and  the  symptoms  may  continue  to  the  end 
of  life.  The  tendency  of  neuralgic  pain  to  spread  widely  has  been 
already  mentioned.  When  tingling  is  felt  in  the  fingers,  it  is  occa- 
sionally also  felt  in  the  foot  of  the  same  side,  and  I  have  once  known 
slight  cramp  in  tbe  leg  to  accompany  such  tingling  and  severe  spasm 
in  the.  hand. 

Pathology. — No  anatomical  changes  are  known  in  winters'  cramp, 
and  none  could  be  found  in  one  case  which  I  had  an  opportunity  of 
examining.  The  pathology  of  the  disease  has  therefore  to  be  inferred 
from  its  symptoms  and  causation.  Three  chief  theories  have  been 
held  regarding  its  nature.  According  to  one,  it  is  essentially  a  local 
disease;  a  weakness  in  some  muscles  permits  the  over-action  of  their 
antagonists,  which  increases  to  spasm.*  A  second  theory  ascribes 
the  spasm  to  reflex  action,  the  result  of  the  stimulation  of  the  sensory 
nerves  in  the  act  of  writing. f  A  third  (held  by  most  writers  on  the 
subject)  regards  the  affection  as  primarily  and  essentially  central, 
the  result  of  a  deranged  action  in  the  centres  concerned  in  the  act  of 
writing.  The  first  two  theories  seem  inadequate,  by  themselves,  to 
explain  the  symptoms.  Most  observers  have  failed  to  find,  in  the  early 
stage  of  true  writers'  cramp,  any  evidence  of  primary  weakness.  The 
initial  disturbance  is  spasm  ;  the  slight  loss  of  power  which  may  be 
found  in  certain  muscles  after  the  disease  has  existed  for  some  time 
does  not  explain  the  spasm,  first  because  this  is  far  wider  in  range 
than  the  antagonists  of  the  feeble  muscle  ;  secondly,  because  the  very 
muscles  that  are  weak  are  often  involved  in  the  spasm ;  thirdly,  because 
local  muscular  weakness  does  not  excite  spasm  of  the  character  pre- 
sented by  a  well-marked  case  of  writers'  cramp.  The  reflex  theory  is 
inadmissible  because,  in  the  majority  of  eases,  there  is  no  evidence 
that  abnormal  sensory  impressions  precede  the  spasm.  Even  in  the 
case  related  on  p.  719,  in  which  pain  was  so  prominent,  it  was  distinctly 
secondary  in  time.  Both  weakness  and  pain  in  the  hand  are  very 
common  without  the  manifestation  of  the  slightest  tendency  to  the 
occurrence  of  writers'  cramp.  Although  neither  the  theory  of  local 
weakness,  nor  that  of  reflex  spasm,  can  be  regarded  as  explaining  the 
phenomena  of  ordinary  cases,  it  is  very  probable  that  each  influence 
may  take  a  share,  in  some  instances,  in  increasing  the  disease,  and 
occasionally  may  help  to  excite  it.  But  the  morbid  state  of  the  centre 
maybe  developed  without  such  aid,  and  must  be  regarded  as  the  chief 
element  in  the  disease. 

All  forms  of  occupation-spasm  affect  movements  that  are  purelv 
acquired,  and  of  all  these  movements  that  of  writing  is  the  most 

*  Dzondi,  Meyer,  Haupt,  Zaradelii.     This  theory  has  been  ably  advocated  by  Poore. 
t  Fritz,  Romberg:. 

VOL.   II.  46 


722  WRITERS     CRAMP. 

complex  and  most  delicate.  The  acquisition  of  the  power  of  performing 
any  action  with  ease,  means  the  "  education"  of  the  nervous  centres 
concerned  in  it,  the  establishment  of  a  tendency  to  the  associated 
action  of  nerve-cells,  in  perfect  adjustment  of  varied  order  and 
degree,  with  the  least  possible  voluntary  effort  of  excitation  and 
control.  This,  in  the  language  of  modern  physiology,  means  the 
establishment  of  lines  of  lessened  resistance  in  centres,  i.  e.  between  con- 
nected cells,  and  doubtless  also  modifications  in  the  force  and  readiness 
with  which  nerve-energy  is  liberated  in  them.  This  education  is  effected 
by  the  repeated  functional  action  of  the  centres  under  the  stimulus  of 
the  will,  at  first  sfrong,  afterwai'ds  gradually  lessening,  as  the  desired 
functional  mechanism  is  developed  by  exercise,  and  established  by  the 
resulting  modifications  of  nutrition.  There, in  health,  the  process  stops. 
"Readily  as  nerve-energy  is  evolved,  it  is  always  under  a  voluntary 
stimulus,  and  exactly  in  the  degree  required.  The  clearest  conception 
we  can  form  of  the  pathology  of  writers'  cramp  is  that  this  process  of 
lowering  of  resistance  between  nerve-cells  has  gone  too  far,  so  that  the 
energy  evolved  is  excessive  and  irregular,  although,  when  the  same 
cells  are  excited  in  a  different  order,  the  resistance  is  noi-mal  in  propor- 
tion as  the  order  differs  from  that  involved  in  the  act  of  writing,  and 
hence,  in  that  degree,  other  movements  escape.  No  doubt  the  impair- 
ment of  function  is  attended  by  impairment  of  nutrition.  In  some 
cases  the  changes  go  so  far  that  all  attempts  at  movement  give  rise  to 
cramp,  and,  at  the  same  time,  the  total  power  that  can  be  exerted  is 
considerably  below  the  normal. 

The  mechanism  of  the  morbid  lowering  of  resistance  may  be  the 
same  as  that  by  which  the  resistance  was  lowered  in  the  education  of 
the  centre,  carried  in  this  case  to  excess.  The  degree  of  exertion 
necessary  to  produce  the  effect  varies  inversely  as  other  influences  co- 
operate, and  tend  to  degrade  nutrition  or  to  disturb  the  centre.  Some 
causes,  such  as  anxiety,  aid  in  the  former  way,  by  impairing  nutrition  ; 
others,  such  as  local  disease  of  the  limb,  in  the  latter,  by  deranging  the 
centre.  The  influence  of  local  pain  and  local  weakness  in  deranging 
movement  is  too  familiar  to  need  illustration,  but  this  effect  is 
probably  produced  through  the  centre,  and  can  only  aid  in  the  pro- 
duction of  writers'  cramp  by  disturbing  the  normal  relation  of  the 
force  evolved,  and  so  aiding  in  the  establishment  of  the  morbid  state 
just  described. 

The  condition  assumed  is  that  which  used  to  be  described  as 
"  irritable  weakness."  In  all  parts  of  the  nervous  system,  when  force 
is  too  readily  evolved,  the  total  amount  of  nerve-force  which  can  be 
liberated  is  usually  below  the  normal.  Thus  there  may  be  weakness 
as  well  as  spasm,  and  as  the  morbid  condition  may  progress  in  one 
part  of  the  centre  more  than  another,  the  weakness  may  be  distinct 
only  in  certain  muscles.  The  fact  that  the  affection  occurs  chiefly  in 
those  who  write  by  means  of  small  muscles,  is  quite  compatible  with 
the  theory  that  the  disease  is  essentially  central.     The   difference 


PATHOLOGY.  723 

between  the  method  of  writing  by  small  or  by  large  muscles  is  that  in 
the  one  case  there  is  extreme  activity  of  comparatively  few  cells  of  the 
cerebral  cortex,  in  the  other  case  there  is  slight  activity  of  many  cells. 
The  morbid  state  of  nutrition  which  accompanies  disturbed  function 
in  a  motor  centre  tends  to  descend  the  motor  fibres,  and  hence  we 
can  understand  that  a  slight  change  in  the  electric  irritability  of  the 
nerves  should  sometimes  be  found,  just  as  in  chorea. 

It  has  been  objected  to  the  central  theory  that  it  assumes  the  exist- 
ence of  a  centre  for  the  co-ordination  of  writing,  and  therefore  of  every 
separate  action  which  any  one  part  of  the  body  can  perform,  and  that 
we  know  nothing  of  the  existence  of  such  centres.  The  objection  is 
invalid  because  no  such  assumption  is  made.  The  theory  does  not 
assume  that  there  is  a  separate  centre  for  writing  or  other  movement, 
but  only  that  there  are  varying  lines  of  resistance  in  the  innumerable 
connections  of  the  motor  nerve-cells,  and  that,  as  each  movement  is 
the  result  of  the  action  of  nerve-cells  in  different  order  and  degree, 
permanent  functional  relations  are  developed  and  may  be  separately 
deranged.  No  separate  co-ordinating  centre  is  assumed,  any  more  than 
in  a  complex  piece  of  machinery,  in  which  the  bars  and  bands  and 
wheels  that  convey  the  force  co-ordinate  it  by  their  arrangement.  It 
must  also  be  remembered  that  the  conception  of  a  physiological  centre 
does  not  necessarily  involve  that  of  a  local  limitation.  Nerve-cells 
act  together  that  are  far  apart,  and  those  that  are  adjacent  are  often 
independent.  Diffused  through  a  mass  of  grey  matter  may  be  many 
separate  mechanisms,  not  necessarily  more  in  one  part  than  inanothei% 
and  if  we  call  them  "  centres  "  we  must  not  allow  mathematical  con- 
ceptions to  govern  our  physiological  ideas. 

The  tendency,  often  seen,  for  the  other  hand  to  be  affected,  affords 
additional  evidence  that  the  disease  is  essentially  central.  Many  facts 
show  that  there  is  a  close  functional  connection  between  the  similar 
mechanisms  on  the  two  sides.  Thus,  as  already  mentioned,  a  patient, 
when  he  tried  to  write  with  his  left  hand,  found  his  right  fingers  per- 
forming slow  movements  of  flexion  and  extension.  On  any  theory,  it 
is  difficult  to  say  why  the  second  side  should  suffer  in  some  cases  and 
not  in  others. 

One  other  symptom  remains  to  be  discussed— the  neuralgic  pain, 
which  gives  to  some  cases  a  special  character.  The  act  of  writing 
involves  afferent  impulses  and  sensory  impressions,  unnoticed  till  they 
become  increased  by  fatigue.  When  cramp  occurs,  these  become 
excessive.  All  increased  sensation  means  increased  action  of  the 
sensory  centres,  and  this,  once  established,  may  assume  a  morbid 
independence,  as  in  many  eases  of  ordinary  neuralgia  (q.  v.),  and,  as 
also  in  neuralgia,  nerve-tenderness  may  be  secondarily  developed. 
There  is  no  justification  for  regarding  these  tender  points  as  evidence 
of  neuritis,  for  even  in  such  a  case  as  that  recorded  on  p.  719  the 
symptoms  are  merely  such  as  are  met  with  in  many  cases  of  neuralgia 
of  primarily  central  origin.      This  case  is  especially  instructive  as 


1-24  WEITEES'   CEAMP. 

showing  how  the  pain,  i.e.  the  morbid  action  of  the  sensory  centre, 
became  gradually  developed  from  the  increased  afferent  impressions 
caused  by  the  spasm.  The  pain  started  from  the  points  at  which  the 
nerves  of  the  skin  were  unduly  stimulated  by  too  firm  a  grasp  of  the 
pen.  It  is  scarcely  necessary  to  point  out  that  the  same  predisposing 
influences  which  facilitate  the  occurrence  of  that  state  of  motor  centres 
which  shows  itself  in  spasm,  may  also  conduce  to  the  development  of 
a  like  state  in  a  sensory  centre,  felt  as  pain.  But  structural  changes 
in  the  nerves  may  occur  as  a  result  of  pain  that  is  purely  central  in 
origin,  and  the  motor  nerves,  in  central  diseases,  as  chorea  and  para- 
lysis aajitans,  may  present  altei'ations  in  electrical  excitability,  which 
are  evidence  of  secondary  changes  in  their  nutrition.  It  is  not 
surprising  that  such  changes  should  be  found  in  "  occupation 
neuroses,"  even  assuming  their  central  origin.  Such  changes,  once 
set  up,  may  develop  in  relative  independence,  especially  under  the 
reflex  influence  of  pain,  and  may  even  induce  secondary  changes  in 
the  irritability  and  nutrition  of  the  muscles.  These  are  exceptional, 
but  they  are  open  to  the  misinterpretation  of  being  regarded  as  the 
primary  element  in  the  disorder. 

There  is,  at  present,  no  direct  evidence  as  to  the  part  of  the  nervous 
svstem  in  which  the  primary  derangement  occurs.  That  the  action  of 
the  motor  and  sensory  nerve-cells  of  the  spinal  cord  must  be  disordered 
is  certain,  since  it  is  through  them  that  spasm  is  produced  and  pain 
perceived.  But  we  do  not  know  whether  their  derangement  is 
primary,  or  whether  it  is  simply  the  effect  of  a  primary  disorder  in 
those  cerebral  centres  in  which  the  movements  are  arranged.  The 
latter  is  the  more  probable,  and  the  central  region  of  the  cortex 
is  that  to  which  we  should  naturally  turn  as  the  seat  of  the  primary 
derangement,  since  it  is  from  this  part  of  the  brain  that  the  spinal 
cells  are  directly  excited.  Analogy  suggests  that  the  sensory  dis- 
turbance is  spinal  in  a  larger  degree  than  are  the  motor  symptoms. 

Diagnosis. — A  well-marked  case  of  writers'  neurosis  is  rarely 
mistaken  for  any  other  affection.  The  initial  limitation  of  the 
symptoms,  whether  spasm  or  pain,  to  the  act  of  writing,  sufficiently 
indicates  the  nature  of  the  case.  But  the  converse  error  is  often 
made ;  cases  are  supposed  to  be  examples  of  writers'  cramp  which  are 
of  a  different  nature.  Many  paralytic  and  painful  affections  of  the 
hand  are  discovered  by  the  interference  they  cause  with  the  action  of 
writing,  because  it  is  the  most  delicate  action  that  the  hand  is  called  on 
to  perform,  and  they  are  supposed  to  be  specially  connected  with  the 
act.  when  this  merely  reveals  their  existence.  I  have  several  times 
known  the  mistake  to  be  made  in  hemiplegia  of  gradual  onset,  and  also 
in  a  case  of  commencing  insular  sclerosis,  and  in  another  of  early  tabes 
affecting  the  arms.  Even  pressui*e-palsy  of  the  musculo-spiral  nerve 
has  been  ascribed  to  writing.  Still  more  frequent  is  the  error  in  cases 
of  pain  in  the  arm  of  various  kinds.     In  acute  neuralgia  and  neuralgic- 


PKOGNOSIS.  '725 

rheumatism  of  the  forearm  muscles,  writing  increases  the  pain,  and  is 
interfered  with  by  it  in  a  way  that  renders  the  mistake  easy.  It  is 
needless  to  enumerate  the  various  other  affections  that  may  be  thus 
confused,  because  the  simple  rule  above  given  suffices  for  their 
distinction — from  the  first,  the  symptoms  are  not  limited  to  the  act 
of  writing.  The  tremulous  form  may  be  mistaken  for  commencing 
paralysis  agitans,  but,  at  the  onset,  the  tremor  is  confined  to  writing, 
and  is  always  conjoined  with  distinct  spasm  produced  by  the  act. 

Writers'  cramp  is  a  disease  that  is  readily  imagined.  Most  persons 
who  have  to  write  much,  experience  at  times  some  discomfort  in  the 
hand  after  writing,  and,  since  such  discomfort  is  one  of  the  early 
•symptoms  of  writers'  cramp,  they  are  apt  to  fancy  that  they  are  the 
subjects  of  the  disease,  and  a  slight  tendency  to  spasm  is  readily 
imagined  in  such  a  case.  The  most  important  diagnostic  indication 
is  the  occurrence  of  actual  visible  spasm,  since  this  is  seldom  absent, 
even  in  the  early  stage.  In  the  cases  in  which  sensory  symptoms  are 
xdtimately  most  prominent,  they  seldom  exist  alone.  If  they  are 
isolated,  the  diagnosis  rests  on  the  initial  relation  to  one  action  and  the 
-unusual  seat  of  the  pain.  In  most  cases  of  the  fancied  disease,  when 
the  patients  are  reassured,  the  discomfort  quickly  ceases  to  be  noticed. 

Peognosis. — The  disease,  when  well  developed,  is  one  in  which  the 
prognosis  is  always  uncertain,  and  often  unfavorable.  "When  the 
affection  occurs  in  a  person  whose  daily  bread  depends  on  the  act  of 
writing,  the  early  warnings  are  neglected,  either  through  ignorance 
or  the  stern  compulsion  of  necessity,  until  the  morbid  action  of  the 
centre  has  become  fixed  by  nutritional  alterations  almost  as  ineradi- 
cable as  those  that  render  permanent  the  results  of  its  early  education. 
The  prognosis  is  especially  unfavorable  if  the  disease  has  lasted  for 
some  time,  and  has  reached  a  considerable  degree  before  the  patient 
comes  under  treatment;  if  perfect  rest  from  writing  cannot  be 
secured;  and  also  if  no.  other  cause  than  the  act  of  writing  can  be 
traced.  It  is  better  if  any  extraneous  and  removable  cause  co- 
operates, such  as  defective  general  health,  anxiety,  and  especiallv  if 
local  causes,  such  as  injury,  have  distinctly  aided  in  the  development 
•of  the  morbid  state.  Even,  however,  under  the  most  unfavorable 
conditions,  recovery  sometimes  occurs.  The  writing  shown  in 
Fig.  157  was  that  of  a  clerk,  aged  thirty-four,  in  whom  no  cause 
•could  be  traced  but  excessive  writiug.  He  had  averaged  ten  hours  a 
day  for  twenty  years,  and  the  affection  had  lasted  for  twelve  months 
before  he  came  under  treatment,  and  yet,  as  already  mentioned  (p. 
720),  recovery  has  been  perfect.  The  prognosis  in  cases  in  which 
the  sensory  trouble  predominates  is  good,  if  the  patient  can  take  a 
long  and  perfect  rest,  but  unless  this  can  be  secured,  the  neuralgic 
pain,  at  first  produced  only  by  the  act  of  writing,  is  likely  to  extend 
and  become  spontaneous.  The  probability  that  the  other  hand  will  be 
affected  is  greater  in  these  cases  than  in  those  of  purely  motor  spasm. 


726  waiters'  cramp. 

Treatment. — Writers'  cramp  is  a  troublesome  arid  difficult  disease 
to  treat,  and  the  question  of  its  prevention  is  therefore  of  corresponding- 
importance.  The  disease  might  probably  be  prevented  to  a  very- 
large  extent,  if  not  entirely.  We  have  seen  that  it  occurs  almost 
exclusively  among  those  who  write  in  a  cramped  manner,  in  the 
first  or  second  of  the  styles  mentioned  on  p.  713,  scarcely  ever, 
and  only  in  slight  degree,  in  those  who  write  in  the  third,  and  never 
in  those  who  write  in  the  fourth.  If  all  persons  wrote  from  the 
shoulder,  writers'  cramp  would  practically  cease.  But  the  mode  of 
writing  is  a  matter  of  education,  and  prevention  of  the  disease  rests 
therefore  not  with  doctors  but  with  teachers.  It  is  probably  impossible 
to  teach  writing  in  the  first  instance  in  a  free  manner,  but  before  a 
boy  is  allowed  to  pass  from  school,  he  should  be  got  out  of  the 
cramped,  and  taught  the  free  method, — taught,  that  is,  to  write  from 
the  shoulder.  It  is  also  desirable  that  those  who  experience  any 
difficulty  or  discomfort  in  writing  should  at  once  change  their  style 
for  the  freer  mode.  To  make  a  person  realise  the  characteristics  of 
the  free  method,  I  have  found  the  following  expedient  useful.  Let 
him  first  draAv  a  line  across  a  sheet  of  paper ;  for  this,  the  arm  must 
be  moved  as  a  whole  from  the  shoulder.  Then  let  him  make  the  line 
wavy,   next  increase  the   wavy  character,   and   then    slightly  slope 

the  waves,  so  as  at  last  to  make  the  line  a  series  of  /a "  s — *?2*?2^*?2*?2. 

These  are  letters,  and  the  transition  to  other  letters  will  then  be  easy. 
As  I  have  already  said,  the  object  to  be  aimed  at  is  to  write  in  such  a 
manner  that  it  shall  be  easy  to  form  an  entire  line  of  words  without 
once  lifting  the  pen  from  the  paper.  The  hand  should  grasp  the  pen 
lightly,  and  move  as  a  whole.  The  comfort  and  ease  experienced 
when  this  method  is  acquired  are  very  remarkable. 

For  the  affection  itself,  treatment,  to  be  effective,  should  be  early. 
The  commencing  symptoms  often  pass  away  with  a  brief  rest ;  a, 
month's  abstinence  from  writing  at  the  onset  will  do  more  than  a 
year's  rest  if  the  disease  has  continued  for  six  months.  When  writing 
is  resumed  in  such  a  case,  it  is  essential  that  its  style  should  be 
changed  as  just  described.  The  amount  of  writing  should,  if  pos- 
sible, also  be  reduced.  It  is  desirable  that  a  soft  quill  should  be 
substituted  for  a  steel  pen,  and  that  a  holder  should  be  employed  that 
is  of  good  size  and  not  smooth  on  the  surface.*  Slight  symptoms  of 
cramp  often  pass  away  at  once  when  this  change  is  made. 

In  cases  in  which  the  disease  has  become  established,  rest  is  still 

*  Quills  are  too  small  and  too  smooth  to  be  held  with  facility  ;  a  quill  nib  should 
be  used  in  a  holder.  The  best  steel  pens  are  those  with  turned-up  points,  as  the 
Waverley.  Similar  gold  pens  are  made  by  Mabie,  Todd  &  Co.  A  good  holder  is 
one  that  is  larger  than  the  average  size,  and  is  covered  with  soft  india  rubber  for 
about  two  inches,  where  the  pen  is  held.  Large  cork  holders  are  also  good.  The 
best  small  holder  is  one  made  by  Brandauer,  of  Birmingham,  in  which  the  metal 
part  is  roughened. 


TBEATMENT.  727 

incomparably  the  most  important  element  in  treatment.  If  writing 
is  continued,  every  method  of  treatment  fails  even  to  check  the  pro- 
gress of  the  disease.  The  various  mechanical  devices  which,  for  a 
time,  aid  handwriting  are  not  to  be  recommended,  since  they  only 
stave  off  the  impending  disability,  while  the  malady  is  really  getting 
worse,  and  they  thus  increase  the  difficulty  of  treatment.  If,  how- 
ever, prolonged  and  complete  rest  from  writing  is  impossible,  the 
patient  should  learn  to  write  with  the  left  hand.  Facility  in  sinistral 
writing  is  acquired  with  a  little  perseverance,  more  readily  if  the  letters 
are  made  upright  or  if  the  customary  inclination  is  reversed.  In  this 
way  complete  rest  may  be  given  to  the  affected  hand.  It  is  true  the 
left  hand  may,  after  a  time,  suffer  in  the  same  way,  but  the  tendency 
to  this  has  been  exaggerated  by  some  writers.  If  it  does,  the  patient 
is  no  worse  off  than  if  he  has  not  learned  to  write  with  the  left  hand  ; 
while  if  it  does  not,  he  may  be  able  to  continue  to  earn  his  living,  and 
may  afford  his  right  hand  a  fair  chance  of  recovery.  The  Government 
clerk  mentioned  on  p.  720  fulfilled  the  duties  of  his  office  for  twelve 
years  with  his  left  hand,  and  although  the  cramp  continued  in  the  right, 
the  left  showed  no  indication  of  the  disease,  and  at  the  end  of  the  twelve 
years  he  was  able  to  retire  on  a  peusion.  Besides  the  case  illustrated 
in  Fig.  157,  I  have  met  with  several  others  in  which  practical  recovery 
occurred  during  the  use  of  the  left  hand. 

For  many  persons  the  use  of  a  type-writer  offers  the  means  of 
abstaining  from  all  the  use  of  the  hand  that  has  brought  on  the 
disease.  The  depression  of  the  keys  of  a  good  type-writer  resembles 
the  movement  of  the  fingers  in  playing  on  the  piano,  but  is  less 
fatiguing,  and  most  sufferers  from  writers'  cramp  are  able  to  use  such 
an  instrument,  even  with  the  affected  hand,  without  any  unpleasant 
symptoms,  while  the  facility  with  which  some  instruments  can  be 
worked  with  the  left  hand  enables  the  right  hand,  if  necessary,  to  have 
absolute  rest.  Unfortunately,  a  type-writer  cannot  often  be  available 
for  the  work  of  the  ordinary  clerk,  who  is  so  frequently  a  sufferer. 
For  most  others  it  offers  a  great  advantage;  the  depression  of  the 
keys,  if  not  continued  to  fatiguing  excess,  constitutes  a  most  useful 
form  of  gymnastic  exercise.  In  those  who  suffer  from  the  neuralgic 
form,  however,  the  pain  is  often  excited  by  any  movement  of  the  arm, 
and  they  may  then  be  unable  to  use  a  type-writer.* 

When  impaired  nutrition  of  the  nervous  system  co-operates  as  a 
cause  of  writers'  cramp,  nervine  tonics,  especially  small  doses  of 
strychnia,  increase  a  tendency  to  recovery,  and  in  all  cases  may  be 
given,  as  having  an  influence  in  the  right  direction,  Sedatives  inter- 
nally, as  a  rule,  effect  little  in  cases  of  pure  cramp,  although  hypo- 
dermic injections  of  atropine  (one  sixtieth  of  a  grain  three  times  a 

*  The  machines  with  a  separate  key  for  each  letter,  although  expensive,  are  alone 
useful.  Those  are  to  he  preferred  which  have  a  separate  set  of  keys  for  capital 
letters,  rather  thnn  those  in  which  the  capitals  are  produced  hy  the  use  of  a  con- 
trolling key,  changing  the  small  letters  to  the  capitals. 


728  DPAT10N   NEUBOSES. 

week)  have  been  strongly  recommended  by  Vance.  In  the  neuralgic 
form,  sedatives  internally  and  locally  are  certainly  of  service.  Indian 
hemp  by  the  mouth,  morphia  beneath  the  skin,  or  inunctions  of  extract 
of  belladonna  and  glycerine,  or  aconite  ointment,  are  the  most  useful. 
I  have  also  found  hypodermic  injection  of  cocaine  beneficial  in  some 
cases  when  there  has  been  pain  about  the  wrist  or  forearm.  If  tender- 
ness of  the  nerves  exists,  counter-irritation  by  blisters  over  the  tender 
points  often  does  considerable  good. 

Electricity  has  been  extensively  used,  and  strongly  recommended, 
in  the  treatment  of  writers'  cramp.  Faradism  is  of  no  value,  and 
even  harmful,  as  a  rule,  but  voltaic  electricity  occasionally  gives  some 
relief  to  the  pain.  In  the  spasmodic  form  Erb  recommends  the 
passage  of  the  voltaic  current  up  and  down  the  ceiwical  spine,  and 
from  the  spine  to  the  muscles.  Poore  advises  the  combination  of  the 
latter  method  with  gymnastic  movements  of  the  band,  and  has  observed 
great  improvement  in  some  cases  from  this  treatment.*  My  own  ex- 
perience has  led  me  to  assign  a  low  position  to  electricity  in  the 
treatment  of  the  spasmodic  form,  although  I  have  given  it  a  thorough 
trial  in  many  cases.  Certainly,  if  the  patient  goes  on  writing,  it  has 
not  the  slightest  influence  on  the  disease.  "With  rest  from  writing, 
there  is,  in  many  cases,  a  tendency  to  recovery  which  has  not  appeared 
to  me  to  be  expedited  by  galvanism  however  applied.  Gymnastic 
exercises  are  often  distinctly  useful,  regular  flexion  and  extension 
movements  of  the  fingers  and  hand,  for  which,  with  advantage,  a 
"  dumb  piano  "  may  be  used.  They  should  be  as  different  as  possible 
from  the  movements  that  induce  the  spasm,  and  should  never  be 
continued  to  fatigue.  Subbing,  and  the  combination  of  rubbing  and 
kneading  that  is  called  massage,  often  gives  considerable  relief  to  dis- 
comfort, and  sometimes  lessens  the  tendency  to  spasm.  It  has  been 
recently  made  the  subject  of  public  attention,  and  has  been  said  to 
give  remarkable  results,  but  it  is  probable  that  these  were  obtained 
chieflv  in  cases  of  the  imaginary  disorder.  "While  there  is  no  doubt 
that  the  treatment  often  lessens  discomfort,  in  the  cases  of  undoubted 
writers'  cramp  that  I  have  known  treated  in  this  manner  by  "  experts," 
the  svmptoms  have  not  been  appreciably  influenced. 

Among  other  means  of  treatment  which  have  been  recommended  is 
tenotomy  (Stromeyer).  In  one  case  (Truppert)  no  less  than  fifty 
tendons  were  successively  divided,  and  it  is  said  that  the  patient  at 
the  end  of  the  treatment  was  slightly  improved  !  I  have  found  no 
good  result  from  rendering  the  arm  fur  a  time  immobile  by  a  plaster- 
of -Paris  bandage. 

Other  Occupation  Neuroses. 

The  general  considerations  regarding  the  pathology,  causation,  and 
treatment  of  writers'   cramp  are  applicable,  mutatis  mutandis,  to  all 
*  '  Handbook  of  Electricity.' 


OCCUPATION  NEUEOSES.  729 

the  other  forms  of  occupation  neurosis.  In  each,  paiu  and  spasm  may 
be  variously  combined,  and  are  at  first  related  solely  to  the  special 
act. 

Pianoforte  players'  Cramp  occurs  chiefly  among  professionals,  and 
more  frequently  among  women  than  among  men.  Both  the  spasmodic 
and  neuralgic  varieties  are  met  with.  In  the  former  at  first  a  fiuger 
or  the  thumb  does  not  move  with  the  necessary  precision,  and  may 
remain  extended  for  a  few  seconds  instead  of  striking  the  required  note. 
In  the  neuralgic  form,  pain  comes  on  after  playing  for  a  short  time, 
and  compels  the  sufferer  to  desist.  Sometimes  the  pain  extends  up  the 
arm.  Erb  has  several  times  met  with  pain  between  the  scapula  and  the 
spine.  I  have  seen  one  case  in  which  the  pain  was  symmetrical  in  the 
outer  border  of  each  hand,  sometimes  extending  down  the  little  finger, 
but  never  accompanied  by  cramp,  although  the  patient  was  liable  to 
the  nocturnal  cramp  in  the  hands  described  at  p.  704. 

Violin  players  are  liable  to  a  similar  affection  in  either  hand, 
especially  in  that  which  fingers  the  strings,  less  commonly  in  that 
which  moves  the  boAv,  but  occasionally  in  both. 

Sempstresses'  Cramp. — The  act  of  sewing  frequently  leads  to  a  similar 
affection  in  sempstresses  and  tailors,  usually  characterised  by  rigidity 
and  cramped  flexion  of  the  fingers  of  the  right  hand,  often  greatest  in 
the  thimble  finger.  Tingling  in  the  fingers  may  accompany  it,  and 
may  cease  as  soon  as  the  attempt  to  sew  is  relinquished.  I  have  met 
with  the  same  trouble  in  a  sail  maker.  In  this  occupation  the  needle  is 
held  between  the  finger  and  thumb,  and  is  pressed  through  the  canvas 
by  a  metal  plate  fixed  on  the  ball  of  the  tbumb.  The  spasm  in  the 
fingers  caused  the  needle  to  slip  off  the  plate,  and  the  attempt  to  work 
occasioned  pain  in  the  fingers,  and  in  the  metacarpo-phalangeal 
joints. 

Telegraphists'  cramp  (first  described  by  Onimus)  affects  exclusively 
those  who  use  the  Morse  macbine,  which  is  worked  by  pressing  down 
a,  stop  with  the  finger,  so  as  to  make  a  dot  or  a  dash  according  to  the 
duration  of  the  pressure.  The  pressure  has  to  be  repeated  for  each 
sign,  and  telegraphists  have  often  to  send  50,000  separate  signs  a  day. 
Spasm  is  set  up,  which  causes  the  pressure  to  be  too  long  maintained, 
and  hence  dots  become  transformed  to  dashes.  One  patient  managed 
to  go  on  for  two  years  by  substituting  his  thumb  for  the  finger,  and 
then  this  became  unmanageable;  afterwards  he  used  the  middle  finger 
and  then  the  closed  fist,  but  the  spasm  followed,  and  be  had  to  give 
xip  his  occupation.  The  neuralgic  variety  is  sometimes  met  with,  and 
I  have  seen  one  case  in  which  the  pain,  for  six  months  excited  only  by 
the  special  work,  subsequently  occurred  on  other  movements.  After  six 
months'  rest  the  patient  resumed  work  as  a  writing  clerk,  and  wrote 
in  comfort  for  two  months.  Then  the  pain  returned  in  connection 
with  writing,  rapidly  increased,  and  became  spontaneous. 

Smiths  are  also,  although  rarely,  liable  to  cramp.  In  one  case,  an 
artisan  who  was  accustomed  to  work  metal  with  a  hammer  and  chisel, 


730  EPILEPSY. 

found  that  his  left  hand,  grasping  the  chisel,  gradually  passed  into  a 
state  of  tremulous  cramp,  and  became  supinated  in  spite  of  his  effort 
to  prevent  it.  The  spasm  was  worst  when  the  elbow  was  flexed,  and 
for  a  time  he  was  able  to  work  with  the  elbow  extended,  but  at  last  he 
had  to  relinquish  his  occupation.  In  another  case,  a  metal-chaser,  who 
worked  with  a  four-pound  hammer,  found  that,  after  using  it  for  about 
an  hour,  clonic  spasm  came  on  in  the  biceps,  and  interfered  with  his 
work.  The  use  of  the  hammer  in  other  kinds  of  work  has  also  induced 
the  affection. 

Among  other  occupations  which  have  been  known  to  lead  to  the 
development  of  cramp,  and  have  suggested  names  for  special  varieties, 
are  those  of  painters,  harpists,  artificial  flower  makers,  turners,  watch- 
makers, knitters,  engravers  (in  using  the  burin),  masons  (in  using  the 
trowel),  sailors  (from  pulling  on  ropes),  treadlers,  compositors, 
enamellers,  cigarette  makers,  shoemakers,  rnilkers,  money  counters, 
letter  sorters,  and  players  on  various  musical  instruments,  besides  those 
above  mentioned,  including  drummers,  in  whom  either  the  extensors  of 
the  thumb  or  the  long  flexor  may  be  affected  (Bruns). 

In  rare  cases  two  actions  are  simultaneously  and  equally  affected, — 
writing  and  some  other.  The  most  common  combination  is  writing 
and  piano  playing  in  ardent  amateur  musicians  ;  occasionally  writing 
and  sewing  are  both  equally  deranged.  I  have  met  with  one  obstinate 
case  with  chiefly  sensory  symptoms,  in  which  they  were  induced  by  any 
prolonged  use  of  the  hands. 


EPILEPSY. 

The  term  "  epilepsy  "  is  applied  to  a  disease  in  which  there  are  con- 
vulsions of  a  certain  type,  or  sudden  loss  or  impairment  of  conscious- 
ness, but  in  which  the  convulsions  are  not  directly  due  to  active  organic 
brain  disease,  to  reflex  irritation,  or  to  abnormal  blood-states,  and  in 
which  isolated  loss  of  consciousness  is  not  the  result  of  primary  failure 
of  the  heart's  action.  In  most  cases,  the  change  in  the  brain  that  causes 
the  convulsions  is  not  visible  to  the  naked  eye,  and  hence  the  condition  is 
often  termed  "  idiopathic  epilepsy."  There  are  cases,  however,  in  which 
similar  convulsions  occur  as  a  result  of  brain  disease,  such  as  a  spot 
of  old  cortical  softening,  stationary  for  years  and  not  irritant,  but 
effective  by  the  damage  to  adjacent  nerve-cells ;  and  also  of  disease, 
sometimes  of  long  duration,  which  causes  a  continuous  irritation,  such 
as  a  depressed  spiculum  of  bone.  These  cases,  when  due  to  a  stationary 
lesion  that  does  not  irritate,  may  resemble  epilepsy  in  their  course,  and 
sometimes  in  their  symptoms  ;  they  often  succeed  a  distinct  attack  of 
hemiplegia,  and  then  are  sometimes  termed  "post-hemiplegic  epilepsy." 

The  convulsions  in  ordinary  epilepsy  may  consist  of  tonic  or  of  clonic 
spasm,  or,  commonly,  of  both,  but  the  attitude  or  movement  which 


ETIOLOGY.  731 

results  always  differs  from  that  which  occurs  in  voluntary  movement. 
On  the  other  hand,  in  the  convulsions  of  hysteria,  the  muscular  spasm 
is  so  arranged  as  to  resemble  that  which  may  result  from  a  voluntary 
action. 

Etiology. — After  one  attack  of  epilepsy,  others  usually  occur  with- 
out any  immediate  discoverable  cause.  Each  fit  apparently  leaves  a 
change  in  the  nerve-centres,  facilitating  the  occurrence  of  other  fits. 
The  immediate  or  exciting  cause  of  the  disease  must  be  sought,  there- 
fore, in  the  cause  of  the  first  fit.  But  when  such  a  cause  can  be 
discovered,  it  is  usually  manifestly  inadequate  alone  to  produce  a  con- 
vulsion, and  can  only  be  effective  in  consequence  of  a  powerful  predis- 
position. The  remote  influences  to  which  the  disease  is  due  are, 
therefore,  its  chief  causes.  The  excitant  is  no  more  than  the  spark 
which  causes  a  conflagration,  rendered  possible  only  by  the  chemical 
constitution  of  the  materials  ignited. 

Remote  Causes. — Females  suffer  from  epilepsy  rather  more  frequently 
than  males,  in  the  proportion  of  about  six  to  five.*  An  inherited 
tendency  (indicated  by  the  presence  in  ancestors  or  collateral  relations 
of  epilepsy  itself,  or  of  insanity)  is  traceable  in  rather  more  than  a 
third  of  the  cases  (35  per  cent.),  and  rather  less  frequently  in 
males  than  in  females  (33  per  cent,  males,  37  per  cent,  females). 
There  is  a  family  history  of  epilepsy  in  two  thirds  of  the  inherited 
cases ;  of  insanity  in  one  third  ;  of  both  in  a  tenth.  When  there  is 
an  inherited  tendency,  the  females  of  a  family  are  rather  more  likely 
to  suffer  than  the  males.  This  is  due  to  two  circumstances ;  the 
inheritance  is  rather  more  frequently  from  the  mother's  side  than 
from  the  father's,  and  more  females  suffer  when  the  heredity  is 
maternal,  more  males  when  it  is  paternal.  The  inheritance  is  less 
frequently  from  the  mother  personally  than  from  the  father,  but  this 
is  due  to  the  fact  that  insanity  is  much  less  common  in  the  mother 
than  in  the  father  ;  epilepsy  is  equally  common  in  the  two.  Occa- 
sionally many  members  of  a  family  suffer;  in  one  instance  no  less  than 
fourteen  were  epileptic,  the  cases  being  distributed  through  four 
generations.  It  is  very  doubtful  whether  any  inherited  morbid  state, 
outside  the  nervous  system,  predisposes  to  epilepsy.  A  proclivity  to 
phthisis  has  been  thought  to  do  so,  but  the  evidence  of  statistics  shows 
that  this  is  an  erroneous  inference,  due  merely  to  the  great  frequency 
of  consumption  in  the  community.  It  is  doubtful  whether  any  closer 
relation  exists  between  epilepsy  and  the  inherited  gouty  diathesis,  to 
which  attention  has  been  lately  called.  Idiopathic  epilepsy,  however, 
sometimes  occurs  in  the  subjects  of  inherited  syphilis,  without  other 
cause  being  traceable.  A  strong  predisposition  to  the  disease  often 
exists  when  there  is  defective  general  development  of  the  brain,  from 
any  influence  acting  on  it  in  early  life,  or  as  a  result  of  the  congenital 

*  These  statements  are  based  on  1450  cases,  the  detailed  analysis  of  which  is  given 
in  a  separate  work  ('  Epilepsy  and  other  Chronic  Convulsive  Diseases,'  London,  1881). 


732  EPILEPSY. 

defect  met  with  in  neurotic  families  and  in. the  offspring  of  consan- 
guineous marriages. 

Three  quarters  of  the  cases  of  epilepsy  begin  under  twenty  years, 
and  nearly  half  (46  per  cent.)  between  ten  and  twenty,  the  maximum 
being  at  fourteen,  fifteen,  and  sixteen.  One  eighth  of  all  cases 
commence  during  the  fix*st  three  years  of  life.  After  twenty,  the 
annual  number  gradually  falls,  but  cases  commence  even  in  old 
age  (over  seventy).  In  the  cases  which  commence  under  thirty, 
females  exceed  males,  in  the  first  ten  years  by  6  per  cent.,  in  the  second 
by  18,  and  in  the  third  by  12.  After  thirty  the  relation  is  reversed, 
and  the  excess  of  males  gradually  increases,  until  after  sixty  the 
malady  practically  begins  in  males  only.  It  has  been  said  that 
heredity  can  be  traced  only  in  the  cases  which  commence  under 
twenty  years,  but  this  is  altogether  erroneous.  Most  cases  of  here- 
ditary epilepsy  begin  before  twenty,  chiefly  because  most  cases  of  all 
kinds  commence  in  tbis  period ;  the  proportion  borne  by  the  in- 
herited to  the  non-inherited  cases  is  considerable  throughout  life. 
In  the  first  twenty  years  of  life  it  is  nearly  38  per  cent.,  in  the  second 
34  per  cent.,  and  in  the  cases  which  commence  after  forty  it  is  26  per 
cent.  I  have  known  inherited  epilepsy  to  commence  at  sixty-five 
and  seventy-one. 

Immediate  Causes. — We  must  regard,  as  the  exciting  cause  of 
epilepsy,  that  to  which  the  first  fit  was  apparently  due ;  and  its  in- 
fluence, as  already  stated,  is  no  doubt  incomparably  smaller  than  that 
of  the  predisposition,  due  to  conditions  involved  in  age  and  heredity. 
The  statements  of  patients  regarding  exciting  causes  have  to  be 
received  with  caution.  Excluding  the  cases  in  which  the  relation  of 
the  supposed  excitant  was  doubtful,  and  excluding  also  the  cases  origi- 
nating in  infantile  "  dentition  convulsions,"  some  exciting  cause  can 
be  traced  in  only  37  per  cent,  of  the  cases.  In  males  it  is  met  with 
more  frequently  than  in  females,  and  the  difference  between  the  sexes 
in  this  respect  is  least  in  childhood,  and  is  greatest  in  the  second 
decade  and  in  the  decline  of  life.  In  women  between  ten  and  forty, 
exciting  causes  are  relatively  infrequent. 

Of  the  cases  that  commence  in  infancy,  at  least  three  quarters  date 
from  infantile  convulsions,  ascribed  to  teething.  Such  convulsions 
are  known  to  be  the  result,  in  most  instances,  of  the  condition  of  defec- 
tive development  termed  rickets.  Whether  this  condition  is  entirely 
preventable  or  not,  it  would  certainly  not  attain  the  degree  in  which  it 
causes  convulsions  if  children  were  properly  fed,  and  thus  a  consider- 
able number  of  cases  of  epilepsy  might,  without  doubt,  be  prevented. 

Mental  emotion — fright,  excitement,  anxiety — is  the  most  potent 
exciting  cause  of  epilepsy.  The  most  frequent  is  fright,  which 
is  powerful  chiefly  in  childhood,  and  at  the  transition  to  adult  life, 
wbile  it  is  very  rare  after  middle  life.  As  might  be  anticipated,  in 
childhood  it  is  equally  effective  in  each  sex,  at  puberty  it  is  most 
effective  in  females,  and  after  twenty  it  is  seldom  traceable  in  men, 


ETIOLOGY.  733 

but  is  still  a  relatively  frequent  cause  iu  women.  The  profoundly 
disturbing  effect  of  alarm  on  the  nervous  system,  deranging,  as  it 
does,  almost  every  function,  enables  us  to  understand  its  f requencv  as 
au  excitant  of  epilepsy.  There  is  usually  an  interval  between  the 
fright  and  the  first  fit.  Fright  excites  hy steroid  as  well  as  epileptic 
fits,  and  in  most  of  the  cases  in  which  a  person  is  immediately 
"  frightened  into  a  fit,"  the  attacks  are  hysteroid.  The  longer  the 
interval,  the  larger  is  the  proportion  of  cases  in  which  the  attacks  are 
distinctly  epileptic.  Other  forms  of  mental  excitement  occasionally 
excite  the  first  fit,  and  most  commonly  at  the  period  of  life,  and  in  the 
sex,  in  which  fright  is  chiefly  influential ;  but  one  emotional  cause, 
prolonged  mental  anxiety,  is  effective  chiefly  in  men,  and  late  in  life. 

Blows  and  falls  on  the  head,  which  cause  no  symptoms  of  coarse 
cerebral  injury,  are  sometimes  followed  by  recurring  convulsions 
having  all  the  characters  of  idiopathic  epilepsy.  They  are  apparently 
due  to  the  general  impairment  of  nutrition  in  the  brain,  and  lowerino- 
of  its  function,  from  the  mechanical  influence  on  the  delicately  con- 
stituted cells.  Such  cases  are  met  with  at  all  ages  ;  in  childhood 
equally  in  the  two  sexes,  but  in  adult  life  most  frequently  in  males, 
doubtless  from  the  risks  of  occupation.  More  frequently  an  injury 
causes  convulsions  that  begin  locally,  by  causing  damage  to  one  spot 
on  the  cortex.  Epilepsy  probably  sometimes  results  from  slight 
bilateral  damage  to  the  cortex  during  birth,  insufficient  to  cause  motor 
paralysis.  Exposure  to  the  heat  of  the  sun  is  frequently  assigned  as 
the  cause  of  the  first  fit,  but  often  merely  because  the  fit  occurred  in 
summer  sunshine,  and  without  adequate  evidence  that  the  attack  was 
thus  caused.  In  some  cases,  chiefly  males,  its  influence  is  probable 
especially  when  the  fits  follow  other  distinct  symptoms  of  sunstroke. 

Acute  disease  is  an  occasional  cause  of  idiopathic  epilepsy,  but 
the  cases  ascribed  to  this  influence  need  careful  scrutiny,  because 
"  post-hemiplegic  epilepsy  "  often  results  from  a  sudden  lesion  of  the 
brain,  during  an  acute  specific  disease,  probably  thrombosis  in  a 
surface  vein,  or  embolism  consequent  on  endocarditis  (see  p.  456). 
Excluding  such  cases,  epilepsy  is  a  sequel  especially  to  scarlet  fever, 
measles,  and  typhoid  fever  in  that  order  of  frequency,  and  more  cases 
are  consecutive  to  scarlet  fever  (apart  from  the  influence  of  nephritis) 
than  to  all  the  other  acute  diseases  put  together.  This,  together  with 
the  fact  that  optic  neuritis  may  follow  scarlet  fever,  without  any 
organic  change  in  the  brain  to  cause  it,  seems  to  show  that  the  scarlet- 
fever  poison  has  a  special  action  on  the  nervous  system. 

Intestinal  worms  are  a  cause  of  reflex  convulsions,  and  these  do  not 
always  cease  when  the  worms  are  expelled.  They  may  continue  as 
idiopathic  epilepsy,  apparently  as  a  result  of  a  change  in  the  nervous 
system  consequent  on  the  primary  convulsions.  It  is  extremelv  rare 
to  meet  with  any  evidence  of  a  reflex  cause  in  the  system  of  the 
cerebro-spinal  nerves,  and  in  the  few  recorded  cases  there  has  been  a 
manifest  and  strong  predisposition  in  the  brain.      A  patient   with 


734  EPILEPSY. 

permanent  imbecility  suffei'ed  from  fits,  beginning  in  the  right  hand, 
after  a  cut  on  one  of  the  fingers  ;  pressure  on  the  scar  caused  pain 
and  excited  a  fit.  The  attacks  ceased  after  amputation  of  the  finger.* 
Minor  attacks,  beginuing  with  a  sensation  on  a  scar  above  one  eye- 
brow, f  ceased,  but  only  for  a  time,  on  excision  of  the  scar.  In  other 
cases,  arrest  has  followed  the  removal  of  a  diseased  testicle  and  of  a 
foreign  body  in  the  nose.J  In  these  cases  the  peripheral  irritation 
seems  to  have  been  the  exciting  cause.  Among  other  rare  causes  of 
the  first  fit  are  severe  digestive  derangement,  asphyxia,  chronic 
alcoholism,  and  chronic  lead-poisoning.  In  the  two  latter  the  con- 
vulsions are  primarily  due  to  the  toxic  influence,  but  may  persist 
when  the  latter  is  lessened  or  removed  by  treatment.  Analogous 
convulsions  are  sometimes  met  with  in  chronic  renal  disease,  apart 
from  any  acute  symptoms  of  uraemia. 

Disturbed  or  delayed  menstruation,  at  the  time  of  puberty,  often 
coincides  with  the  onset  of  epilepsy,  but  it  is  very  difficult  to  deter- 
mine the  exact  relationship  between  the  two.  As  a  rule,  when 
epilepsy  is  once  set  up,  the  establishment  of  regular  menstruation 
appears  to  exert  no  influence  on  the  disease.  The  fact  that  so  many 
cases  commence  at  the  time  of  puberty  seems  due  rather  to  the 
developmental  changes  in  the  nervous  system  at  this  epoch  than  to 
any  direct  influence  exerted  by  the  organs  of  generation.  No  case  has 
come  under  my  notice  suggesting  that  uterine  or  ovarian  disease  can 
"be  regarded  as  a  cause  of  epilepsy.  Occasionally  the  first  fit  occurs 
during  pregnancy,  or  after  parturition,  without  any  secondary  cause 
to  which  it  could  be  ascribed. 

Masturbation  in  boys  is  undoubtedly  an  occasional  cause,  but  the 
attacks  which  result  from  this  influence  are  more  frequently  hysteroid 
than  epileptic,  or  they  present  a  hybrid  character,  so  that  it  is  difficult 
to  say  in  which  category  they  are  to  be  placed. 

Syphilis  is  a  frequent  cause  of  chronic  convulsions,  but  these  are 
usually  due  to  organic  disease,  a  meningeal  growth  or  chronic  inflam- 
mation. Fournier  believes  that  the  syphilitic  poison,  during  the 
secondary  period,  has  a  direct  action  on  the  nervous  system,  and  may 
cause  pure  neuroses,  epilepsy  among  the  number.  Evidence  of  this, 
that  will  bear  a  close  scrutiny,  is  scanty.  Convulsions  may  be  the 
only  sign  of  organic  changes,  which  sometimes  occur  early  in  the 
course  of  syphilis.  The  occurrence  of  epilepsy,  apparently  idiopathic, 
in  the  subjects  of  inherited  syphilis,  has  been  already  mentioned. 

It  is  not  rare  for  no  cause,  remote  or  immediate,  to  be  traceable.  This 
fact  will  be  less  surprising  when  the  probable  nature  of  the  malady  is 
understood. 

Symptoms. — Epileptic    attacks   are   commonly    divided    into    two 
classes,  "  major  "  or  severe,  and  "  minor  "  or  slight.     These  two  forms, 
*  Guder,  'Zeitsch.  f.  Psych.,'  1890.  f  Rik,  'Zeitsch.  f  Heilk.,5  1889. 

t  Hausdale,  'Am.  J.  Med.  Sc.,'  1S89. 


SYMPTOMS.  735 

although  clearly  distinguished  in  their  general  characters,  are  not 
separated  by  any  sharp  demarcation.  In  the  major  attacks  {grand 
mal)  there  is  loss  of  consciousness  and  severe  muscular  spasm.  In 
the  minor  attacks  {petit  mal)  there  is  usually  brief  loss  of  conscious- 
ness, often  without  any  muscular  spasm,  sometimes  with  slight  spasm, 
and  very  rarely  there  is  slight  spasm,  or  some  sudden  sensation,  with- 
out loss  of  consciousness.  In  severe  attacks  the  patient,  if  standing, 
falls  to  the  ground  (hence  the  old  English  name,  "  falling  sickness  ")  ; 
in  slight  attacks  he  may  or  may  not  fall.  In  very  severe  fits  muscu- 
lar spasm  and  loss  of  consciousness  are  simultaneous  in  onset,  but  in 
less  severe  fits  the  muscular  spasm  may  commence  before  conscious- 
ness is  lost ;  the  patient  is  then  aware  of  the  onset.  Still  more  fre- 
quently the  spasm  and  loss  of  consciousness  are  preceded  by  some 
sensation.  The  sensation,  or  spasm,  which  informs  the  patient  of  the 
oncoming  attack,  constitutes  the  "warning"  or  "  aura"  of  the  fit. 

Major  Fits. — At  the  onset  of  the  severe  fit  the  spasm  is  tonic  in 
character, — rigid,  violent,  muscular  contraction,  fixing  the  limbs  in 
some  strained  position.  There  is  usually  deviation  of  the  eyes  and 
of  the  head  towards  one  side,  and  this  may  amount  to  rotation  involving 
the  whole  body,  and  may  actually  cause  the  patient  to  turn  round,  even 
two  or  thi'ee  times.  The  features  are  distorted  ;  the  colour  of  the  face, 
unchanged  at  first,  rapidly  becomes  pale,  then  flushed,  and  ultimately 
livid,  as  the  fixation  of  the  chest  by  the  spasm  stops  the  movements 
of  respiration.  The  eyes  are  open  or  closed ;  the  conjunctiva  is 
insensitive ;  the  pupils  dilate  widely  as  cyanosis  comes  on.  As  the 
spasm  continues,  it  commonly  changes  in  its  relative  intensity  in 
different  parts,  causing  slight  alterations  in  the  position  of  the  limbs. 
When  the  cyanosis  has  become  intense,  the  fixed  tetanic  contractions 
of  the  muscles  can  be  felt  to  be  vibratory,  and  the  vibrations  gradu- 
ally increase  until  there  are  slight  visible  remissions.  As  these 
become  deeper,  the  muscular  contractions  become  more  shock-like  in 
character,  and  the  stage  of  clonic  spasm  is  reached,  in  which  the  limbs, 
head,  face,  and  trunk  are  jerked  with  violence,  and  through  similar 
spasms  in  the  tongue  and  muscles  of  the  jaws  the  former  is  often  bitten. 
The  shocks  of  spasm  effect  slight  movements  of  the  thorax,  so  that 
air  is  expelled,  and  saliva  is  frothed  out  between  the  lips.  The  air 
that  enters  the  lungs  is  at  first  insufficient  to  lessen  the  lividity,  and 
the  patient  may  seem  to  be  at  the  point  of  death,  but  as  the  remissions 
become  deeper,  more  air  enters  the  chest,  and  the  lividity  gradually 
lessens.  In  becoming  less  frequent,  the  contractions  do  not  become  less 
strong,  and  the  last  jerk  is  often  as  violent  as  those  which  have  pre- 
ceded it.  At  last  the  spasm  is  at  an  end,  and  the  patient  lies  sense- 
less and  prostrate,  sleeps  heavily  for  a  time,  and  then  can  be  roused. 
Urine  frequently,  and  faeces  occasionally,  are  passed  during  the  fit. 

In  some  cases  the  spasm  is  more  deliberate  in  its  onset.  Instead 
of  commencing  simultaneously  in  all  the  muscles  of  the  body,  it 
begins  in  one  region,  as  the  face  or  arm,  and  thence  spreads,  first  to 


736  EPILEPSY. 

the  limbs  on  the  same  side,  the  head  and  eyes  "being  turned  towards 
that  side,  and  then,  lessening  on  the  side  first  affected,  it  invades  the 
limbs  on  the  opposite  side,  with  a  corresponding  rotation  of  the  head. 
Such  attacks  may  commence  with  tonic  spasm,  or  they  may  com- 
mence by,  and  sometimes  consist  only  of,  clonic  spasm.  This  form 
of  convulsion  is  that  which  (as  we  have  already  seen,  p.  90)  is  most 
common  in  organic  cerebral  disease,  such  as  tumour,  but  it  is  also 
occasionally  met  with  in  idiopathic  epilepsy.  In  such  cases  con- 
sciousness is  often  lost  late,  so  that  the  patient  is  aware  of  the  com- 
mencing spasm. 

Minor  Attacks. — The  slight  attacks  of  epilepsy  may  be  characterised 
only  by  loss  of  consciousness.  The  individual  suddenly  stops  in  his 
occupation,  looks  strange  for  a  moment,  and  then  goes  on  with  what 
he  is  doing,  may  even  finish  a  sentence  that  he  had  commenced,  and 
be  aware  of  what  has  happened  only  by  finding  that  he  has  dropped 
something  which  was  in  his  hands,  or  that  he  is  the  object  of  anxious 
observation.  Sometimes  there  is  pallor  at  the  moment  of  the  attack, 
more  frequently  after  the  onset,  and  very  commonly  the  face  subse- 
quently becomes  flushed.  Yery  often,  moreover,  the  slight  seizure 
is  heralded  by  some  sensory  warning  or  aura,  such  as  precedes  the 
severe  attacks.  There  may  also  be  slight  visible  spasm,  such  as 
putting  the  arms  forward  and  bending  the  head  down,  or  there  may 
be  slight  convulsion  in  the  part  in  which  the  spasm  commences  in  the 
severe  attacks,  and,  in  some  cases,  the  minor  attack  may  consist  only 
of  such  spasm,  without  loss  of  consciousness.  After  a  slight  attack 
is  over,  the  patient  may  be  at  once  quite  well.  Often  he  is  stupid  and 
dull  for  a  little  time,  and  sometimes  proceeds  to  perform  some  action 
in  a  dream-like,  automatic  manner,  such  as  undressing  himself, 
retaining  afterwards  no  recollection  of  what  he  has  done.  Occasion- 
ally this  stage  is  attended  by  passion  and  violence,  a  brief  maniacal 
condition  constituting  one  form  of  epileptic  mania.  After  an  attack, 
severe,  or  more  frequently  slight,  the  patient  may  pass  into  a  state  of 
actual  hysteroid  convulsion,  and  in  such  cases  the  minor  epileptic  seizure 
may  be  unnoticed,  all  the  obtrusive  phenomena  of  the  attack  being  of 
a  hysteroid  character. 

Symptoms  in  Detail. — Precursory  symptoms  occasionally  precede  a 
fit  for  some  hours  or  days,  and  indicate  to  the  patient  or  his  friends 
that  an  attack  is  impending.  The  most  frequent  of  these  indications 
are  sudden  jerks  of  the  body  or  limbs,  persistent  giddiness,  flashes  of 
light  before  the  eyes,  irritability  of  temper,  or  an  unnatural  degree  of 
appetite.  In  rare  cases  there  is  considerable  mental  change,  even  with 
delusions,  for  some  hours  before  an  attack. 

Mode  of  Onset ;  Warning ;  Aura. — The  word  aura  (vapour)  origi- 
nated with  the  old  Greek  theory  that  the  fit  began  by  the  ascent  of  a 
vapour  up  the  vessels  of  the  limb.  In  later  times  it  was  thought  that 
the  sensation  felt  in  the  periphery  does  begin  there,  as  a  disturbance 


SYMPTOMS    IN    DETAIL.  737 

ascending  the  nerves  ;  and  the  opinion  was  thought  to  be  confirmed  by 
the  fact  that  a  ligature  arouud  the  limb  would  arrest  the  ascending 
aura.  But  the  fact  (observed  first  in  the  beginning  of  this  century) 
that  the  commencing  fit  may  be  equally  arrested  when  its  cause  is  a 
tumour  of  the  brain,  has  shown  that  the  aura  is  merely  the  effect  on 
consciousness  of  the  commencing  discharge  in  the  brain,  either  a  direct 
effect,  felt  as  a  sensation  and  referred  to  the  periphery,  or  an  indirect 
effect,  due  to  actual  spasm  at  the  periphery.  But  the  fact  that  the  aura 
is  the  result  of  the  commencing  central  process  renders  its  study  of 
great  importance,  since  it  gives  us  information  of  the  functional  region 
of  the  brain  in  which  the  process  of  the  fit  begins. 

Some  form  of  aura  is  met  with,  at  least  occasionally,  in  about  one 
half  of  the  cases  of  epilepsy.  Iu  the  other  half  the  loss  of  conscious- 
ness always  occurs  so  early  that  the  patient  is  uuaware  of  the  onset  of 
the  fit.  We  may  provisionally  group  the  various  aurae  into  certain 
classes  for  convenience  of  description.  The  classification  must  be,  in 
the  main,  empirical. 

(1)  The  commencement  of  the  attack  may  be  by  a  motion  or  sensa- 
tion in  some  part  of  one  half  of  the  body,  most  frequently  in  the  arm, 
less  frequently  in  the  face  or  leg,  occasionally  in  the  tongue,  very 
rarely  in  the  side  of  the  trunk.  Such  local  commencement  is  not 
frequent  in  idiopathic  epilepsy,  although  it  is  sometimes  met  with ; 
it  is  the  common  mode  of  onset  in  cases  of  organic  brain  disease.  In 
any  part,  the  first  symptom  may  be  a  spasm,  or  a  sensation,  or  both. 
In  the  upper  limb  the  aura  usually  commences  in  the  hand.  When 
it  is  a  spasm,  it  generally  commences  in  the  hand  as  a  whole,  less 
commonly  in  the  arm  as  a  whole,  rarely  in  the  shoulder.  When  a 
sensation,  it  is  usually  described  as  "  numbness,"  "tingling,"  &c,  and 
commences  generally  in  a  definite  part  of  the  hand, — thumb,  fore- 
finger, all  the  fingers,  palm,  or  wrist :  never  higher  up  the  arm.  Some- 
times there  is  a  sensation  of  motion  without  actual  spasm.  The  aura, 
whether  motor  or  sensory,  if  it  commences  in  the  hand,  may  be  felt- 
to  ascend  the  arm  and  may  pass  to  the  head,  trunk,  or  leg,  before 
consciousness  is  lost.  Commencement  in  the  leg  is  less  frequent,  and 
presents  the  same  variations  in  character  and  seat ;  the  sensation  or 
spasm  may  pass,  before  consciousness  is  lost,  up  or  down  the  limb 
(according  to  the  place  of  commencement),  or  to  the  trunk,  arm,  or 
head.  When  the  aura  passes  from  the  arm  to  the  leg,  or  vice  versa, 
it  may  do  so  by  two  modes  :  it  may  pass  from  one  limb  to  the  other 
through  the  trunk,  and  then  pass  clown  the  limb  secondarily  affected ; 
or  it  may  commence  at  the  extremity  of  the  second  limb,  and  thus  pass 
up  both.  In  the  former  ca.se,  as  a  rule,  a  pure  sensation  leads ;  the 
course  of  the  aura  is  determined  by  the  discharge  in  the  sensory 
centre,  in  which  no  doubt  the  r*epresentation  of  the  cutaneous  nerves 
is  as  continuous  as  their  distribution  in  the  skin.  Sometimes  a  purely 
sensory  aura  (discharge  limited  to  a  sensory  centre)  may  pass  up  one 
limb,  along  the  side  of  the  trunk,  and  down  the  other  limb,  and  onlv 

vol.   n.  47 


738  EPILEPSY. 

when  it  reaches  the  extremity  of  this  latter  is  spasm  added,  which  may 
pass  back  up  the  limb,  the  discharge  extending  to  the  related  motor 
centre  only  when  it  reaches  tbe  limit  of  the  sensory  centre. 

Fits  begin  in  the  face  much  less  frequently  by  a  sensation  than  by 
spasm  ;  the  latter  is  genei'ally  in  the  zygomatic  muscles,  sometimes  in 
the  orbicularis.  In  slight  attacks  on  the  right  side,  the  commencement 
in  the  face  is  often  associated  with  inability  to  speak.  An  aura  in  the 
tongue  is  usually  sensory ;  it  may  be  associated  with  movement  in  the 
jaw  or  with  nausea,  and  in  these  combinations  we  may  trace  physio- 
logical associations. 

(2)  Bilateral  and  general  warnings.  Fits  occasionally  commence 
by  a  sensation  or  motion  in  the  limbs  on  both  sides  simultaneously. 
An  aura  felt  in  the  trunk  and  not  distinctly  visceral  is  rare,  and 
is  generally  referred  to  the  spine.  General  tremor  or  shivering,  and 
general  starts  or  jerks,  are  occasional  warnings ;  and  so  are  a  general 
sense  of  malaise,  of  powerlessness,  of  heat,  and  a  feeling  of  faintness. 

(3)  Visceral  and  pneumogastric  warnings.  A  frequent  form  of 
aura  is  that  which  is  referred  to  the  internal  viscera,  and  especially  to 
those  which  are  in  the  region  of  the  pneumogastric  nerve,  including 
the  respiratory  portion  of  the  spinal  accessory.  The  most  common  is 
some  sensation  at  the  epigastrium,  usually  vague,  but  sometimes  actual 
pain.  Rarely  it  seems  to  commence  lower  in  the  abdomen  ;  occasion- 
ally it  is  referred  to  the  left  of  the  middle  line,  scarcely  ever  to  the 
right.  When  the  sensation  is  actual  pain,  it  remains  at  the  epigas- 
trium until  consciousness  is  lost;  it  is  sometimes  associated  with  nausea, 
and  then  seems  referable  to  disturbance  in  the  central  relations  of  the 
gastric  division  of  the  vagus.  When  the  sensation  is  other  than  pain, 
it  may  also  only  be  felt  at  the  epigastrium,  but  frequently  it  seems  to 
ascend  through  the  chest  to  the  throat  or  head.  On  reaching  the 
throat  there  is  a  sensation  of  choking,  apparently  identical  with  the 
globus  hystericus.  The  warning  may  also  be  this  sensation  of  choking 
without  any  preceding  epigastric  aura.  Now  and  then  other  vague 
feelings  are  described  in  the  throat  or  thorax.  These  aurae,  ascending 
to  or  felt  in  the  throat,  seem  to  be  the  expression  of  a  disturbance  of 
the  central  processes  connected  with  the  respiratory  function  of  the 
pneumogastric.  Another  organ  within  the  innervation  of  the  vagus 
is  the  heart,  and  various  cardiac  sensations,  such  as  palpitation,  or  pain, 
or  vague  discomfort,  sometimes  constitute  the  aura. 

(4)  Cephalic  sensations.  A  sensation  of  giddiness,  vague  or  definite 
vertigo,  is  a  very  frequent  aura,  and  is  often  associated  with  actual 
turning  of  the  head  and  eyes,  seldom  of  the  whole  body,  more  fre- 
quently to  the  left  than  to  the  right.  In  bilateral  fits  the  convulsion 
is  never  quite  equal  on  the  two  sides,  and  the  deviation  of  the  head  is 
perhaps  due  to  the  inequality  of  discharge,  and  the  vertigo  its  sensory 
effect  (see  "Vertigo").  Giddiness  is  occasionally  associated  with 
nausea,  and  sometimes  with  loss  of  sight.  Other  sensations  referred 
to  the  head  are  also  common  ;  actual  pain,  usually  indefinite  in  seat, 


SYMPTOMS    IN    DETAIL.  739 

sometimes  a  sense  of  "  rushing  of  blood  to  the  head,"  or  vague  "  heavi- 
ness."    A  sudden  sense  of  somnolence  is  also  sometimes  described. 

(5)  Psychical  aurse  occasionally  herald  attacks,  and  may  consist  in 
an  emotion  or  an  idea.  The  emotion  is  uniform  in  the  same  case,  some 
form  or  degree  of  fear.  It  bears  no  relation  to  emotion  as  a  canse  of 
the  first  fit.  The  idea  is  usually  too  vague  or  imperfectly  remembered 
to  be  described  in  words.  Occasionally  the  psychical  aura  consists  of 
a  vague  "  dreamy  state  ;"  sometimes  it  is  a  sudden  sense  of  strangeness 
— familiar  objects  seem  unfamiliar.  Very  rarely,  there  is  a  sudden 
sense  that  whatever  is  happening  is  morally  wrong. 

(6)  Special  sense  aurse  are  very  frequent  and  important.  Olfactory 
sensations  are  rare ;  when  experienced  they  are  usually  unpleasant  in 
character,  a  "  sulphurous,"  "  foetid,"  or  "  indescribable  "  smell.  When 
due  to  organic  brain  disease,  this  has  sometimes  involved  the  uncinate 
gyrus.  G-ustatory  aurse — a  sour,  bitter,  or  metallic  taste — are  still 
more  rare.  Flavours  (an  olfactory  sensation)  are  never  combined 
with  a  sensation  of  an  odour  as  a  warning,  but  sometimes  are  with  a 
true  gustatory  sensation — a  fact  of  much  physiological  interest.  An 
auditory  warning  is  more  common.  There  may  be  a  sudden  loss  of 
hearing — a  strange  stillness,  for  a  moment,  before  consciousness  is 
lost.  More  frequently  there  is  a  warning  sound,  usually  of  low  elabo- 
ration— a  crash,  whiz,  a  hiss  or  whistle,  and  the  sound  may  seem  to 
get  louder  and  nearer  until  the  patient  knows  nothing  more.  Very 
rarely  a  more  elaborate  sensation  is  described,  or  music,  or  words,  and 
the  sensation  is  usually  the  same  before  each  fit.  One  patient  de- 
scribed, as  the  constant  aura,  a  curious  perception  of  hearing  words 
without  any  sensation  of  hearing  them. 

A  visual  warning  is  twice  as  frequent  as  all  the  other  special  sense 
aurse  together.  It  may  be  sudden  loss  of  sight ;  but  more  frequently 
it  is  a  visual  sensation,  a  flash  of  light,  or  sparks,  or  flashes  of  colour. 
Usually  many  colours  are  seen,  sometimes  one  only.  Red  and  blue 
are  the  most  frequent ;  no  other  colour  is  seen  alone,  and  both  are 
never  absent.  Occasionally  the  visual  sensation  is  much  more  elabo- 
rate, a  vague  vision  of  some  beautiful  place,  or  a  definite  image  of 
some  object,  an  old  woman  with  a  dress  of  a  certain  colour,  uglv 
faces,  animals,  &c.  Objects  actually  before  the  patient  may  appear 
to  approach,  or  more  frequently  to  recede,  as  the  fit  is  coming  on.  The 
recession  is  apparently  due  to  a  slight  degree  of  the  inhibition  of  the 
visual  centre,  which,  in  greater  degree,  causes  the  loss  of  sight.  It  is 
noteworthy  that  lights  may  be  seen  after  sight  is  lost,  an  instance  of 
"discharge"  in  an  inhibited  centre,  and  an  important  fact  in  connection 
with  the  physiological  pathology  of  the  disease.  Various  special  sense 
aurse  may  be  combined.* 

Very  rarely  an  attack  is  preceded  by  some  co-ordinated  movement. 
A  patient,  for  instance,  may  invariably  commence  running,  and  after 

*  Many  illustrations  of  the  different  kinds  of  warning  will  be  found  in  my 
treatise  on  "  Epilepsy." 


740  EPILEPSY. 

ruuniug  a  few  yards,  fall  down  in  a  fit, — the  "  epilepsia  cursiva  "  of 
Bootius.  I  have  kuown  a  patient  always  to  turn  round  and  retrace 
his  steps  immediately  before  an  attack,  and  another  would  spring  up 
and  jump  about  the  room  for  a  few  seconds.  In  one  instance  the 
forward  run  before  the  fall  was  preceded  by  senseless  laughter  and 
irregular  movement  of  the  arms.* 

A  peculiar  sound,  the  "  epileptic  cry,"  is  produced  at  the  onset  of 
the  attack  in  some  cases.  It  may  be  a  harsh  weird  scream,  but  more 
often  it  is  a  sort  of  prolonged  laryngeal  groan,  not  very  loud,  but  very 
characteristic.  The  sounds  are  probably  due  to  narrowing  of  the 
glottis  at  the  moment  when  air  is  expelled  from  the  chest  by  the  tonic 
spasm.  As  a  rule  the  patient  is  not  aware  of  the  cry,  but  sometimes 
he  can  hear  and  remember  it,  although  he  cannot  prevent  it. 

The  convulsion,  as  a  rule,  begins  by  tonic,  spasm,  which  causes  rota- 
tion of  the  head  and  deviation  of  the  eyes  and  of  the  mouth  to  the  side 
on  which  the  convulsion  is  most  intense.  The  posture  of  the  limbs 
varies.  Commonly  the  arms  are  slightly  abducted  at  the  shoulder, 
the  elbow  and  wrist  are  flexed,  and  the  fingers  are  flexed  at  the  meta- 
carpophalangeal joints,  extended  at  the  others,  the  thumb  being 
adducted  into  the  palm,  or  pressed  against  the  fingers.  The  position 
is  thus  nearly  that  seen  in  tetany.  The  legs  may  be  extended,  but 
often  there  is  slight  flexion  at  the  hip-  and  knee-joints.  Sometimes 
initial  extension  of  the  legs  gives  place  to  strong  flexion  in  the  later 
stages  of  the  fit.  Usually  the  limbs  of  the  two  sides  do  not  perfectly 
correspond  in  position,  but  the  difference  is  slight.  In  other  cases 
the  arms  are  extended,  and  in  some  the  fingers  are  flexed  at  all  joints, 
the  fists  being  "  clenched."  In  others  again,  instead  of  a  combination 
of  flexion  and  extension,  flexion  predominates  throughout.  The  head 
is  bent  forwards,  the  arms  and  legs  are  strongly  flexed,  so  that  the 
fists  are  in  contact  with  the  chest,  and  the  knees  with  the  abdomen. 
At  the  commencement  of  such  flexor  fits  the  patient  often  falls  for- 
wards. In  rare  cases  the  arms  are  raised  up  above  the  head  at  the 
onset  of  the  attack,  and  may  be  kept  in  that  position  throughout,  or 
put  straight  forwards.  The  neck,  in  these  fits,  is  often  bent  back- 
wards ;  the  legs  may  be  extended,  or  one  or  both  may  be  flexed.  The 
violence  of  the  tonic  spasm  is  often  very  great ;  the  shoulder  may  be 
dislocated  by  it,  and  when  this  accident  has  once  happened  it  is  very 
apt  to  recur.  It  is  generally  during  the  stage  of  clonic  spasm  that 
the  tongue  is  bitten ;  it  is  pushed  by  the  spasm  between  the  teeth, 
while  the  jaws  are  jerked  by  the  contraction  in  the  muscles  of  mas- 
tication. Yery  rarely  it  is  bitten  during  the  tonic  stage.  Now  and  then, 
instead  of  this  shock-like  clonic  spasm,  into  which  the  tonic  spasm 
gradually  passes,  the  clonic  spasm  is  finer  in  range  and  quicker  in 
time,  and  is  superadded  to,  instead  of  superseding,  the  tonic  spasm. 
The  latter  continues  while  the  strained  rigid  limbs  are  agitated  by 
the  coarse  tremor.     This  form  of  clonic  spasm  is  most  common  in  the 

*  Marrey,  '  Rev.  de  Med.,'  1889. 


SYMPTOMS    IN    DETAIL.  741 

cases  which  present  extension  in  the  arms  and  flexion  of  all  the  joints 
of  the  fingers. 

In  some  epileptic  fits  there  is  but  one  form  of  spasm,  either  tonic  or 
clonic.  As  a  rule,  those  which  consist  only  of  tonic  spasm  are  general 
fits  of  slight  severity.  A  patient  falls  unconscious,  is  rigid  for  a  few 
moments,  and  then  is  better.  Severer  tonic  fits  are  sometimes  seen — 
the  "  tetanoid   epilepsy  "  of  Pritchard. 

The  attacks  which  consist  only  of  clonic  spasm  are  slight  fits  of 
partial  distribution,  beginning  in,  and  often  confined  to,  one  limb, 
especially  the  hand  and  arm.  They  are  less  common  in  cases  having 
the  character  of  idiopathic  epilepsy  than  in  organic  brain  disease. 
Severer  fits  consisting  only  of  clonic  spasm  are  very  rare.  Earely 
fine  general  tremor  constitutes  all  the  convulsive  phenomena,  or  suc- 
ceeds tonic  spasm  (Fere). 

The  course  of  the  spasm  in  fits  which  begin  locally  has  been  alluded 
to  in  the  account  of  the  modes  of  onset.  The  relation  of  the  spasm 
to  the  muscles  of  unilateral  and  bilateral  use  is  an  important  point, 
which  has  been  already  considered  (p.  90). 

The  slight  convulsion  at  the  onset  of  fits  which  begin  deliberately 
seems  to  cause  little  pain,  but  occasionally  the  pain  felt  in  such  cases 
is  very  great.  In  some  of  these  cases  it  is  probable  that  the  pain  is 
due  to  discharge  in  the  sensory  centres. 

Other  Symptoms  of  Attacks. — The  pupils  are  said  to  be  occasionally 
contracted  at  the  onset  of  a  fit,  but  such  contraction  is  certainly  not 
invariable.  As  a  rule,  as  soon  as  the  tonic  stage  is  well  established, 
the  pupils  are  dilated,  and  continue  so  until  the  fit  is  over ;  the  iris 
does  not  contract  to  light.  When  signs  of  consciousness  can  be 
elicited,  the  dilatation  ceases,  and  it  is  not  uncommon  after  the  fit  for 
the  pupil  to  present  alternate  contraction  and  dilatation  every  one  or 
two  seconds,  continuing  for  a  few  minutes,  a  phenomenon  first  pointed 
cut  by  Reynolds. 

The  passage  of  urine  during  an  attack,  already  mentioned,  is  not 
due  merely  to  the  state  of  the  bladder  or  rectum,  or  to  the  loss  of 
consciousness,  but  is  the  result  of  some  peculiarity  in  the  convulsion, 
since  it  occurs  invariably  in  some  patients,  never  in  others.  The 
pulse  may  be  feeble  at  the  onset,  but  I  have  never  noted  an  initial 
failing,  although  I  have  several  times  had  my  finger  on  the  pulse 
when  a  fit  came  on.  A  tracing  published  by  Voisin  shows  that  the 
heart's  action  may  be  perfectly  normal  during  the  stage  of  the  aura. 
A  stoppage  of  the  pulse  has  been  described  by  Moxon,  but  is  cer- 
tainly altogether  exceptional.  As  the  muscular  spasm  becomes  con- 
siderable the  pulse  is  increased  in  frequency  and  in  force,  but  falls 
when  the  fit  is  over.*     The  face  is  often  pale  at  the  onset,  but  pallor 

*  In  a  case  in  which  Dr.  Money  was  listening  to  the  he;irt  at  the  time  of  the 
•onset,  its  sounds  were  regular  and  vigorous  up  to  the  time  when  pallor  and  tonic 
si  asm  came  on,  when  he  had  to  leave  off  listening.  The  pulse  continued  full  and 
steady  throughout,  hut  was  rather  infrequent.     (Oral  communication.) 


742  EPILEPSY. 

is  less  constant  than  is  currently  asserted.  It  may  come  on  after, 
and  not  before  the  commencement  of  the  tonic  spasm,  but  as  this 
continues  the  face  becomes  congested  and  then  cyanotic.  The  bloated 
dusky  aspect  of  the  face,  with  features  distorted  by  the  spasm,  renders 
the  appearance  of  the  patient  most  alarming  to  those  unaccustomed  to 
the  disease.  When  the  clonic  spasm  becomes  completely  intermittent, 
air  is  changed  in  the  lungs  and  the  cyanosis  lessens.  During  the 
course  of  the  fit,  the  surface  often  becomes  covered  with  sweat.  It  is- 
doubtful  whether  there  is  any  change  in  the  retinal  vessels  until  the 
veins  become  swollen  in  the  course  of  the  venous  congestion.  In  con- 
vulsions which  begin  locally,  I  have  watched  the  fundus  and  have 
seen  that  there  is  no  initial  alteration  in  the  state  of  the  vessels. 

Excitants  of  Attacks. — In  some  patients  attacks  may  be  excited  by 
certain  influences,  but  such  cases  are  as  rare  in  epilepsy  as  they  are 
common  in  hysteria.  The  excitants  which  have  come  under  my  notice 
are  emotion,  a  "  startling"  noise,  a  bright  light,  and  voluntary  motion 
after  rest.  It  is  excessively  rare  for  cutaneous  irritation  to  excite  a 
fit.  Epileptogenic  zones,  analogous  to  those  of  Brown- Sequard's 
guinea-pigs,  are  practically  unknown.* 

Arrest  of  Fits. — Attacks  which  begin  deliberately  can  sometimes  be 
cut  short,  and  the  means  by  which  this  may  be  effected  are  of  consi- 
derable interest,  and  of  some  practical  importance.  Those  which 
commence  by  a  bilateral,  visceral,  cephalic,  or  special  sense  aura  can 
rarely  be  -arrested ;  but  now  and  then  they  can  be  stopped  by  some 
muscular  exertion,  as  by  walking  quickly,  or  by  some  strong  sensory 
impression,  such  as  the  application  of  ammonia  to  the  nostrils,  swal- 
lowing a  mouthful  of  common  salt,  or  by  the  inhalation  of  nitrite  of 
amyl.  The  attacks  that  can  most  frequently  be  arrested  are  those 
which  commence  by  a  motion  or  sensation  in  the  hand  or  foot.  The 
oldest  and  usual  method  of  effecting  this  is  by  a  ligature  around  the 
limb  above  the  seat  of  the  spasm  or  sensation.  The  strong  peripheral 
impression  apparently  raises  the  resistance  in  the  nerve-cells  of  the 
affected  part  of  the  brain,  and  so  arrests  the  spread  of  the  discharge. 
The  influence  must  be  exerted  first  on  the  sensory  centre,  and  through 
this  on  the  motor  centre.  If  the  commencing  fit  has  got  beyond  the 
part  to  which  the  ligature  has  been  applied,  the  attack  is  not  arrested. 
A  ligature  acts  better  than  other  peripheral  impressions,  probably 
because  it  is  most  readily  applied,  and  because  the  cutaneous  nerves 
are  stimulated  in  the  entire  cii-cumference  of  the  limb,  and  so  influ- 
ence the  entire  extent  of  grey  matter  in  which  the  discharge  is  advanc- 
ing. Occasionally,  a  more  limited  cutaneous  impression,  a  pinch  or 
prick,  has  the  same  effect.  The  fits  which  begin  by  spasm  may  some- 
times be  arrested  in  another  way — by  preventing  the  movement,  and 
forcibly  extending  the  contracting  muscles,  sometimes  by  rubbino- 
them.     The  mechanism  is  pi-obably  the  same.     Eubbing  has  a  ten- 

*  See,  however,  a  curious  case  recorded  by  Hughlings  Jackson  ('  Proc.  Med.  Soc 
Load./  vol.  x,  1887.  p.  78). 


SYMPTOMS   IN   DETAIL.  743 

dency  to  lessen  all  forms  of  spasm,  even  that  of  tetanus.  Both 
methods  of  arrest  were  known  to  the  ancients. 

Conditions  after  Attacks. — The  coma,  into  which  the  patient  usually 
passes  at  the  end  of  an  epileptic  fit,  often  continues  as  heavy  sleep, 
lasting  for  a  quarter  of  an  hour  or  longer.  After  the  first  few  minutes 
the  patient  can  be  roused.  The  sleep  is  often  followed  by  a  severe 
headache,  enduring  for  several  hours  or  the  remainder  of  the  day. 
Occasionally  the  sleep  is  not  followed  by  headache,  but  if  the  patient 
is  roused  and  is  not  allowed  to  sleep,  the  pain  in  the  head  is  severe. 
In  some  cases  there  is  neither  sleep  nor  headache. 

For  a  few  seconds  after  a  severe  fit,  reflex  action  in  the  limbs 
remains  absent.  Tickling  the  sole  no  longer  causes  a  movement  of 
the  leg,  and  the  loss  may  involve  the  muscle-reflex  action,  so  that  the 
knee-jerk  can  no  longer  be  obtained,  as  Westphal  first  showed.  But 
this  stage  of  loss  is  succeeded  by  temporary  increase  in  the  myotatic 
irritability,  so  that  the  knee-jerk  is  excessive  and  the  foot-clonus  may 
be  obtained.  Iu  most  cases  this  increase  is  alone  to  be  detected.  It 
may  be  present  only  on  the  side  on  which  the  convulsion  was  most 
severe,  i.  e.  on  the  side  towards  which  the  head  is  turned  (Beevor). 
It  lasts  a  few  minutes  and  then  passes  away.  These  phenomena  are 
probably  the  result  of  temporary  exhaustion  of  the  centres  concerned 
— of  the  muscle-reflex  centre  in  the  case  of  loss,  of  the  controlling  struc- 
tures (the  terminations  of  the  pyramidal  fibres)*  in  the  case  of  excess. 

Loss  of  motor  power,  paralysis,  may  succeed  a  fit  of  epileptic  type 
— post-convulsive  paralysis,  as  already  described  (p.  92).  It  is  most 
distinct  after  unilateral  convulsions  (and  constitutes  the  "  epdeptic 
hemiplegia  "  of  Todd),  but  the  general  prostratiou  after  a  bilateral  con- 
vulsion is  probably  analogous.  After  a  severe  fit  it  may  be  due  to 
exhaustion  of  the  nerve-elements,  but  the  transient  palsy  that  succeeds 
a  very  slight  fit  must  be  ascribed  to  inhibition  of  the  motor  centres. 
In  many  of  these  cases  there  is  conspicuous  sensory  discharge, 
"tingling,"  &c,  passing,  for  instance,  up  the  arm,  and  down  the  side 
to  the  leg ;  there  may,  indeed,  be  no  motor  spasm.  In  such  a  case 
of  purely  sensory  discharge,  the  arm  may  be  for  a  time  almost  power- 
less. .Just  as  such  a  discharge  in  the  sensory  centre  may,  as  we 
have  seen,  set  up  secondai*y  discharge  in  the  motor  centre,  so  it  may, 
when  slight,  merely  inhibit  the  centre.  Loss  of  speech  sometimes 
occurs  after  right-sided  seizures,  and  probably  has  the  same  inhibitory 
origin.  These  forms  of  transient  palsy  must,  however,  be  distinguished 
from  palsy  due  to  cerebral  haemorrhage  caused  by  the  fit  (an  exces- 
sively rare  event),  and  also  from  the  condition  in  which  convulsions 
merely  attend  the  onset  of  an  acute  cerebral  lesion. 

Automatic  action  and  by  steroid  phenomena  are  very  common  after 
slight  attacks  of  epilepsy,  and  occasionally  succeed  a  severe  fit.  For 
instance,  a  girl  aged  seventeen  bad  suffered  from  six  years  of  age 
from  severe  epileptic  seizures  with  tongue-biting  ;  at  the  age  of  puberty 

*  See  vol.  i,  p.  201. 


741  EPILEPSY. 

the  attacks,  without  change  in  character,  were  succeeded  by  hysteroid 
convulsions.  In  one  that  was  seen,  she  suddenly  fell  with  a  scream  ; 
her  head  was  turned  to  the  left,  the  limbs  were  rigid,  the  face  cyanotic, 
clonic  spasm  succeeded,  with  frothing  at  the  mouth ;  the  tongne  was 
bitten.  The  fit  lasted  two  minutes  and  a  half.  She  then  lay  uncon- 
scious, breathing  heavily,  and  still  frothing  at  the  mouth.  Then  she 
opened  her  eyes,  looked  strange,  kicked  and  threw  her  arms  about, 
dashed  her  head,  and  arched  her  back  for  four  minutes.  She  then 
went  to  sleep,  and  slept  for  an  hour. 

The  temperature  may  be  raised  half  a  degree  or  a  degree  by  a 
severe  convulsion,  or  it  may  present  no  alteration.  When  attacks 
follow  each  other  at  intervals  of  only  a  few  minutes  (status  epilep- 
ticus),  the  temperature  may  rise  to  105°  or  107°  (Bourneville). 
The  strain  may  cause  small  vessels  to  rupture,  usually  in  the  face 
and  conjunctiva,  so  that  the  face  may  be  spattered,  as  it  were,  with 
small  hsemorihagic  points.  After  death  in  a  convulsion,  similar  extra- 
vasations may  be  found  in  internal  organs. 

Yomiting  occurs  after  fits,  in  some  patients.  It  is  a  dangerous 
symptom,  on  account  of  the  liability  of  food  to  get  into  the  larynx  in 
the  state  of  insensibility.  Excessive  hunger  is  an  occasional  sym- 
ptom after  an  attack,  and  a  patient  who  has  had  a  hearty  meal 
before  a  fit  will  eat  another  directly  after  it.  The  urine  is  rarely 
altered  in  its  constitution  by  an  epileptic  seizure.  Now  and  then  a 
trace  of  albumen  or  of  sugar  may  be  found,  but  the  frequency  of  this 
has  been  greatly  exaggerated ;  each  is  rare.  There  is  no  necessary 
increase  in  the  amount  of  urea.  It  has  been  said  that  every  fit 
causes  a  loss  of  body-weight  (Kowalewsky),  but  this  has  not  been 
found  by  others  (Lehmann,  Beevor,  &c). 

Minor  Attqcks. — The  slight  attacks  of  epilepsy  vary  much  in  cha- 
racter, and  hence  patients  speak  of  them  under  various  designations, 
such  as  "sensations,"  "faints,"  "losses,"  "turns,"  "giddiness" 
Hence,  also,  their  nature  is  often  not  recognised  by  the  patients  or 
their  friends.  As  a  rule  there  is  brief  loss  of  consciousness,  and  this, 
as  already  stated,  may  constitute  the  only  apparent  symptom.  Often, 
however,  there  is  a  slight  stoop  forwards,  or  a  slight  quivering  of  the 
eyelids.  The  patient  may  or  may  not  fall.  The  colour  of  the  face, 
in  many  cases,  undergoes  no  change ;  there  is  scarcely  ever  pallor  at 
the  moment  of  onset,  but  in  a  second  or  two  the  face  becomes  slightly 
pale  in  many  cases,  and  when  the  attack  is  over,  whether  there  has  or 
has  not  been  pallor,  the  face  commonly  becomes  a  little  flushed.  Nor 
is  there  any  change  in  the  retinal  vessels.  In  one  case  I  was  observ- 
ing the  vessels  when  an  attack  came  on ;  the  eyes  were  open  and 
fixed,  and  for  several  seconds  after  the  onset,  as  well  as  before  it,  I 
could  not  perceive  the  slighest  change  in  their  size.  In  many  patients 
the  loss  of  consciousness  is  preceded  by  some  warning  sensation,  and 
it  is  from  this  circumstance  that  the  minor  seizures  are  so  often 
termed  "  sensatious."      The  patient  may  know  nothing  of  the  loss 


SYMPTOMS    IN    DETAIL.  745 

■of  consciousness,  and  be  aware  only  of  the  sensation.  Very  often 
a  warning  occurs  only  before  the  minor  seizure,  the  severe  fits 
•coming  on  so  rapidly  that  loss  of  consciousness  is  the  earliest  sym- 
ptom. When  each  kind  of  attack  is  preceded  by  an  aura,  this  is 
usually  similar  in  character,  although,  as  already  mentioned,  it  may 
be  more  elaborate  before  the  slight  than  before  the  severe  seizures. 
It  is  rare  for  the  aura  of  each  to  be  altogether  different. 

The  following  list  comprehends  the  chief  characteristic  features  of 
minor  seizures.  They  are  arranged  in  the  order  of  frequency.  In  most 
cases  there  is,  in  addition,  brief  loss  of  consciousness.  The  first  of 
the  list  occurs  in  one  third  of  the  cases,  and  the  second  in  a  sixth,  so 
that  these  two  are  the  characteristics  of  about  half  the  minor  epi- 
leptic seizures  met  with. 

1.  Sudden  momentary  unconsciousness,  or  "  fainting  "  or  "  sleepi- 
ness," without  warning. 

■2.  Giddiness. 

3.  Jerks  or  starts  of  the  limbs,  trunk,  or  head. 

4.  Visual  sensation  or  loss. 

5.  Mental  state ;  sudden  sense  of  fear,  &c. 
•6.  Unilateral  peripheral  sensation  or  spasm. 

7.  Epigastric  sensation. 

8.  Sudden  tremor. 

9.  Sensations  in  both  hands. 

10.  Pain  or  other  sensation  in  the  head. 

11.  Choking  sensation  in  the  throat. 

12.  Sudden  scream. 

13.  Olfactory  sensation. 

14.  Cardiac  sensation. 

15.  Sensation  in  nose  or  eyeball. 

16.  Sudden  dyspnoea. 

17.  General  "  indescribable  "  sensations. 

"While  giddiness  is  thus  one  of  the  most  common  sensations,  it  is 
only  present  in  a  small  proportion  of  the  total  number,  and  it  is  a 
mistake  to  employ  the  term  "  epileptic  vertigo "  (as  it  has  been 
employed)  as  a  general  designation  for  attacks  of  minor  epilepsy. 
The  sense  of  vertigo  usually  involves  an  apparent  movement,  some- 
times in  the  patient,  sometimes  in  objects  seen ;  the  direction  of  these 
apparent  movements  is  usually  the  same  ;*  the  vertigo  is  sometimes 
attended  with  actual  rotation.  Special-sense  auree  are  also  frequent 
in  minor  epilepsy,  and  present  the  characters  already  described ; 
the  visual  sensation  is  the  only  frequent  one.  The  epigastric  sensa- 
tion is  much  less  common  than  before  severe  fits. 

Loss  of  consciousness  is  the  rule,  but  exceptions  are  often  met  with, 

*  The  explanation  of  the  fact  will  be  given  in  the  account  of  vertigo.  It  may  be 
well  to  remind  the  observer  that  the  term  "giddiness"  or  "dizziness"  is  often 
applied  to  any  obscuration  of  consciousness,  and  the  exact  character  of  the  sensation 
should  always  be  ascertained. 


746  EPILEPSY. 

in  which  there  is  merely  obscuration  of  consciousness  for  a  few  seconds, 
and  no  absolute  loss.  In  the  cases  in  which  the  minor  attacks  consist 
of  sudden  starts,  or  of  a  visual  sensation,  consciousness  may  be 
apparently  unaffected. 

Urine  is  often  passed  during  a  minor  attack ;  in  such  cases  there 
is  almost  always  loss  of  consciousness,  but  one  patient  was  always 
aware  of  it,  although  unable  to  prevent  it.  In  some  cases  micturition 
is  almost  invariable,  in  others  it  never  occurs.  The  accident  is  far 
more  common  in  females  than  in  males  ;  perhaps  because  the  process 
can  occur  more  quickly  on  account  of  the  shortness  of  the  urethra. 

In  some  cases  the  minor  attacks  may  be  accompanied  with  slight 
convulsive  spasm,  tonic  when  general,  but  usually  clonic  when  it  is 
local.  In  such  cases  attacks  occur  which  present  every  gradation 
between  the  slight  and  severe  seizures.  The  degree  which  is  the 
maximum  in  one  case  may  be  the  minimum  in  another. 

Conditions  after  Minor  Attacks. — The  return  of  consciousness  to  its 
average  degree  often  occurs  slowly  ;  the  patient  is  dazed  and  stupid 
for  a  few  minutes,  makes  random  remarks,  and  occasionally  performs, 
in  an  automatic  manner,  some  action  of  which  he  afterwards  retains 
no  recollection.  Such  automatic  action  was  formerly  regarded  as  con- 
stituting the  minor  attack  of  epilepsy,  and  these  cases  were  therefore 
called  "  masked  epilepsy  "  (Esquirol),  or  "  epilepsia  larvata  "  (Morel). 
I  believe  that  the  old  view  is  not  altogether  untrue  ;  that  in  some  cases, 
imperfect  loss  of  consciousness,  with  automatic  action,  does  constitute 
the  minor  seizure,  without  any  initial  stage  more  distinctly  epileptic. 
But  it  is  certain  that,  much  more  frequently,  the  automatism  succeeds 
a  slight  attack,  and  is  really  a  post-epileptic  phenomenon.  It  has 
been  ascribed  to  the  temporary  failure  of  the  highest  centres  to  con- 
trol those  next  below  them,  which  consequently  act  in  an  automatic 
manner  (Anstie,  Thompson-Dickson,  Hughlings  Jackson).  The  con- 
dition is  not  merely  of  clinical  interest,  but  also  of  medico-legal 
importance,  since  the  performances  may  be  complex,  and  may  have  all 
the  aspect  of  deliberate  volition ;  the  initial  epileptic  seizure  may  be 
unnoticed  by  those  around,  and  even  unknown  to  the  patient.  One 
of  the  most  common  actions  is  that  of  undressing,  which  is  occasion- 
ally very  inconvenient.  It  is  possibly  suggested  by  a  feeling  of  illness, 
and  so  likewise  may  be  another  occasional  action,  an  attempt  to  walk 
upstairs,  which  is  also  awkward  if  (as  happened  in  two  cases)  the 
shelves  of  a  dresser,  or  the  dinner-table,  is  mistaken  for  the  stair- 
case. A  very  common  action,  still  more  equivocal  in  its  aspect,  is  to 
put  in  the  pocket  any  object  which  may  be  near,  irrespective  of  its 
ownership.  This  gave  rise  at  first  to  grave  suspicion  in  the  case  of 
one  of  my  patients,  a  draper's  assistant,  who  had  gone  to  a  new  situa- 
tion. Very  complex  actions  may  be  performed  in  this  state.  I  have 
known  a  carman,  alter  an  attack,  to  drive  through  the  most  crowded 
parts  of  London  without  any  object,  but  also  without  any  accident. 
Occasionally  the  automatic  action  displays  emotion,  and  even  anger 


SYMPTOMS   IN    DETAIL.  747 

and  violence.  One  patient  struck  a  friend  who  was  with,  him  a  violent 
blow  on  the  face,  and  was  in  consequence  taken  to  the  police  station. 
Another,  a  woman,  immediately  after  a  fit,  threw  her  baby  downstairs. 
"Without  doubt  many  crimes  have  been  committed  in  this  state, 
and  the  point  has  formed  a  medico-legal  question  at  many  criminal 
trials. 

Instead  of  presenting  such  automatic  action,  some  patients  pass,  as 
already  mentioned,  into  a  state  of  violent  hysteroid  convulsion. 
This  sequel  occurs  chiefly  at  the  age  at  which  hysteria  is  met  with, 
under  thirty-five.  It  is  most  common  in  young  women,  frequent  in 
boys  and  girls,  occasional  in  young  men.  Hence  it  is  evidently  the 
result,  not  merely  of  the  preceding  epileptic  fit,  but  also  of  the  presence 
of  the  cerebral  state  which  underlies  other  manifestations  of  hysteria. 
Some  patients  have  similar  attacks  at  other  times  as  well  as  after  their 
epileptic  fits.  In  others  there  are  no  separate  hysterical  phenomena, 
the  hysterical  tendency  being  apparently  insufficient  to  lead  to  inde- 
pendent symptoms,  although  it  manifests  itself  during  the  morbid 
state  immediately  after  an  epileptic  fit.  As  an  example  of  these  phe- 
nomena may  be  mentioned  the  case  of  a  girl,  aged  fourteen,  who  had 
had  many  severe  epileptic  fits  accompanied  by  tongue-biting,  and  also 
slighter  attacks  followed  by  hysteroid  convulsions.  I  witnessed  one 
of  the  latter.  When  speaking  to  me  she  suddenly  stopped,  bent  for- 
wards, and  remained  still  for  a  few  seconds  ;  then  she  suddeuly  threw 
her  arms  about,  stamped  with  her  feet,  and  became  stiff  and  rigid  for 
a  few  minutes  in  a  characteristic  hysteroid  convulsion.  It  is  often 
said  that  attacks  in  childhood  were  slight,  and  at  the  time  of  puberty 
became  severe,  when  further  inquiry  shows  that  the  severe  fits  con- 
sisted only  in  the  addition  of  hysteroid  convulsion  to  the  slight 
attacks.  There  is  another  post-epileptic  action  which  is  automatic, 
and  may  occur  alone  or  with  hysteroid  convulsion,  and  is  important  on 
account  of  its  danger — a  tendency  to  turn  over  on  the  face.  If  the 
patient  is  in  bed,  suffocation  may  easily  occur  during  the  comatose 
sleep  that  follows,  and  without  doubt  many  epileptics  have  died 
from  this  cause.  Some  patients  never  present  this  tendency,  others 
always  do,  and  their  friends  should  be  warned  of  its  danger.  Minor 
attacks,  when  frequent,  may  entail  great  physical  weakness,  so  that 
the  patient  can  scarcely  walk.  In  other  cases  no  such  effect  is  pro- 
duced.* 

Mental  Disturbance  in  Epileptics. — The  occun-ence  of  transient 
"  epileptic  mania  "  as  a  sequel  to  attacks  has  been  already  mentioned. 
It  is  uncertain  whether  such  an  outbreak  may  take  the  place  of  a  fit, 
but  we  are  not  at  present  justified  in  denying  its  possibility.     In  this 

*  It  has  been  said  that  there  is  commonly  to  be  found,  in  epileptics,  some  restric- 
tion of  the  fields  of  vision,  especially  after  a  fit,  and  that  it  is  greatest  in  the  upper 
inner  half  of  the  left  eye  and  the  lower  outer  half  of  the  right  eye  (Otolonghi, 
'  Lombroso's  Archiv,'  1890).  I  have  met  with  general  reduction  of  the  fields  to  a 
third,  after  an  attack. 


748  EPILEPSY. 

condition  the  patient  is  often  violent  and  homicidal,  and,  although 
perfectly  sane  in  the  intervals,  is  one  of  the  most  dangerous  of  lunatics. 
The  mania  is  usually  brief,  often  lasting  only  a  few  minutes,  rarely 
more  than  an  hour.  But  occasionally,  after  a  fit  or  a  series  of  fits, 
mental  disturbance  may  come  on  and  last  for  several  days,  a  state  of 
dementia,  or  of  mania,  with  delusions  or  hallucinations,  often  with 
irritability  and  violence.  It  may  even  occur  during  the  temporary 
cessation  of  attacks. 

The  interparoxysmal  mental  state  of  epileptics  often  presents  grave 
deterioration,  and  this  is  one  of  the  most  serious  and  most  dreaded 
effects  of  the  disease.  In  its  slighter  degree  there  is  merely  defective 
memory,  especially  for  recent  acquisitions.  In  greater  degree  the 
intellect  suffers  generally,  and  there  is  often  defective  moral  control. 
Mischievous  restlessness  and  irritability  in  childhood  may  develop  to 
vicious  and  even  criminal  tendencies  in  adult  life.  Every  grade  of 
defect  may  be  met  with,  to  actual  imbecility.  The  mental  state  is 
not,  in  all  cases,  entirely  the  result  of  the  attacks  of  epilepsy.  In 
some  it  is,  in  part  at  least,  the  expression  of  a  cerebral  imperfection, 
of  which  the  epilepsy  is  another  manifestation.  In  such  instances 
mental  defect  may  exist  before  the  occurrence  of  the  first  fit,  or  may 
follow  attacks  very  rapidly.  Iu  other  cases  the  failure  is  apparently 
produced  solely  by  the  attacks.  It  succeeds  them  in  time,  and  may 
lessen  when  treatment  renders  them  less  frequent. 

A  comparison  of  cases  with  considerable  mental  defect,  and  others 
in  which  no  mental  failure  was  noted,  shows  that  the  deterioration 
cannot  be  ascribed  to  any  one  element  in  the  disease.  The  most 
influential  agents  are  the  early  commencement  of  the  disease,  its 
duration,  and  the  frequency  of  attacks.  The  tendency  is  greater  in 
the  cases  that  commence  in  childhood  than  in  those  which  commence 
between  ten  and  twenty,  and  greater  in  tuose  which  begin  in  the  first 
than  in  the  second  five  years  of  life.  The  influence  of  duration  is 
shown  by  the  fact  that,  of  the  cases  with  mental  failure,  nearly  three 
quarters,  and  of  those  without,  less  than  half,  had  lasted  more  than 
four  years.  The  influence  of  frequency  of  attack  is  shown  by  the  fact 
that  the  average  interval  in  the  weak-minded  cases  was  fifteen  days, 
in  the  others  twenty-six  days.  On  the  other  hand,  the  influence  of 
form  of  attack  (major  or  minor),  of  heredity,  and  of  sex  is  not  great. 
Considerable  failure  is  often  seen  in  patients  who  have  only  minor 
attacks,  but  extended  observation  does  not  show  that  it  is  more  com- 
mon in  such  cases  than  in  others.  That  there  is  no  necessary  rela- 
tion between  any  of  these  conditions  and  mental  failure  is  shown  by 
the  fact  that  each  one  may  be  met  with  in  high  degree  without  any 
impairment  of  the  intellect.  On  the  other  hand,  there  is  no  condition 
in  which  mental  deterioration  does  not  occasionally  occur.  The  con- 
clusion is  that  mental  failure  is  determined  less  by  single  conditions 
than  by  their  combinations,  and  it  is  probable  that  a  more  potent 
cause  than  the  attacks  themselves  is  a  predisposition  to  suffer  under 


SYMPTOMS    IN   DETAIL.  749 

their  influence,  a  predisposition  that  is  related  to  the  ultimate  causes 
of  the  disease,  rather  than  to  its  developed  characters. 

When  attacks  that  have  occurred,  during  many  years,  stop  sud- 
denly, whether  the  stoppage  is  spontaneous  or  clue  to  the  influence  of 
drugs,  patients  may  become  dull,  forgetful,  sometimes  irritable,  and 
sometimes  half  idiotic.  The  effect  is  often  ascribed  to  the  remedy 
used,  especially  if  this  is  bromide ;  but  it  seems  to  be  due  rather  to 
the  general  depression  of  cerebral  function  by  the  condition  of  the 
nerve- cells,  which,  by  repeated  discharge,  have  developed  a  tendency 
to  over-production  of  nerve-force,  and  this  is  no  longer  released  in  the 
fits.  A  fit  may  completely  remove  the  state.  It  is  common  for 
patients  to  say  that  they  feel  better  when  they  are  having  fits  than 
when  they  are  not.  The  cerebral  depression  is  probably  increased, 
when  it  is  not  caused,  by  full  doses  of  bromide. 

The  general  health  of  epileptics  may  be  perfect.  Often  there  is  some 
defect,  especially  in  the  functions  of  the  digestive  organs.  The  circu- 
lation is  sometimes  feeble,  the  pulse  small,  unduly  frequent,  and  very 
often  slightly  irregular.  No  abnormal  state  of  the  pupil  or  retinal 
circulation  can  be  found  with  any  special  frequency  in  the  intervals 
between  the  attacks. 

Post-hemiplegic  Epilepsy. — In  a  considerable  proportion  of  the  cases 
of  epilepsy  the  convulsions  succeed  an  attack  of  hemiplegia,  sudden  in 
onset,  and  therefore  presumably  due  to  a  vascular  lesion.  The  palsy 
may  lessen  or  disappear,  and  the  convulsions,  continuing  years  after, 
may  resemble  those  of  the  idiopathic  form,  and  are  often  supposed 
to  be  of  this  nature.     Hence  it  is  convenient  to  consider  them  here. 

Eecurring  convulsions  may  follow  hemiplegia  at  any  age,  but  are 
far  more  frequent  after  that  which  occurs  in  infancy  than  after  hemi- 
plegia in  adult  life.  In  two  thirds  of  the  cases  the  onset  is  before 
five  years  of  age,  and  in  nearly  half  it  is  during  the  first  two  years  of 
life.  In  the  cases  that  date  from  infancy,  females  are  twice  as 
numerous  as  males  ;  after  five  years  of  age,  there  is  little  difference  in 
the  frequency  with  which  each  sex  suffers.  The  paralysis,  in  the 
infantile  cases,  is  more  frequently  on  the  left  side  than  on  the  right, 
but  after  the  fifth  year  it  is  as  frequently  on  one  side  as  on  the  other. 
The  conditions  of  onset,  and  the  probable  nature  of  the  lesion,  in  the 
infantile  cases,  have  been  already  considered  (p.  456).  In  later  life, 
when  there  is  any  indication  of  the  cause  of  the  hemiplegia,  this  also 
(heart  disease,  rheumatic  fever,  constitutional  syphilis,  the  puerperal 
state)  points  to  vascular  obstruction.  In  softening  from  this  cause, 
the  brain  tissue  adjacent  is  usually  damaged  by  the  collateral  conges- 
tion, and  it  is  easy  to  understand  that  the  nerve-cells  may  suffer  a 
permanent  change  in  their  nutrition  and  function,  causing  instability, 
perpetuated  by  their  repeated  discharge.  Moreover,  acute  softening 
often  affects  the  cortex  of  the  brain,  where  organic  changes  most 
frequently  cause  convulsions.  In  a  few  cases  the  condition  is  said  to 
date  from  birth ;  in  most  of  these  the  labour  was  difficult,  and  then 


750  EPILEPSY. 

meningeal  haemorrhage,  with  laceration  of  the  cortex,  is  probable  (see 
p.  413). 

In  half  the  cases,  convulsions,  often  repeated  and  severe,  attend  the 
onset  of  the  hemiplegia.  The  chronic  recurring  fits  date  from  the 
onset  in  about  a  third  of  the  cases.  In  the  rest  there  is  an  inteival 
before  the  recurring  fits  commence,  which  is  usually  at  least  a  year, 
and  may  be  fifteen  or  twenty  years.  It  is  uot  uncommon  for  the 
hemiplegia  to  occur  in  infancy,  and  the  convulsions  to  commence  at 
the  epileptogenic  period  of  puberty ;  sometimes  a  distinct  exciting 
cause  can  then  be  traced.  When  the  attacks  date  from  the  onset,  as  a 
rule  this  was  attended  with  convulsions,  but  the  converse  does  not 
hold  good.  When  the  hemiplegia  came  on  in  adult  life,  a  long 
interval  is  rare  ;  the  fits  usually  commence  in  less  than  a  year. 

The  degree  of  the  hemiplegia  at  the  onset  varies  ;  it  may  be  con- 
siderable or  slight ;  in  young  children,  when  trifling,  it  may  be  over- 
looked, the  more  readily  if  the  child  is  gravely  ill.  Still  more  various 
is  the  degree  of  paralysis  which  persists.  The  leg  has  usually  reco- 
vered, to  a  Jarge  extent  or  altogether.  The  arm  is  more  often  weak, 
sometimes  powerless  and  small ;  occasionally  it  presents  little  or  no 
eAridence  of  the  initial  weakness.  In  half  the  cases  the  hand  presents 
a  state  of  "  mobile  spasm,"  in  slight  or  considerable  degree  (see  p.  86), 
and  it  is  important  to  look  for  traces  of  this  in  doubtful  cases,  since 
it  may  be  distinct  when  the  weakness  is  not. 

The  convulsive  attacks,  in  the  majority  of  cases,  begin  in.  and  are 
confined  to,  the  paralysed  side.  In  rare  cases,  in  which  the  attacks  are 
severe,  they  may  be  always  general.  A  distinct  warning  is  present  in 
about  five  sixths  of  the  cases,  far  more  frequently  than  in  idiopathic 
epilepsy ;  and  in  half  the  cases  it  consists  in  a  deliberate  commence- 
ment of  the  attack  in  some  part  of  the  paralysed  side.  The  other 
less  frequent  warnings  are  for  the  most  part  similar  to  those  of 
the  idiopathic  form.  The  spasm  is  usually  also  of  the  same 
character. 

Minor  attacks  are  frequent  in  these  cases,  sometimes  similar  to 
those  of  idiopathic  epilepsy  (a  faint,  sudden  giddiness,  &c),  but  more 
frequently  they  consist  of  the  aura  of  the  severe  fit,  often  without 
loss  of  consciousness.  Hysteroid  seizures  are  also  common  in  these 
cases,  and  so  is  considerable  mental  defect. 

The  Complications  of  epilepsy  are  chiefly  the  conditions  that  induce 
it,  when  they  persist ;  these  have  been  mentioned  in  the  account  of 
its  cause :  secondly,  its  effects  on  the  nervous  system  and  general 
health,  especially  associated  hysteroid  disturbance.  Migraine  and 
epilepsy  are  occasionally  associated,  sometimes  in  apparent  indepen- 
dence, while  sometimes  the  migraine  ceases  when  the  fits  begin.  In 
one  remarkable  case  of  this  character  the  preliminary  sensory  disturb- 
ance of  typical  migraine  persisted,  in  briefer  form,  as  the  aura  of 
characteristic  epileptic  fits. 

The  T'arieties  of  epilep>sy  have,  for  the  most  part,  been  mentioned 


SYMPTOMS    IN    DETAIL.  751 

in  the  account  of  the  symptoms.  The  most  important  classes  are  the 
idiopathic  and  organic  forms,  the  latter  including  post-hemiplegic 
epilepsy  and  epilepsy  from  active  irritant  brain  disease.  By  some, 
the  organic  forms  are  termed  epileptoicl  convulsions,  but  they  may 
become  established  as  an  ineradicable  disease,  through  the  effect  of 
the  repeated  discharges,  to  the  idiopathic  form. 

Besides  these,  patients  sometimes  suffer  from  sudden  brief  sym- 
ptoms, bearing  more  or  less  resemblance  to  some  element  of  the 
minor  epileptic  attack,  such  as  sudden  transient  causeless  vertigo,  or 
recurring  causeless  faints  that  have  the  aspect  of  cardiac  faints. 
Many  of  these  cases  are  probably  on  the  border  line  of  epilepsy,  into 
which  some  would  pass  unless  relieved.  There  is,  indeed,  some  reason 
to  think  that  cardiac  faints,  often  occurring,  may  establish  in  the 
brain  a  tendency  to  pass  into  a  state  of  similar  functional  abeyance — 
essentially  petit  mal. 

Course  of  Epilepsy. — The  disease  may  commence  by  severe  fits  or 
by  slight  ones.  The  latter  may  exist  alone  for  months  or  years,  and 
their  nature  may  be  unsuspected  until  a  severe  fit  occurs.  The 
interval  between  the  first  and  second  severe  fit  is  sometimes  pro- 
longed, and  is  a  point  of  considerable  importance.  When  a  single 
convulsive  attack  has  occurred,  the  anxious  question — whether  it  is 
epilepsy  ? — can  only  be  answered  by  the  occurrence  or  absence  of 
other  fits.  In  one  third  of  the  cases  the  interval  is  less  than  a 
month  ;  in  another  third  it  is  between  one  and  twelve  months  ;  in  the 
remainder  it  is  more  than  a  year,  and  it  is  occasionally  ten  years. 
Thus  the  chance  of  recurrence  does  not  materially  lessen  until  a  year 
has  elapsed. 

When  the  disease  is  established  the  interval  between  severe  fits 
varies  greatly.  It  is  less  than  a  month  in  three  quarters  of  the  cases; 
in  about  half,  it  does  not  exceed  two  weeks  ;  in  about  a  tenth,  fits  occur 
daily.  Usually  the  intervals  vary,  and  they  correspond  to  our  current 
divisions  of  time  only  in  the  cases  (not  frequent)  in  which  attacks  in 
women  are  related  to  the  menstrual  periods. 

The  attacks  may  be  isolated  or  grouped ;  the  former  is  more  common. 
When  grouped,  several  attacks  occur  together,  and  then  there  is  an 
interval  of  freedom.  The  number  in  each  group  varies  from  two  or 
three  to  twenty.  The  patient  usually  recovers  consciousness  between 
each.  In  rare  instances  a  series  of  fits  occurs  in  which  the  patient 
does  not  recover  consciousness  ;  during  the  coma,  one  fit  after  another 
comes  on.  This  has  been  termed  the  status  epilepticus,  and  is  a  very 
grave  condition.  In  its  most  severe  form,  the  intervals  between  the 
fits  become  shorter,  the  coma  deepens,  the  pulse  and  respiration 
become  very  frequent,  and  the  temperature  rises,  it  may  be  to  105°  or 
107°  (Bourneville).  The  patient  may  die  in  a  state  of  collapse,  from 
the  violence  of  the  convulsions,  or,  the  fits  ceasing,  he  may  become 
delirious,  and  present  symptoms  of  meningitis,  with  rapid  formation 
of  bedsores,  and  may  die  in  this  stage.     At  any  period  the  symptoms 


752  EPILEPSY. 

may  lessen,  and  the  patient   recover.      Many   cases,    however,   end 
fatally,  but  foi'tunately  the  condition  is  rare. 

Minor  attacks  occur  in  less  than  half  the  cases  of  epilepsy.  They 
may  occur  alone,  without  severe  fits,  but  both  kinds  are  usually  asso- 
ciated. The  slight  seizures  are,  as  a  rule,  frequent.  In  more  than 
half  the  cases  in  which  they  occur  at  all,  there  are  daily  attacks, 
usually  from  two  to  twenty  each  day,  and  I  have  even  known  as  many 
as  two  hundred  to  occur  every  day.  When  there  are  no  other  attacks,, 
the  minor  fits  are  usually  frequent,  and  daily.  They  may  also  occur 
daily  when  there  are  severe  fits,  but  when  the  minor  attacks  are  less 
frequent,  the  patient  usually  has  also  severe  fits.  "When  the  latter 
are  frequent,  minor  attacks  are  often  less  frequent.  Now  and  then, 
when  the  interval  between  the  severe  fits  is  more  than  two  weeks, 
the  minor  attacks  occur  for  a  few  days  before  (less  commonly  after) 
the  severe  fits. 

Epileptic  fits  may  come  on  when  the  patient  is  asleep  or  awake,  or 
in  both  conditions.  They  occur  in  both,  or  in  the  waking  state  only, 
twice  as  frequently  as  in  the  sleeping  state  only.  Very  rarely  the 
patient  has  them  only  in  the  act  of  going  to  sleep  or  of  waking  up. 
!Now  and  then  they  are  confined  to  the  early  morning.  When  fits  that 
have  occurred  only  during  the  night,  occur  during  the  day,  they 
usually  continue  during  the  night,  but  if  they  have  previously  been 
diurnal  only,  and  commence  in  the  night,  they  very  often  cease  during 
the  day.  Attacks  which  have  occurred  both  day  and  night  often 
cease  in  the  day  and  continue  in  the  night,  but  very  rarely  cease  at 
night  and  continue  during  the  day. 

In  women,  attacks  often  occur  at  the  menstrual  period,  although 
wrhen  closely  investigated  the  relation  is  not  found  to  obtain  in  more- 
than  about  half  the  cases.  The  usual  relation  is  for  the  attack  to 
occur  before,  or  (rather  less  frequently)  during  the  period,  rarely 
after  it.  The  relation  does  not  seem  to  be  connected  with  any 
abnormal  state  of  the  uterine  organs. 

Death  is  a  rare  consequence  of  epilepsy,  especially  when  allowance 
is  made  for  the  frequency  of  the  disease,  and  the  alarming  aspect  of 
the  fits.  When  it  does  occur,  it  is  scarcely  ever  from  the  direct  effect 
of  the  convulsion,  except  in  the  "  status  epilepticus."  It  usually 
results  from  some  accident  to  which  the  fit  leads,  such  as  a  fall  into 
the  water  or  a  burn.  It  may  also  be  due  to  suffocation  produced 
during  the  state  of  coma,  either  by  vomited  food  getting  into  the 
larynx,  or  by  the  patient  in  bed  turning  over  on  the  face. 

Pathological  Anatomy. — The  naked-eye  appearance  of  the  nerve- 
centres  in  epilepsy  is,  for  the  most  part,  that  of  healthy  organs.  In 
cases  of  long  duration  there  is  occasionally  slight  opacity  and  thick- 
ening of  the  meninges,  and  after  death,  in  the  status  epilepticus,  there- 
may  be  signs  of  meningitis,  but  these  are  apparently  merely  secondary 
changes.     If  the  patient  has  died  in  a  fit,  the  post-mortem  usually 


PATHOLOGY.  753 

shows  signs,  in  all  organs,  of  the  intpnse  venous  engorgement  which  Is 
so  conspicuous  during  life,  and  small  extravasations  of  blood  may  be 
found,  such  as  are  met  with  in  all  cases  of  asphyxia.  Of  the  histo- 
logical changes  revealed  by  the  microscope,  most  of  those  which  are 
not  common,  apart  from  symptoms,  are  apparently  of  secondary  origin, 
the  result  and  not  the  cause  of  the  convulsions  ;  and  the  various  changes 
that  have  been  described,  and  have  been  supposed  to  be  related  to  the 
origin  of  the  disease,  have  probably  no  connection  with  it,  and  do  not 
even  deserve  enumeration.  No  greater  significance  can  be  ascribed  to 
the  induration  of  the  cornu  ammonis  (pes  hippocampi),  to  which 
weight  has  been  attached  by  Meynert.  Nor  is  there  at  present 
much  likelihood  that  our  knowledge  will  be  more  definite.  The 
changes  in  the  neiwe-elements  are  probably  of  that  molecular  cha- 
racter which  is  revealed  only  by  altered  function,  and  eludes  the  most 
minute  research. 

Pathology. — In  the  absence  of  any  help  from  anatomy  and 
histology  the  pathology  of  idiopathic  epilepsy  is  a  matter  of  hypo- 
thesis, based  on  the  influence  of  organic  disease  in  causing  similar 
symptoms,  on  the  results  of  experiments  on  auimals,  and  on  the 
indications  afforded  by  a  study  of  the  symptoms  in  the  light  of 
cerebral  physiology. 

It  may  be  premised,  as  admitting  of  no  question,  that  the  muscular 
spasm  is  to  be  regarded  as  the  result  of  the  sudden  over-action  ("  dis- 
charge ")  of  nerve-cells,  the  violent  liberation  of  nerve-force,  and 
that  the  sensations  which,  in  some  cases,  the  patient  experiences 
before  losing  consciousness  must  be  due,  directly  or  indirectly,  to  the 
same  cause  (see  p.  737).  The  problem  is,  how  this  over-action  is 
brought  about,  and  where  it  occurs. 

What  is  the  primary  seat  of  discharge?  Experiment  teaches  that 
irritation  of  both  the  cortex  cerebri*  and  the  medulla  oblongataf  may 
cause  convulsion,  although  it  is  doubtful  how  far  the  latter  gives  rise 
to  convulsions  resembling  true  epilepsy. J  The  teaching  of  pathology 
is,  that  disease  which  excites  convulsions  is  most  frequently  at  the 
cortex,  and  that  whenever  organic  disease  causes  convulsions  that 
begin  locally,  the  disease  is  almost  invariably  at  the  cortex.  In  idio- 
pathic epilepsy  the  convulsions  sometimes  begin  in  this  manner,  and 
this  suggests  very  strongly  that  in  such  cases  the  process  occurs  in 
the  cortex. 

A  further  study  of  the  mode  of  onset  throws  some  light  on  the 

*  Ferrier,  Lucumi,  Bartholow,  Horsley,  &c. 

f  Brown-Sequard,  Kussmaul,  Nothnairel. 

%  Binswanger  ('Arch.  f.  Psych.,'  1888;  found  that,  in  animals,  tetanoid  attacks 
of  spasm  in  the  limbs  and  trunk  could  be  produced  by  electrical  stimulation  of  the 
lower  half  of  the  tloor  of  the  fourth  ventride  on  each  side,  and  concluded  that  they 
were  reflex  from  a  centre  in  the  dorsal  and  upper  region  of  the  pons;  but  he  never 
succeeded  in  causing  epileptic  attacks  of  the  common  type. 

vol.  n.  48 


754  EPILEPSY. 

question,  because  the  character  of  tbe  aura  indicates  the  function  Of 
the  part  in  which  the  discbarge  commences.  The  aurse  that  consist 
in  a  disturbance  of  the  fuuction  of  the  special  sense  centres,  indicate 
that  the  discharge  commences  in  those  centres, — that  is,  in  the  case  of 
smell  and  vision  at  least,  within  the  cerebral  hemispheres.  In  all 
cases  in  which  organic  disease  causes  convulsions  so  commencing,  the 
disease  has  been  in  or  close  to  the  cortex  (see  p.  92).  The  warnings 
which  consist  of  an  intellectual  process  or  an  emotion,  also  point  to 
the  cortex  as  the  seat  of  the  primary  discharge.  Thus  the  significance 
of  all  the  facts  regarding  the  modes  of  onset  that  we  can  interpret,  is 
that  the  discharge  in  epilepsy  begins  in  the  cortex  of  the  cerebral 
hemispheres.  The  conclusion  is  confirmed  by  rare  cases  in  which  a 
lesion  interrupting  the  internal  capsule  occurs  in  a  person  subject  to 
general  epileptic  fits.  The  effect  is  that  the  fits,  which  before  were 
general,  almost  cease  on  the  paralysed  side.*  Such  cases  show  that 
the  discharge  causing  the  general  convulsions  occurred  above  the 
internal  capsule,  i.  e.  in  the  cortex  o£  the  brain.  If  there  is  evidence 
that  so  many  cases  of  idiopathic  epilepsy  depend  on  discharge  of  the 
grev  matter  of  the  cortex,  it  is  probable  that  the  conclusion  is  true  of 
all  cases.  The  wide  variety  of  aura9  seems  to  show  that  the  primary 
discharge  may  occur  in  various  parts  of  the  cortex.  The  fact  that 
the  first  discharge  may  be  uniform  in  character  in  the  same  case — 
may  be  such,  for  instance,  as  to  cause  a  definite  and  even  complex 
sensation — can  only  be  explained  by  the  theory  that  the  derangement 
of  function  in  the  nerve-cells  is  inherent  in  them,  and  is  not  the 
result  of  any  random  influence  outside  them. 

All  parts  of  the  brain  are  intimately  connected,  and  the  siidden, 
i.  e.  instantaneous,  derangement  of  the  fuuction  of  any  part  appears 
incompatible  with  the  integrity  of  consciousness.  This  is  shown  by 
many  facts  of  organic  disease.  Hence  it  is  intelligible  that  sudden 
discharge,  wherever  it  occurs,  may  cause  loss  of  consciousness.  But 
if  there  is  reason  to  believe  that  sudden  discharge  may  occur 
in  any  part  of  the  grey  matter  of  the  cortex,  it  may  occur  in  that 
which  subserves  directly  the  phenomena  of  consciousness,  and 
a  sudden  alteration  in  the  functional  state  of  these  structures 
may  well  be,  as  Hughlings  Jackson  has  suggested,  the  most  probable 
explanation  of  the  attacks  which  consist  only  of  such  momentary 
loss. 

It  is  necessary,  however,  to  allude  briefly  to  other  theories  which 
have  been,  and  are  still,  current  regarding  the  nature  of  epilepsy.  It 
has  been  widely  held  that  the  morbid  action  in  the  brain  is  excited  by 
arterial  spasm,  causing  cerebral  anaemia,  and  also  that  the  convulsions 
originate  from  the  primary  discharge  of  a  convulsive  centre  in  the 
medulla,  but  that  the  loss  of  consciousness  is  produced  by  vaso-motor 
spasm  in  the  brain.     In  each  theory  it  is  assumed  that  the  vaso-motor 

*  Oebeke  has  recorded  such  a  case,  and  I  have  met  with  a  similar  instance, 
although  unconfirmed  by  nutopsy. 


PATHOLOGY.  755 

spasm,  is  due  to  the  sudden  over-action  of  the  vaso-motor  centre  in  the 
medulla;  The  evidence  on  which  these  theories  are  based  is  that 
cerebral  anaemia  will  cause  loss  of  consciousness  and  convulsion,*  and 
that  at  the  onset  of  epileptic  fits  there  is  always  pallor  of  the  face. 
But  the  latter  statement  is,  as  we  have  seen,  incorrect.  If  it  were 
true,  it  would  not  justify  the  conclusion  drawn  from  it.  We  do  not 
infer  that  the  brain  is  congested  whenever  the  face  blushes,  and  why 
should  we  assume  that  the  brain  is  anaemic  when  the  face  becomes 
pale  ?  There  is  no  necessary  correspondence  between  the  condition  of 
vessels  in  the  skin  and  in  the  viscera  beneath,  and  probably  even  less 
in  the  case  of  the  brain  than  in  that  of  other  organs.  It  is  far  more 
probable  that  the  spasm  of  the  vessels  of  the  face  is  the  result  of  the 
cerebral  discharge,  just  as  the  arteries  of  a  frog's  foot  will  contract 
when  its  brain  is  irritated.  In  rare  cases  in  which  an  early  failure  of 
the  heart  occurs,  this  may  also  be  the  effect  of  the  discharge,  which, 
as  it  often  influences  consciousness  first  through  the  central  connec- 
tion of  the  pneumogastric  (see  p.  738),  may  also  affect  the  periphery 
by  the  same  chaunel.  The  arteries  of  the  brain  may  possibly  be  thus 
influenced  in  a  secondary  manner.f  That  sudden  aneemia  of  the 
brain  will  cause  convulsions  is  no  proof  that  the  fits  of  idiopathic 
epilepsy  are  so  produced.  Such  a  theory  can  give  no  explanation  of 
the  complex  character  of  the  commencing  discharge,  or  of  its  uni- 
formity in  the  same  patient. 

Thus  the  vaso-motor  theory  of  epilepsy  is  alike  uuneeded,  unproved, 
and  inadequate.  The  phenomena  indicate  that  there  is  discharge  of 
grey  matter,  and  there  is  nothing  to  warrant  us  in  going  beyond  the 
grey  matter  concerned,  in  our  search  for  the  origin  of  the  discharge ; 
it  is  certain  that  this  may  commence  in  various  parts  of  the  cerebral 
cortex,  and  there  is  no  evidence  that  it  is  dependent  upon  any  ante- 
cedent. 

Can  we  form  any  opinion  as  to  the  nature  of  the  change  in  the  grey 
matter  which  permits  the  sudden  liberation  of  nerve-force  ?  It  is 
necessary  to  remember  that  we  have  direct  evidence  only  of  libera- 
tion of  force,  but  we  must  recognise,  in  all  nerve-cells,  a  function  by 
which  the  liberation  of  energy  is  restrained,  a  resistance  to  action  as 
well  as  a  capacity  for  action. J  Of  the  nature  of  this  resistance  we 
can  form  no  idea,  but  we  cannot  conceive  of  the  function  of  cells 
without  it,  and  the  idea  has  underlain  such  expressions  as  "  nerve 
tension"  and  the  like,  which  have  been  long  employed.  The  pheno- 
mena of  epilepsy  suggest  that  the  instability  of  the  grey  matter,  its 
tendency  to  discharge,  depends  on  instability  of  resistance,  rather  than 
on  any  primary  change  in  the  energy-producing  action  of  the  cells, 

*  Kussmaul  and  Tenner. 

f  Hume  observed  that  the  pulsation  of  the  brain,  in  the  opening  left  by  trephining 
for  traumatic  epilepsy,  ceased  during  the  fits,  and  that  the  brain  became  less  pro- 
minent ('New  York  Med.  Rec.,'  1889). 

J  Handfield  Jones,  Michael  Foster,  Ringer,  &c. 


756  EPILEPSY. 

although  the  latter  normally  in  constant  activity  may  be  secondarily 
augmented  by  the  increased  demand.  Analogy  suggests  that  the 
internal  resistance  to  action  is  a  higher  function  of  the  cells  than  the 
production  of  force.  Hence  the  fact  that  there  is  over-action  is 
consistent  with  the  evidence  that  there  is  imperfect  nutrition.  More- 
over, the  view  that  it  is  the  resistance  which  is  unstable  enables  us 
to  understand  the  phenomena  of  inhibition  which  sometimes  occur  as 
part  of  the  attack.  In  a  slight  degree  of  disturbance  the  resistance 
may  be  suddenly  raised  instead  of  being  lowered.  It  is  possible 
that  the  attacks  in  which  there  is  loss  of  consciousness  only,  may 
be  thus  produced, — may  be  analogous  to  the  fits  in  which  there  is 
sudden  darkness  rather  than  to  those  in  which  there  is  a  flash  of 
light. 

Diagnosis. — The  first  point  in  the  diagnosis  of  epilepsy  is  the 
recognition  of  the  occurrence  of  attacks.  Convulsive  attacks,  which 
occur  in  the  daytime,  are  never  overlooked,  but  if  an  attack  occurs 
during  sleep,  and  its  onset  does  not  awaken  the  patient,  he  may  sleep 
on  when  it  is  over,  and  be  unaware  of  its  Occurrence.  Often  there 
are  some  subsequent  indications  of  what  has  happened.  The  tongue 
may  be  sore,  there  may  be  a  little  blood  on  the  pillow,  an  extravasation 
beneath  the  conjunctiva,  eccbymoses  on  the  face,  or  a  severe  headache. 
These  (except  the  last)  are  of  unequivocal  significance,  but  the  patient 
may  be  unaware  of  their  occurrence,  and  nocturnal  attacks  may 
occur  for  twenty  years  without  the  patient  or  his  friends  suspecting 
the  fact.  Minor  seizures  are  also  often  unrecognised,  not  because 
they  are  unnoticed,  but  because  they  are  not  thought  to  be  of  any 
significance  or  serious  nature.  Those  that  consist  only  in  a  sub- 
jective sensation  may  not  be  mentioned  by  the  patient.  It  is  usually 
sufficient  to  be  aware  of  their  common  forms,  and  to  inquire  for 
these,  in  order  to  ascertain  their  occurrence. 

Certain  forms  of  minur  attack  may.  however,  be  confounded  with 
other  paroxysmal  symptoms  of  different  nature.  The  simplest  form, 
in  which  there  is  merely  brief  unconsciousness,  is  not  only  called  a 
"  faint,"  but  is  often  supposed  to  be  actually  syncopal  in  nature.  The 
distinction  from  syncope  rests,  first,  on  the  absence  of  obvious  exciting 
influences,  such  as  cause  ordinary  fainting.  Epileptic  faints  often 
occur  when  the  patient  is  sitting  still,  in  a  cool  room,  under  no 
excitement.  Consciousness  is  lost  more  suddenly  in  epilepsy  than  in 
syncope.  The  latter  is  usually  preceded  by  a  sensation  of  faintness, 
but  so  also,  sometimes,  are  the  minor  seizures  of  epilepsy.  The 
presence  of  this,  and  of  vague  "  dizziness,"  palpitation  of  the  heart,, 
nausea,  and  cephalic  sensations  other  than  pain,  is  of  little  diagnostic 
significance.  On  the  other  hand,  the  absence  of  any  waruing  sensa- 
tion, or  the  occurrence  of  a  distinct  warning  other  than  one  of  those 
just  mentioned,  is  in  favour  of  the  epileptic  nature  of  the  attack.  A 
sudden  return  of  normal  consciousness  is  in  favour  of  epilepsy.     If  a 


DIAGNOSIS.  757 

normal  condition  is  slowly  regained,  there  is  physical  prostration  in 
syncope,  mental  confusion  in  epilepsy,  and  in  the  former  the  pulse  at 
the  wrist  is  often  scarcely  perceptible.  The  passage  of  urine  during 
the  attack,  muscular  spasm,  however  slight,  and  automatic  action  or 
deep  sleep  after  the  attack,  are  certain  proof  of  its  epileptic  character. 
In  many  cases  the  patient  has  had  other  more  severe  seizures  which 
assist  the  diagnosis. 

The  attacks  characterised  by  vertigo  have  to  be  distinguished  from 
other  forms  of  sudden  giddiness.  The  latter  are  scarcely  ever  attended 
by  loss  of  consciousness,  and  are  usually  followed  by  long-continued 
vertigo,  which  persists  while  the  patient  is  recovering,  and  slowly 
passes  away.  In  epilepsy  there  is  generally  loss  of  consciousness, 
and  the  patient  is  either  quickly  well,  or  is  a  little  "  dazed "  after 
the  attack;  the  vertigo  maybe  associated  with  some  other  warning 
sensation,  and  there  is  often  micturition.  The  vertigo  most  likely 
to  be  confounded  with  epilepsy  is  that  connected  with  a  morbid 
action  of  the  auditory  nerve,  "  labyrinthine  vertigo."  In  addition  to 
the  diagnostic  indications  just  mentioned,  there  is  usually,  in  this 
form,  slight  persistent  giddiness  in  the  intervals,  persistent  tinnitus 
aurium,  and  some  deafness.  In  epileptic  vertigo  there  may  be  an 
auditory  sensation,  with  giddiness,  as  the  aura  of  the  attack,  but 
there  are  no  persistent  symptoms.  It  must  not  be  forgotten  that 
auditory  vertigo  and  epilepsy  may  be  associated ;  I  have  seen  several 
instances  of  this. 

If  a  patient  suffers  from  distinct  convulsion,  the  next  question  is, 
are  the  attacks  epileptic  or  hysteroid  ?  If  an  attack  can  be  witnessed, 
the  nature  of  the  convulsion  is  usually  obvious.  The  violent  tonic 
spasm  and  shock-like  clonic  spasm  of  the  typical  epileptic  fit,  with 
complete  unconsciousness  and  with  cyanosis,  and  also  the  brief  dura- 
tion of  the  attack,  are  wholly  unlike  the  prolonged  tonic  contraction, 
opisthotonos,  wild  co-ordinated  movements,  quick  clonic  spasm, 
perverted  mental  state,  talking,  biting,  and  convergent  strabismus  of 
the  hysteroid  seizure.  More  difficulty,  however,  may  be  presented  by 
the  untypical  forms  of  epileptic  fits,  especially  by  those  which  consist 
only  of  tonic  spasm.  Evidence  of  their  epileptic  nature  is  afforded 
by  the  brevity  of  the  attacks,  their  suddenness  of  onset,  their  occur- 
rence apart  from  emotion  and  when  the  patient  is  alone,  and  the 
absence  of  hysteroid  symptoms.  When  an  attack  has  not  been 
witnessed,  and  the  diagnosis  has  to  be  made  from  the  description  of 
the  patient  or  friends,  it  is  a  much  less  easy  task.  The  chief  diagnostic 
indications  between  pure  epileptic  and  pure  hysteroid  fits  are  given 
in  a  tabular  form  on  the  next  page.  Especial  care  should  be  taken, 
in  asking  about  the  character  of  the  convulsion,  to  avoid  a  leading 
question,  and  if  suggestions  are  indispensable,  to  put  them  alterna- 
tively, thus  :  "  Should  you  say  that  the  patient  struggled  or  jerked 
during  the  fit  ?" 

If   there   is   evidence  that  the  visible  convulsion    is   hysteroid  in 


758 


EPILEPSY. 


character,  we  have  still  to  ascertain  whether  it  is  primary  or  is 
consecutive  to  an  epileptic  seizure,  and  this  is  often  most  difficult. 
When  the  initial  epileptic  fit  is  severe,  its  occurrence  can  usually  be 
ascertained,  and  tongue-biting  alone  may  be  taken  as  establishing  its 


Epileptic. 

Hysteboid. 

Apparent  cause 

none                                            emotion. 

Warning 

any,  but  especially  unilateral  palpitation,  malaise,  choking, 

or  epigastric  aurae 

bilateral  foot  aura. 

Onset 

always  sudden 

often  gradual. 

Scream 

at  onset 

during  course. 

Convulsion 

rigidity  followed  by  "jerk-  rigidity    or     "struggling," 

ing,"  rarely  rigidity  alone 

throwing  about  of  limbs  or 
bead,  arching  of  back 

Biting 

tongue 

lips,  hands,  or  other  people 
and  things. 

Micturition 

frequent 

never. 

Defaecation 

occasional 

never. 

Talking 

never 

frequent. 

Duration 

a  few  minutes 

more  than  ten  minutes,  often 
much  longer. 

Restraint  necessary 

to  prevent  accident 

to  control  violence. 

Termination 

spontaneous                              ; spontaneous      or       induced 

(water,  &c). 

occurrence.*  It  is  when  the  epileptic  attack  is  of  the  minor  form  that 
the  diagnostic  difficulty  arises,  because  the  initial  stage  of  many  hys- 
teroid  fits  has  a  pseudo-epileptic  aspect.  The  most  important  guide  is 
the  fact  that  most  patients  in  whom  the  hysteroid  attacks  are  post- 
epileptic, have  at  other  times,  or  have  had  in  the  past,  epileptic  fits, 
major  or  minor,  without  this  sequel,  and  the  character  of  these  corre- 
sponds to  the  commencement  of  the  compound  attack.  In  many  cases 
the  characters  of  the  initial  stage  include  some  feature,  such  as 
micturition,  which  is  conclusively  epileptic.  In  most  patients,  more- 
over, who  have  had  recurring  attacks  during  several  years,  these 
are  epileptic,  and  the  hysteroid  convulsion  is  secondary.  The  fact 
that  the  patient  presents  other  symptoms  of  hysteria  should  be 
allowed  no  weight  until  all  indications  of  epilepsy  have  been  excluded, 
because,  as  already  stated,  it  is  only  in  those  who  are  in  some  degree 
the  subjects  of  hysteria  that  the  combination  occurs.  It  must  not  be 
forgotten,  also,  that  separate  hysterical  and  epileptic  attacks  some- 
times occur  in  the  same  individual. 

If  the  attacks  are  recognised  to  be  epileptic  in  character,  before  we 
can  refer  them  to  idiopathic  epilepsy  we  have  to  ascertain  that  they 
are  not  due  to  reflex  irritation,  to  toxaamia,  or  to  organic  brain 
disease.  The  irritation  of  dentition,  intestinal  worms,  and,  occa- 
sionally, indigestible  food,  are  the  most  frequent  causes  of  fits  that 

*  It  is  said  that  French  hysterics  bite  their  tongues  during  the  attacks.  In  this 
country  tongue-biting  is  practically  confined  to  epilepsy. 


DIAGNOSIS.  759 

may  be  confounded  with  tbose  of  epilepsy.  In  all  cases  in  which  the 
convulsions  are  of  recent  origin,  these  causes  should  be  sought  for 
and  excluded,  if  necessary,  by  treatment.  There  is  no  other  way  of 
avoiding  error,  since  the  indication  derived  from  the  character  of  the 
attacks  is  an  uncertain  criterion.  It  must  be  remembered  that  fits 
may  be  at  first  of  reflex  origin,  and  may  persist,  when  the  peripheral 
irritation  is  removed,  as  idiopathic  epilepsy.  It  is  most  unlikely  that 
fits  that  have  continued  for  more  than  a  year  are  still  due  to  reflex 
influences. 

Convulsions  that  are  due  to  blood-states  (alcohol,  lead,  uraemia) 
are  rarely  confounded  with  those  of  epilepsy,  because  they  are  merely 
part  of  a  group  of  symptoms  of  obtrusive  significance.  The  import- 
ance of  an  examination  of  the  urine  in  all  doubtful  cases  need  not  be 
insisted  on.  The  recurring  fits  which  may  occur  in  chronic  Bright's 
disease  without  other  signs  of  uraemia,  and  in  some  cases  of  lead 
poisoning,  may  resemble  epilepsy  very  closely,  and  are  to  be  distin- 
guished only  by  the  discovery  of  the  underlying  condition.  A  mistake 
in  diagnosis  is  especially  probable  in  cases,  previously  unknown,  in 
which  albumen  is  present  in  the  urine  after  an  attack.  But  the 
absence  of  other  indication  of  chronic  and  advanced  renal  disease  should 
prevent  a  mistake. 

The  problem  of  the  diagnosis  of  epilepsy  from  the  convulsions  of 
organic  brain  disease  presents  many  aspects,  and  is  of  great  import- 
ance. Those  convulsions  which  attend  a  sudden  acute  cerebral  lesion 
are  not  likely  to  be  mistaken  for  epilepsy,  nor  is  the  converse  mistake 
probable,  except  during  the  transient  "  post-convulsive  "  weakness 
after  a  first  unilateral  fit.  Chronic  brain  disease,  however,  may 
cause  convulsions,  readily  mistaken  for  those  of  epilepsy.  Those 
convulsions  usually  begin  locally,  and  may  be  partial  in  range.  This 
character,  while  it  suggests,  does  not  prove,  that  they  have  this 
origin,  since  the  convulsions  of  idiopathic  epilepsy  may  commence  in 
a  similar  manner,  and,  moreover,  the  convulsions  of  organic  disease 
may  not  begin  locally,  but  may  be  at  once  general.  For  the  diagnosis, 
a  careful  search  must  be  made  for  other  svmptoms  of  organic  disease, 
— persistent  headache,  permanent  hemiplegic  weakness  (not  merely 
after  au  attack),  paralysis  of  cranial  nerves  (especially  diplopia), 
vomiting,  and  optic  neuritis.  The  importance  of  an  ophthalmoscopic 
examination  in  such  cases  cannot  be  too  strongly  insisted  on.  In  any 
case  of  doubt,  causal  influences  may  be  allowed  weight.  A  history  of 
syphilis,  which  so  often  causes  cortical  disease  and  convulsions,  on  the 
one  hand,  or  a  family  history  of  epilepsy  or  insanity  on  the  other, 
may  rightly  turn  the  diagnostic  scale. 

Convulsions  may  be  due  not  only  to  active  brain  disease,  but  to  the 
influence  of  an  old  cerebral  lesion,  an  atrophied  tumour,  and  espe- 
cially a  spot  of  old  softening.  In  the  former  case  the  diagnosis  rests 
on  the  history  of  the  early  symptoms.  The  latter  are  the  cases  of 
post-hemiplegic  epilepsy  already  described.     The  distinction  of  these 


760  EPILEPSY. 

from  ordinary  epilepsy  is  easy  if  distinct  hemiplegia  persists,  but 
may  be  difficult  if  this  bas  passed  away.  The  difficulty  arises  only  in 
tbe  cases  which  date  from  childhood.  In  all  such  cases,  if  the  fits  are 
unilateral,  careful  search  should  be  made  for  signs  of  weakness  or  of 
spasmodic  over-action.  Sligbt  traces  of  tbe  latter  are  significant. 
The  circumstances  of  origin  should  also  be  ascertained.  In  infancy 
trifling  hemiplegia  is  l'eadily  overlooked,  and  if  the  first  convulsions 
were  severe  and  unilateral,  corresponding  in  seat  to  those  which 
still  occur,  the  case  is  probably  post-hemiplegic,  even  though  no 
hemiplegia  was  noted,  and  although  an  interval  of  years  elapsed 
between  the  initial  convulsions  and  their  recurrence.  Epileptoid 
fits  may  be  an  early  symptom  of  general  paralysis  of  the  insane, 
but  the  tremor  of  lips  and  tongue,  the  unequal  pupils,  and  the  nienta 
change  render  the  diagnosis  easy  in  most  cases. 

The  simulation  of  an  epileptic  fit  is  on  the  whole  rare,  and  the  pre- 
tended fit  never  closely  resembles  a  genuine  seizure.  In  all  cases  the 
perfect  reaction  of  the  pupil  to  light  throughout  the  fit  will  be  con- 
clusive evidence.  Too  much  Aveight  must  not  be  placed  on  the  un- 
typical character  of  the  attack,  because  true  epileptic  fits  may  deviate 
much  from  the  usual  type. 

Prognosis. — The  risk  to  life  in  epilepsy  is  not  great.  The  mere 
violence  of  the  fit,  appalling  as  may  be  its  aspect,  rarely  causes  death. 
The  dangerous  "  status  epilepticus  "  is  too  exceptional  to  constitute  a 
measurable  element  in  the  prognosis.  The  greatest  danger  is  in  the 
cases  in  which  there  is  a  tendency  to  turn  on  the  face,  or  to  vomit  after 
a  fit,  but  even  this  is  slighter  than  that  of  the  accidents  to  which  the 
attacks  expose  the  patient.  Many  epileptics  die  by  drowning;  the 
fit  not  only  occasions  the  fall  into  the  water,  but  prevents  any  effort 
to  escape,  and  hence  an  epileptic  has  more  than  once  been  drowned  in 
a  ditch. 

The  prospect  of  a  spontaneous  cessation  of  the  fits  is  small ;  the 
tendency  of  the  disease  is  to  self-perpetuation.  Occasionally  convul- 
sions, during  infancy,  cease  at  four  or  five  years  of  age.  Attacks 
which  have  continued  till  puberty  rarely  cease  at  that  epoch.  After 
twentv,  spontaneous  cessation  does  sometimes  occur,  and  I  believe  that 
it  becomes  more  frequent  as  life  advances,  but  it  is  too  rare  to  be 
reckoned  on. 

The  chief  question,  therefore,  is— what  is  the  prospect  that  the 
disease  will  be  cured,  or  held  in  abeyance,  by  treatment  ?  We  cannot 
at  present  separate  the  two  points,  and  the  only  way  known  of 
curing  the  disease  is  to  keep  the  fits  away  for  a  sufficient  length 
of  time  to  permit  the  morbid  tendency  to  subside.  Hence  the 
question  resolves  itself  into  the  probability  of  complete  arrest. 
The  prospect  of  arrest  is  slightly  better  in  males  than  females, 
better  if  the  disease  begins  after  twenty  than  before,  and  better 
the  shorter  the  duration  of  the  disease,  being  greatest  in  the  cases 


TREATMENT.  761 

In  which  it  has  existed  for  less  than  a  year.  It  is  rather  easier 
to  arrest  the  fits  -when  there  is  an  hereditary  tendency '  than 
wheu  there  is  not — a  curious  fact,  which  was  also  pointed  out  by 
Herpin.  The  presence  or  absence  of  an  exciting  cause  for  the  first 
fit  does  not  influence  the  prognosis.  A  longer  interval  between  the 
fits  increases  the  prospect  of  arrest;  this  is  extremely  rare  if  fits 
occur  daily.  But  this  consideration  is  interfered  with  by  the  great 
difficulty  of  getting  patients,  whose  fits  occur  at  long  intervals,  to 
persevere  with  treatment.  The  prognosis  is  better  if  the  fits  occur 
only  during  the  sleeping  or  the  waking  state,  than  if  they  occur  in 
both.  It  is  better  if  there  is  no  considerable  mental  change,  and  if 
tbe  attacks  are  all  of  the  severe  variety  than  if  there  are  minor  seizures, 
and  better  if  the  attacks  are  preceded  by  an  aura  than  if  they  occur 
without  warning.  In  cases  of  post-hemiplegic  epilepsy  the  prognosis 
is  much  less  favorable  than  in  the  idiopathic  cases. 

Treatment. — The  treatment  of  epilepsy  consists  partly  in  the 
general  management  of  the  patient,  and  partly  in  the  administration 
of  drugs  to  influence  the  attacks, — to  arrest  their  occurrence,  or,  failing 
this,  to  render  them  less  frequent  and  less  severe.  Unfortunately, 
the  influence  of  all  drugs  is  transient,  and  has  to  be  repeatedly 
renewed.  No  means  is  known  of  suddenly  curing  the  disease,  of 
suddenly  effecting  such  a  change  in  the  nerve-centres  that  the  attacks 
do  not  again  occur,  nor  are  there  at  present  any  iacts  which  render 
it  likely  that  such  means  will  be  discovered.  I he  only  method  of 
producing  such  a  change  is  by  the  continued  administration  of  drugs 
for  a  long  time,  so  as  to  prevent  the  occurrence  of  the  nervous  dis- 
charge, and  thus  to  produce  such  a  change  in  the  cells  that  the 
medicine  may  ultimately  be  discontinued  without  a  recurrence  of 
attacks.  It  is  of  great  importance  that  this  need  for  prolonged  treat- 
ment should  be  made  clear  to  all  patients,  and  its  reason  to  all  those 
who  can  understand  it. 

Since  the  introduction  of  bromide  salts  for  the  treatment  of  epilepsy 
they  have  superseded  other  drugs  to  a  large,  and  some  think  a  too  great, 
extent.  In  the  majority  of  cases  their  influence  is  incomparably 
greater  than  that  of  any  other  remedies,  but  in  a  minority  of  cases 
they  fail,  and  in  some  of  these  other  agents  are  more  powerful.  They 
only  do  permanent  good  by  continued  administration.  The  absence  of 
a  permanent  effect  from  a  short  course  of  treatment  is,  however, 
ecpually  conspicuous  in  the  case  of  other  remedies.  Bromides  are  said 
to  cause  contraction  of  the  small  arteries  of  the  brain,  but  it  is  exceed- 
ingly doubtful  whether  any  part  of  their  influence  in  epilepsy  is  due 
to  this  action.  The  various  effects  of  their  administi-ation  suggest 
strongly  that  they  have  a  direct  action  on  the  nerve-cells.  On  any 
theory  of  epilepsy  we  must  ascribe  it  ultimately  to  the  disturbed 
action  of  nerve-cells  in  some  situation,  and  it  is  unnecessary  to  go 
beyond  this  influence  of  bromide  on  nerve-cells  to  explain  its  action. 


762  -EPILEPSY.     ' 

If  we  regard  the  morbid  state  in  epilepsy  as  an  instability  in  the 
resistance  of  nerve-cells,  it  seems  probable  that  the  effect  of  bromide 
is  to  increase  the  stability  of  that  resistance. 

The  bromides  of  potassium,  sodium,  and  ammonium  are  extensively 
used,  and  bromide  of  lithium  is  occasionally  employed ;  some  authorities 
express  a  preference  for  one,  some  for  another,  some  for  a  combination. 
My  own  experience  has  been  that  the  influence  of  each  on  the  disease 
is  nearly  the  same,  but  that  the  bromides  of  sodium  and  lithium  are 
rather  less  effective  than  the  others,  and  that  the  bromide  of  potas- 
sium is  a  little  better  borne  than  the  bromide  of  ammonium.  It  is 
probable  that  very  little,  if  any,  of  the  bromide  salt  is  decomposed  in 
the  system,  and  that  the  base  does  not  exert  its  special  influence. 
Bromide  of  gold,  of  nickel,  and  that  of  ammonium  and  rubidium  have 
been  tried,  but  the  evidence  of  their  value  is  inconclusive.  The 
administration  of  free  bromine  has  been  suggested,  but  it  is 
difficult  to  give  it  in  sufficient  quantity,  and  it  must  be  trans- 
formed into  bromide  as  soon  as  it  enters  the  alkaline  blood.  This 
is  true  also  of  hydrobromic  acid.  No  salt  of  bromine  has  much  less, 
tendency  than  another  to  produce  acne,  and  this  can  always  be  pre- 
vented or  rendered  extremely  slight  by  giving  arsenic  at  the  same 
time.     Periodical  omission  does  not  prevent  the  rash. 

Bromide  is  usually  given  continuously  in  the  smallest  doses  which 
will  arrest  the  fits,  or,  failing  this,  in  such  doses  as  produce  the  most 
marked  effect  upon  them.  When  the  fits  occur  at  a  certain  time,  one 
daily  dose  may  be  given  two  or  three  hours  earlier.  If  the  attacks 
occur  at  various  times  the  bromide  must  be  taken  two  or  three  times 
a  day.  The  total  daily  quantity  may  vary  between  fifteen  grains  and 
two  drachms,  according  to  the  age  of  the  patient  and  the  effect  of  the 
drug.  Few  patients  are  able  to  bear  more  than  a  drachm  and  a  half 
a  day  without  becoming  what  is  termed  "bromised,"  lethargic  and 
dull,  physically  and  mentally,  with  cold  extremities,  and  a  feeble 
pulse  ;  the  best  results  are  usually  obtained  with  not  more  than  a 
drachm  a  day.  If  this  does  not  arrest  the  attacks,  larger  doses  rarely 
succeed,  and  combinations  of  bromide  with  other  drugs  are  more 
useful.  The  effect  of  bromide  is  sometimes  immediate  :  after  the  first 
dose  the  attacks  may  cease  ;  often,  however,  its  influence  is  gradually 
produced.  When  the  attacks  have  ceased  under  its  administration, 
they  too  often  relapse  if  it  is  discontinued,  and  then  are  less  easily 
arrested  than  at  first.  Belapse  usually  occurs  within  a  iew  weeks 
(sometimes  within  a  few  days)  of  a  too  early  cessation  of  treatment ; 
after  a  year  of  freedom  without  treatment  it  is  probable  (though  not 
certain)  that  the  disease  will  not  recur.  As  a  rule,  bromide  should  be 
continued,  without  any  diminution  of  the  dose,  for  two  years  after  the 
last  fit.  It  should  not  then  be  suddenly  discontinued,  but  the  daily 
dose  should  be  gradually  lessened  through  another  year.  The  con- 
tinued use  of  bromide  in  moderate  doses  has  no  necessary  influence  on 
the  general  health  or  intellectual  energy.     At  first,  however,  some  cere- 


TBEATMtiJS'T.  763 

bral  depression  may  of  ten  follow  the  arrest  of  fits  (see  p.  749),  and  this 
is  often  erroneously  regarded  as  the  effect  of  the  bromide  alone.  If 
moderate  in  degree  it  is  better  to  combat  it  by  tonics  than  to  reduce  the 
bromide.  Occasionally  the  depression  becomes  so  alarming  that  it  is 
necessary  to  stop  or  lessen  the  medicine,  and  even  to  allow  a  fit  to 
occur,  and  to  go  on  with  smaller  doses. 

In  order  to  facilitate  the  occurrence  of  the  change  in  the  nutrition 
of  the  nerve-cells  which  we  must  assume  to  underlie  the  cure  of 
epilepsy  by  bromide,  I  have  found  it  well,  in  cases  in  which  a 
moderate  dose  stops  the  fits,  to  administer  a  series  of  large  doses  at 
increasing  intervals,  beginning  with  two  drachms  every  second  morning, 
and  increasing  to  three  drachms  every  third  morning,  and  four  every 
fourth  ;*  the  dose  and  interval  are  then  reduced  in  the  reverse  order, 
so  as  to  spread  the  course  over  about  six  weeks.  The  dose  should  be 
given  after  breakfast,  in  about  half  a  pint  of  water.  After  such  a 
course,  if  the  bromide  is  discontinued,  patients  remain  free  from  fits 
much  longer  than  after  bromide  has  been  given  for  the  same  time  in 
ordinary  doses,  showing  that  more  effect  on  the  nerve-elements  has 
been  produced.  But  a  permanent  result  is  seldom  obtained  from  such 
a  course  alone  ;  it  is  still  necessary  to  continue  small  doses  for  a  year  or 
more.  I  believe,  however,  that  the  prospect  of  cure  is  increased  by  this 
cumulative  treatment. 

When  bromide  alone  fails,  it  may  succeed  when  combined  with 
certain  other  drugs,  most  of  which  have  by  themselves  some  influence 
on  the  disease.  One  of  these  is  digitalis,  a  popular  remedy  for  epilepsy 
in  the  west  of  England  two  centuries  ago.  The  combination  is  useful, 
as  might  be  expected,  when  there  is  cardiac  dilatation  and  valvular 
disease,  but  it  is  also  specially  useful  in  nocturnal  epilepsy,  and  in  some 
other  cases.  Digitalis  probably  has  an  action  on  the  central  nervous 
system,  as  well  as  on  that  of  the  heart  and  vessels,  although  some 
part  of  its  influence  may  be  due  to  the  regulation  of  the  blood- supply. 
Five  or  seven  minims  of  the  tincture  may  be  given  with  each  dose  of 
bromide.  Another  combination  of  value  is  that  with  belladonna, 
which  is  also  an  old  remedy  ;  and,  although  very  rarely  successful  alone, 
it  is  a  useful  adjuvant,  in  doses  of  five  or  ten  minims  of  the  tincture. 
Atropine  may  be  given  instead,  one  or  two  drops  of  the  B.  P.  solution. 
The  combination  of  bromide  treatment  with  the  occasional  passage  of 
a  voltaic  current  from  the  hand  to  the  opposite  side  of  the  skull,  over 
the  motor  region  of  the  cortex,  would  scarcely  deserve  mention,  had  it 
not  received  the  surprising  commendation  of  Niemeyer. 

Cannabis  indica  is  occasionally  beneficial,  both  alone  and  in  combina- 
tion with  bromide  ;  the  combination  is  most  useful  incases  with  a  good 
deal  of  persistent  headache.  Opium  and  its  alkaloid  morphia  are  of 
little  service  in  epilepsy.     The  hypodermic  injection  of  morphia  in  full 

*  I  have  several  times  increased  the  dose  up  to  an  ounce  every  five  days  (more  is 
usually  vomited),  but  flight  mental  derangement,  lasting  for  a  few  weeks,  is  apt  to 
be  set  up.     The  chief  immediate  effect  of  a  dose  of  four  to  tight  drachms  is  head  ache 


764  EPILEPSY. 

doses  is  attended  with  considerable  danger.  If  an  attack  occurs  after 
the  injection  has  been  given,  and.  the  post-epileptic  coma  coincides  with 
the  narcotism,  the  patient's  life  may  be  in  great  danger,  and  I  have 
known  death  to  occur,  apparently  from  this  cause. 

Zinc  has  long  been  held  in  repute,  and  with  some  reason.  It.  is  far 
inferior  to  bromide  in  most  cases,  but  now  and  then  succeeds  when 
bromide  fails.  The  lactate  of  zinc,  introduced  by  Herpin,  is  the  most 
convenient  form ;  it  is  the  most  soluble  of  the  less  irritant  salts  of 
zinc,  and  if  given  after  meals  it  can  generally  be  increased  to  eight 
•or  ten  or  even  fifteen  grains,  twice  or  three  times  a  day,  without  pro- 
ducing nausea.  The  oxide  of  zinc  may  be  given  if  the  lactate  is  not 
accessible,  but  the  limits  of  toleration  are  sooner  reached.  The 
citrate  answers  almost  as  well  as  the  lactate.  The  bromide  of  zinc  is 
also  a  useful  form.  Either  may  be  combined  with  belladonna  or  with 
bromide  of  potassium,  and  the  combination  of  the  three  sometimes 
succeeds  when  each  alone  fails. 

Iron,  in  the  opinion  of  some  distinguished  authorities,  should  not 
be  given  to  epileptics,  because  it  is  thought  to  increase  the  frequency 
and  severity  of  the  fits.  This  opinion,  as  a  general  principle,  is 
certainly  erroneous.  I  have  given  iron  to  several  hundred  epileptics, 
and  instances  of  apparent  aggravation  of  attacks  are  extremely  rai*e. 
In  most  cases  it  may  be  given  without  any  ill  effect  on  the  disease, 
and  in  some  its  use  is  distinctly  beneficial.  I  have  known  attacks  to 
cease  entirely  when  hx>n  was  added  to  bromide,  and,  in  rare  cases, 
when  iron  was  substituted  for  bromide.  Care  must  of  course  be 
taken  not  to  ascribe  to  the  iron  any  effect  of  the  discontinuance  of  the 
bromide.  Iron  seems  to  have  a  direct  action  on  the  nerve-centres, 
analogous  to  that  of  zinc. 

In  some  cases  of  inveterate  epilepsy,  in  which  bromide  had  no 
influence,  I  have  found  borax  distinctly  useful.  From  fifteen  to  thirty 
grains  may  be  given  after  food  three  times  a  day,  and  it  may  be  con- 
tinued for  years  without  any  ill  effect  beyond  a  possible  eruption  of 
psoriasis,  amenable  to  arsenic.  A  little  gastro-enteric  disturbance 
may  occur  at  the  commencement  of  administration,  but  quickly  ceases 
if  the  dose  is  lessened.  Of  course  the  influence  of  borax  is  not  com- 
parable to  that  of  bromide  in  cases  in  which  this  is  effective.* 

Nitro-glycerine  is  sometimes  useful,  especially  for  the  minor  attacks. 
It  may  be  given  in  doses  of  -^^  of  a  grain  to  begin  with,  increased 
gradually  to  -^,  half  a  minim  to  1|  minims  of  the  Tinct.  Trinitrini  (of 
the  B.  P.  Supplement)  after  food,  three  times  a  day.  In  one  case,  with 
rather  sevei'e  fits,  these  became  fewer  as  the  dose  was  increased,  and 
finally  ceased  when  the  patient  was  taking  -J-  grain,  and  did  not 
recur.     It  often  prevents  the  occurrence  of  the  post-epileptic  hysteroid 

*  The  use  of  borax  was,  I  believe,  first  recommended  in  my  Gulstonian  lectures 
on  Epilepsy  (1870).  Its  value  in  cases  that  resist  bromide  has  been  amply  confirmed 
by  Folsom,  Jones  Hill,  Stewart,  and  others  in  America,  by  Mairet  in  France,  and  by 
Spencer,  Eussell  and  Taylor,  and  others  in  England. 


TREATMENT.  765 

convulsion.  The  alcoholic  solution  is  the  best  form,  and  may  be 
combined  with  bromide,  if  a  few  drops  of  hydrobromic  acid  are 
added.  Among  other  drugs  which  I  have  tried  without  seeing  benefit, 
other  than  slight  and  rare,  from  their  use,  are  aconite,  hydrocyanic 
acid,  bromide  of  camphor,  nitrite  of  soda,  nitrite  of  arnyl  (by  the 
mouth),  chloral  hydrate,  paraldehyde,  benzoate  of  soda,  Piscidia  ery- 
thrina,  Calabar  bean,  ergot,  sclerotic  acid,  codeia,  and  cocculus  in- 
dicus.  It  is  singular  that  the  last,  injected  beneath  the  skin,  will 
infallibly  pi-oduce  a  fit  in  an  epileptic  patient.  From  nitrate  of 
silver  I  have  seen  little  benefit,  and  I  have  had,  among  my  patients, 
several  who  were  discoloured  by  it,  in  the  prebromidic  days,  without 
any  alteration  in  the  severity  of  the  attacks.  Antipyriu  (25  grains 
daily)  is  said  to  have  arrested  attacks  in  a  child  of  three.* 

The  treatment  of  minor  attacks  is  on  the  whole  the  same  as  of  the 
severer  seizures.  They  are  often  arrested  by  bromide,  but  it  is  far 
more  common  for  bromide  to  have  no  influence  in  the  case  of  petit 
mal  than  in  convulsive  attacks.  The  latter  may  be  arrested,  and  the 
former  may  continue  or  even  become  more  frequent.  The  other  drugs 
above  mentioned  are  sometimes  effective  when  bromide  fails,  especially 
the  salts  of  zinc,  belladonna,  and  Indian  hemp.  Bromide  of  zinc 
has  been  already  mentioned ;  it  may  be  given  in  doses  of  two  to  four 
or  five  grains  after  food,  well  diluted,  and  combined  with  alkaline 
bromides  in  cases  in  which,  both  forms  of  attack  occur.  There  is 
much  variation  in  the  individual  gastric  tolerance  of  zinc ;  it  can 
often  be  better  borne  with  -^  gr.  of  cocaine  hydrochlorate.  Ethylene 
bromide  has  been  said  to  lessen  minor  seizures,  but  not  to  arrest  them. 
Arrest  of  Attacks. — The  means  by  which,  commencing  fits  may  be 
arrested  have  been  already  mentioned.  In  attacks  commencing  in 
one  extremity,  the  ligature  is  often  successful.  The  most  convenient 
method  of  applying  it  is  for  the  patient  to  double  a  piece  of  tape,  and 
pass  it  round  the  arm  above  the  elbow,  with  the  ends  through  the 
loop  formed  by  the  doubled  part,  and  brought  down  to  the  lower  part 
of  the  sleeve  so  as  to  be  accessible,  and  easily  pulled  tight,  as  soon  as 
the  warning  is  felt.  Now  and  then  the  repeated  arrest  of  fits  produces 
a  permanent  effect :  in  one  patient,  for  instance,  the  aura  ultimately 
stopped  spontaneously  at  the  place  where  it  had  been  many  timea 
arrested  by  the  ligature.  In  cases  of  this  kind  an  attempt  has  been 
made  to  produce  a  more  permanent  effect  by  a  blister  around  the  limb.f 
It  is  occasionally  successful ;  but  the  arrest  of  the  fit,  by  the  ligature 
or  a  blister,  sometimes  causes  so  much  giddiness  and  distress  that 
some  patients  have  considered  the  remedy  worse  than  the  disease. 

Of  methods  of  arresting  fits  which  begin  in  other  ways,  inhalation 
of  nitrite  of  amy!  is  that  most  frequently  (though  not  invariably) 
successful ;  it  doubtless  acts  by  flooding  the  brain  with  arterial  blood,, 
a  potent  agent  for  modifying  the  action  of  the  nerve-elements. 

*  Anderson,  'Am.  Jonrn.  Med.  Sc.,'  1891. 

t  An  old  method  of  treatment,  revived  by  Brown-Sequard  and  Buzzard. 


766  EPILEPSY. 

During  an  attach  little  treatment  is  necessary.  In  patients  who 
bite  the  tongue,  a  cork  or,  better,  a  small  piece  of  india-rubber  placed 
between  the  teeth  will  prevent  this  accident.  The  patient  should  be 
laid  down,  for  obvious  reasons ; ,  it  is  doubtful,  however,  whether 
posture  influences  the  duration  or  severity  of  the  attacks.  It  is 
necessary  to  see  that  the  clothes  are  loose  about  the  neck ;  if  they  are 
tight  when  the  neck  becomes  turgid  and  swollen,  the  resistance  to 
the  return  of  blood  is  increased,  and  extravasations  into  the  skin 
and  conjunctiva?  are  more  probable.  After  the  attack,  the  patient 
should  be  allowed  to  sleep,  if  inclined  to  do  so,  for  at  least  half  an 
hour. 

In  the  status  epilepticus  bromide  often  fails.  The  inhalation  of 
chloroform  usually  effects  only  a  transient  amelioration.  Nitrite  of 
amyl  has  been  recommended  by  Crichton-Browne.  In  the  cases  I 
have  seen,  most  influence  has  been  exerted  by  chloral  (gr.  xv  every 
three  or  four  hours),  subcutaneous  injections  of  morphia  (gr.  -J^),  and 
the  application  of  ice  to  the  spine. 

General  Management. — It  has  been  l'ecommended,  on  theoretical 
grounds,  that  the  diet  of  epileptics  should  contain  little  or  no  animal 
food.  The  evidence  of  experience,  as  far  as  I  have  seen,  is  opposed 
to  this  opinion.  I  have  known  the  exclusion  of  meat  from  diet  to 
cause  a  great  increase  in  the  severity  of  the  fits,  which  became  slighter 
when  meat  was  again  given;  and  I  believe  that  patients  do  best 
if  a  moderate  quantity  of  animal  food  is  given  twice  a  day,  care 
being  taken  to  avoid  that  which  is  indigestible.  I  have  known  one 
case,  however,  in  which  the  patient  could  never  take  beef  without 
bringing  on  an  attack,  although  he  could  take  other  kinds  of  meat 
with  impunity.  Stimulants  should  be  taken  sparingly  ;  young  per- 
sons do  better  without  alcohol.  In  all  cases  it  is  most  important 
that  the  regular  action  of  the  bowels  should  be  secured. 

Moderate  exercise  of  body  and  mind  does  good,  but  severe  and 
exhausting  exertion  is  undesirable,  and  the  excitement  of  competi- 
tive and  other  examinations  should  be  avoided.  The  education  of 
children  should  not  be  entirely  neglected.  It  must  be  remembered 
that  there  are  many  positions  in  life  for  which  epilepsy  constitutes  no 
insuperable  disqualification,  and  for  which  they  may  be  trained,  should 
the  disease  not  be  arrested.  In  this  choice  of  an  occupation,  so  much 
depends  upon  personal  opportunities  that  it  is  difficult  to  lay  down 
general  rules.  But  there  is  one  consideration  to  which  all  other's  must 
be  subordinate, — the  calling  must  be  one  which  involves  no  risk  of 
life  from  the  occurrence  of  an  attack  while  the  patient  is  at  work. 
An  outdoor  life  is  better  than  sedentary  occupations,  but  the  choice 
of  the  latter  is  so  much  larger  that  in  most  cases  a  sedentary  calling 
has  to  be  selected. 

The  parents  of  a  sufferer  often  conceal  from  him  or  her  the  nature 
of  the  malady,  terming  the  seizures  "  faints,"  in  order  to  avoid 
distress.     Sometimes,  however,  it  is  impossible  to  secure  the  needful 


TREATMENT.  767 

caution,  and  persistence  in  treatment,  unless  the  nature  of  the  malady 
is  known.  But  it  is  wise  for  the  practitioner  to  cultivate  the  hahit 
of  using  the  word  "attack"  rather  than  fit,  lest  he  give  inadvertently 
a  grave  shock  to  a  patient  who  was  before  in  ignorance. 

The  question  of  marriage  presents  itself  under  two  aspects,  as 
regards  the  individual  and  as  regards  the  poss  ble  offspring.  Marriage 
has  no  influence  on  the  disease,  beneficial  or  the  reverse,  except  so 
far  as  it  may  involve  deleterious  sexual  excess.  But  with  reference 
to  the  offspring  the  question  is  veiy  important.  There  is  no  certainty 
that  the  taint  will  be  transmitted ;  on  the  contrary,  as  regards  any 
individual  child  there  is  a  probability  that  it  will  escape.  But  the 
probability  is  also  against  the  escape  of  all  the  offspring  from  diseases 
of  the  nervous  system,  at  least  when  the  disease  in  the  parent  is 
inherited. 

Surgical  Treatment. — Counter-irritation  in  the  neck  or  scalp  has 
been  often  employed,  the  usual  method  being  by  a  seton  in  the  neck. 
That  it  occasionally  does  good  is  undeniable,  and  the  same  is  true  of 
an  extensive  accidental  burn.  In  most  cases  the  effect  is  temporary 
only.  As  the  cases  mentioned  in  the  section  on  Etiology  show,  in  the 
rare  form  of  epilepsy  in  which  the  fits  are  excited  by  pressure  on  a 
tender  cicatrix,  or  are  preceded  by  pain  at  such  a  scar,  it  is  right  to 
excise  the  cicati'ix,  amputate  a  finger,  or  at  least  resect  a  nerve. 

Trephining,  an  old  remedy,  has  been  lately  brought  into  fresh 
prominence.  The  mere  formation  of  a  hole  in  the  skull,  without  in- 
terference with  the  brain,  has  been  employed  in  many  cases  of  idio- 
pathic epilepsy,  but  the  results  obtained  are  little  better  than  those  of 
a  seton  in  the  neck,  and  it  is  doubf  ul  whether  the  operation  has  other 
influence  thau  that  of  an  energetic  counter-irritation.  But  the  local 
commencement  of  the  fit  in  one  limb  means  local  excessive  instability 
in  the  corresponding  cortical  centre,  and  in  some  cases  it  means  also 
old  organic  disease.  (When  there  is  active  disease  there  is  probably 
a  tumour,  and  such  cases  have  been  already  considered.)  The  ques- 
tion comes,  Is  the  removal  of  such  disease  justifiable  ?  The  answer 
must  depend  on  the  character  of  the  fits,  and  on  their  apparent  cause. 
If  many  of  these  are  local  and  partial,  and  there  is  reason  to  believe 
that  there  is  disease  that  can  be  completely  removed,  an  operation  is 
justifiable.  If,  indeed,  there  is  no  evidence  of  removable  disease, 
the  excision  of  the  centre,  stimulation  of  which  causes  the  movement 
with  which  the  fits  commence,  may  arrest  them,  and  if  the  area  ex- 
cised is  not  very  extensive,  the  loss  of  power  it  causes  soon  lessens 
to  a  moderate  degree,  as  Horsley  and  others  have  abundantly  proved. 
If,  on  the  other  hand,  the  fits  generally  spread,  not  only  through  the 
side  on  which  they  began,  but  also  to  the  other  side ;  if  they  begin 
with  an  aura  such  as  is  common  in  idiopathic  epilepsy;  or  if  the 
patient  has  also  minor  attacks  similar  to  those  of  the  idiopathic  form, 
the  probability  of  benefit  is  much  diminished.  Apparently  the 
repeated  discharges  have  led  to  so  wide  a  deficiency  in  the  stability 


768  CONVULSIONS. 

of  the  nei've- cells  that  the  discharge  will  start  from  other  regions  if 
the  primary  lesion  is  removed.  This  is  the  teaching  of  experience  in 
a  considerable  number  of  such  cases  in  which  the  operation  has  been 
performed,  including  some  in  which  they  were  caused  by  the  pressure 
of  depressed  bone  or  an  exostosis,  and  the  cause  of  the  irritating  pres- 
sure could  be  easily  removed,  as  well  as  others  in  which  the  affected 
centre  was  excised.  On  the  other  hand,  in  both  sets  of  cases,  when 
the  attacks  always  began  by  local  spasm  and  remained  one-sided,  the 
operation  has  been  successful,  even  after  many  years.* 

Ligature  of  the  carotid  artery  has  been  performed  without  result. 
Ligature  of  one  or  both  vertebrals  has  been  practised  by  Dr.  Alexander, 
of  Liverpool  (and  by  others  after  him),  as  a  cure  for  epilepsy,  but  the 
results  obtained  are  not  commensurate  with  the  risk,  although  this 
is  not  so  great  as  might  be  thought.  In  a  few  cases  the  attacks  have 
ceased ;  in  the  majority  they  have  returned  after  a  period  of  a  few 
weeks  or  months. 


CONVULSIONS :  ECLAMPSIA. 

Convulsions,  resembling  more  or  less  closely  those  of  epilepsy,  may 
occur  from  various  causes.  In  epilepsy,  however  the  disease  was 
originally  excited,  the  recurring  convulsions  are  the  result  solely  of 
the  tendency  of  the  brain  to  "  discharge,"  and,  beyond  trifling  dis- 
turbing influence,  no  cause  outside  the  brain  can  be  discovered. 
"When  such  fits  are  due  to  some  other  cause,  they  are  called  simply 
"convulsions."  But  this  term  has  also  a  wider  application;  it  is 
applied  to  the  fits  of  epilepsy,  and  also  to  those  that  are  produced  by 
organic  brain  disease.  Hence  the  word  "  eclampsia  "  has  come  to  be 
used  as  a  name  for  the  condition  in  which  convulsions  occur  from 
other  causes  than  primary  states  of  the  brain.  In  epilepsy,  the  con- 
vulsions themselves  are  the  sole  evidence  of  their  cause  ;  in  eclampsia, 
the  cause  of  the  fits  manifests  itself  by  other  symptoms,  often  by 
symptoms  outside  the  nervous  system. 

The  term  "  eclampsia  "  is,  however,  chiefly  used  as  a  designation 
for  convulsions  that  recur.  It  is  not  applied  to  the  single  fit  that  a 
child  may  have  at  the  onset  of  an  acute  fever,  or  in  consequence  of  an 
indigestible  meal.  Moreover,  the  convulsive  attacks  that  form  part 
of  the  manifestations  of  hysteria  are  also  excluded  from  the  meaning 
of  the  term.  There  are  three  special  varieties  of  eclampsia, — infan- 
tile, puerperal,  and  uraemic. 

*  Such  cases  are  witliin  the  province  of  surgery  rather  than  that  of  medicine. 
Details  of  many  cases  of  the  kind  will  be  found  in  the  writings  of  Horsley,  MacEwen, 
and  others. 


INFANTILE    CONVULSIONS.  769 

Infantile  Convulsions  :   Infantile  Eclampsia. 

Convulsions  occur  in  young  children  with  great  readiness,  and  have 
many  causes.  The  special  liability  of  infants  is  probably  due  to  the 
condition  of  development  of  the  nervous  system.  At  the  time  of  birth, 
only  parts  of  it  are  structurally  complete.  Extensive  tracts  of  fibres 
have  not  yet  acquired  their  white  medullary  substance,  and  until  the 
axis-cylinders  are  thus  clothed,  the  fibres  have  but  little  conducting 
power,  although  it  is  probable  that  such  power  is  not  altogether 
absent.  But  the  lower  centres  are  farther  advanced  than  the  higher 
ones,  and  are,  in  consequence,  imperfectly  controlled.  This  is  pro- 
bably the  chief  reason  why  reflex  disturbance  so  readily  occurs  in 
early  childhood.  By  far  the  most  potent  cause  of  convulsions  in 
children  is  the  constitutional  condition  termed  "  rickets."  The  essen- 
tial element  in  rickets  is  defective  development ;  the  perversion  of 
development  that  occurs  (e.  g.  in  the  bones)  is  secondary  to,  and  con- 
sequent on,  its  defect.  At  the  time  at  which  this  constitutional  state 
chiefly  occurs,  the  structural  development  of  the  nervous  system  is 
complete.  But  it  is  probable  that  functional  capacity  is  only  fully 
developed  atter  structural  perfection,  and  the  parts  last  developed  must 
suffer  from  the  general  delay  in  development  more  than  those  parts 
that  have  been  longer  perfect  and  longer  in  full  use.  The  lower 
motor  centres  in  the  spinal  cord,  medulla  oblongata,  and  even  in  the 
cerebral  cortex,  are  under  less  than  the  normal  amount  of  control ; 
they  pass  into  a  condition  of  over-activity,  are  excited  by  peripheral 
impressions  with  undue  readiness,  and  thence  is  produced  the  series  of 
symptoms  of  excessive  reflex  action,  laryngismus  stridulus,  carpo-pedal 
contractions,  tetany,  and  convulsions.  It  is  probable  that  the  morbid 
tendency  is  exalted  by  an  inherited  neurotic  disposition. 

The  period  at  which  rickets  chiefly  occurs  is  between  the  sixth  and 
eighteenth  months  of  life.  This  period  corresponds  with  the  active 
epoch  of  dentition.  Dentition  is  delayed,  with  other  developmental 
processes,  and  hence  the  fits  have  commonly  been  ascribed  to  denti- 
tion, and  have  been  called  "  teething  fits."  It  is  probable  that,  in 
some  cases,  the  process  of  dentition  has  an  influence  ;  it  involves 
irritation  of  the  sensory  nerves,  and  so  may  excite  the  convulsion. 
But  it  is  certain  that  this  exciting  influence  is  only  a  small  part  of  the 
process  of  causation,  and  that  it  was  formerly  over-estimated,  even 
after  the  relation  of  the  fits  to  rickets  had  been  conclusively  proved 
by  Sir  William  Jenner.  The  convulsions  may  occur  without  any 
discoverable  exciting  cause,  or  they  may  be  produced  by  various  peri- 
pheral impressions  besides  those  of  the  teeth,  both  in  children  who 
are  rickety  and  in  those  who  possess  only  the  predisposition  inherent 
in  infancy.  Of  these  causes  the  most  frequent  is  some  irritation  of 
the  gastro-intestinal  mucous  membrane,  especially  by  worms  or  by 
some  substance  in  food  that  is  absolutely  indigestible,  such  as  the 

vol.  it.  49 


570  INFANTILE    CONVULSIONS. 

skins  of  dried  fruit,  currants,  &c.  Among  worms,  lumbrici  are 
chiefly  influential;  tapeworms  are  rare  in  young  children,  and 
threadworms  scai'cely  ever  cause  couvulsions,  although  they  are 
often  thought  to  do  so.  The  influence  of  irritation  of  the  alimentary 
membrane  in  causing  convulsions  is  remarkable ;  the  effect  often 
occurs  with  very  little  conscious  sensation,  while  contractions  of  the 
intestines  that  cause  acute  pain  have  no  corresponding  influence. 

Infantile  convulsions  may  also  he  caused  by  morbid  blood-states, 
and  may  attend  the  onset  of  many  acute  diseases.  They  also  occur  in 
states  of  general  exhaustion,  however  these  are  produced,  especially 
in  that  caused  by  diarrhoea.  Thus  they  may  form  part  of  the  con- 
dition called  "  hydrocephaloid "  (p.  370).  The  pi'edisposition  in 
these  cases  probably  depends  on  the  acute  impairment  of  nutrition 
of  the  nerve- elements,  perhaps  also  on  the  deficient  blood-pressure, 
of  which  the  depressed  fontanelle  is  evidence.  On  the  other  hand, 
they  result  also  from  mechanical  congestion  of  the  brain,  which 
involves,  among  other  conditions,  a  deficiency  in  the  supply  of  arterial 
blood.  Hence  pai-oxysnial  cough,  of  whatever  nature,  but  especially 
that  of  pertussis,  may  lead  to  a  general  convulsion.  Possibly,  in 
whooping-cough,  convulsions  may  be  in  part  due  to  the  spread,  in 
the  predisposed  bi'ain,  of  the  "  discharge  "  causing  the  cough.  It  is 
doubtful  whether  convulsions  ever  result  from  active  congestion  of  the 
brain,  which  was  once  thought  to  be  their  common  cause.  If  the 
condition  ever  has  this  effect,  it  is  only  in  excessively  rare  cases,  or 
when  the  congestion  is  the  first  stage  of  inflammation.  During  the 
first  few  days  of  life  convulsions  are  not  uncommon,  but  they  pro- 
bably always  depend  on  direct  injury  to  the  brain  during  the  process 
of  birth  (see  p.  414).  At  all  periods  of  infancy  and  childhood  they 
may  be  due  to  the  occurrence  of  an  acute  cerebral  lesion,  but  these 
cases  do  not  come  within  the  class  considered  in  this  chapter. 

Symptoms. — Infantile  convulsions  are  often  preceded  by  other 
signs  of  disturbance  of  the  nervous  system.  Tbe  child  is  restless  and 
irritable ;  the  aspect  of  the  face  often  changes  ;  there  may  be  a  little 
twitching  of  the  mouth  at  times,  or  some  abnormal  movement  of  the 
eyes.  In  rickets,  there  is  often  inversion  of  the  thumbs  and  great 
toes — "  carpo-pedal  contractions  " — or  there  have  been  attacks  of 
"  laryngismus  stridulus,"  or  more  distinct  partial  convulsions.  The 
actual  attack  usually  comes  on  suddenly,  and  may  occur  during  either 
the  waking  or  the  sleeping  state.  Sometimes  a  severe  attack  resem- 
bles closely  an  epileptic  fit,  but  in  general  the  attacks  are  slighter 
than  typical  epileptic  couvulsions.  There  is  a  sudden  fixation  of  the 
eyes,  which  are  often  rolled  up  or  down,  or  to  one  side,  or  may 
converge  or  diverge.  The  face  and  lips  become  pale.  The  limbs  and 
trunk  are  rigid  and  stiff,  the  head  turned  to  one  side  or  retracted. 
Respiration  is  interfered  with,  and  the  face  becomes  dusky.  After  a 
minute  or  so,  the  spasm  may  relax,  or  (less  frequently)  may  become 


DIAGNOSIS.  771 

clonic  as  in  an  epileptic  fit.  Sometimes  the  spasm  is  entirely  clonic, 
but  it  is  then  slight,  and  involves  chiefly  the  face  and  eyes,  or  the 
hands  and  feet.  In  other  cases,  again,  a  slighter  tonic  spasm  may 
continue  for  a  considerable  time,  half  an  hour  or  more ;  it  is  then 
insufficient  to  stop  breathing,  but  may  interfere  with  this  enough  to 
cause  a  slight  change  in  the  colour  of  the  face.  In  these  cases  the 
spasm  may  not  change  the  position  of  the  limbs,  and  may  not  be 
noticed  until  the  alteration  in  the  colour  of  the  face  attracts  atten- 
tion, when  the  rigidity  is  discovered.  Such  persistent  spasm,  how- 
ever, usually  varies  from  time  to  time,  so  that  there  is  really  a  series 
of  convulsions,  with  imperfect  recovery  in  the  intervals.  Many  slight 
attacks  are  accompanied  by  a  scream,  and  are  popularly  called 
"  screaming  fits ;"  there  may  be  nothing  more  than  a  scream  and 
quick  breathing  or  grinding  of  the  teeth,  and  brief  rigidity  of  the 
limbs.  Such  convulsions  are  probably  always  bilateral ;  it  is  doubtful 
whether  the  fits  in  true  infantile  eclampsia  are  ever  confined  to  one  side. 

The  attacks  termed  "laryngismus  stridulus"  consist  of  laryngeal 
spasm,  analogous  to  the  convulsions,  and  under  the  same  conditions. 
They  consist  of  sudden  spasm,  stopping  the  breath  and  causing  the 
child  to  seem  on  the  point  of  death  from  suffocation.  Then  the  spasm 
relaxes,  and,  with  a  loud  crowing  inspiration,  as  the  vocal  cords  recede, 
the  child  gets  its  breath  again.  Such  attacks  often  occur  many  times 
daily,  spontaneously,  or  excited  by  some  sudden  alarm,  or  by  some 
peripheral  impression. 

The  convulsions  of  rickets  may  be  few,  and  cease  after  a  few  days, 
or  tbey  may  recur  during  several  weeks,  or  even  months.  Not  un- 
commonly they  begin  at  eight  or  nine  months,  and  go  on  through  the 
second  year  of  life,  and  then  cease.  They  may,  however,  "continue  for 
a  still  longer  time,  and  the  condition  must  then  be  regarded  as 
epilepsy.  Indeed,  whenever  attacks  continue  after  their  cause  has 
ceased,  the  condition  is  inseparable  from  epilepsy.  Some  of  the 
children  in  whom  the  fits  cease  after  lasting  for  a  year  or  so,  become 
epileptic  in  later  childhood  or  at  puberty. 

Diagnosis. — The  chief  point  in  the  diagnosis  of  the  nature  of 
infantile  eclampsia  is  to  distinguish  from  it  the  convulsions  that 
are  due  to  organic  brain  disease.  Those  produced  by  such  processes 
as  tumour  or  meningitis  are  soon  accompanied  by  other  symptoms 
of  the  morbid  process.  It  is  important,  however,  to  bear  in  mind 
the  fact  that  a  commencing  organic  process  may  increase  the  irri- 
tability of  the  brain  before  it  causes  other  symptoms,  and  then  some 
peripheral  impression  may  excite  a  convulsion.  It  must  be  remembered 
that  a  fit,  even  in  a  young  child,  generally  means  some  increased 
central  excitability,  and  the  older  the  child  the  greater  is  its  significance 
in  this  respect.  If  there  is  not  evidence  of  a  cause  of  increased 
excitability  (such  as  prostration  or  rickets),  the  possibility  that  there 
may  be  commencing  organic  disease  should  always  be  remembered. 


772  INFANTILE    CONVULSIONS. 

A  special  difficulty  is  presented  by  the  cases  in  which  convulsions- 
are  due  to  a  sudden  cortical  lesion  and  recur  (see  p.  750).  The 
distinction  of  these  fits  from  those  of  eclampsia  rests  especially  on  the 
fact  that  they  are  generally  unilateral,  and  often  commence  locally  in 
some  part  of  one  side.  When  they  are  accompanied  by  distinct 
evidence  of  hemiplegia,  corresponding  in  side  to  the  convulsions,  the 
diagnosis  is  easy.  Often,  however,  the  paralysis  is  slight  and 
unnoticed.  Whenever  fits  are  one-sided,  and  commence  with  a  sudden 
series  of  severe  convulsions,  accompanied  by  the  signs  of  a  cerebral 
illness,  it  is  exceedingly  probable  that  they  are  of  this  nature.  If 
recurring  eclamptic  convulsions  are  ever  unilateral,  they  are  not 
constant  in  seat,  but  affect,  at  different  times,  one  side  and  the  other. 

In  all  cases  of  infantile  convulsions  a  careiul  search  should  be  made 
for  any  peripheral  cause  of  irritation,  such  as  local  suppuration,, 
intestinal  worms,  and  the  like. 

Prognosis. — There  is  more  danger  to  life  in  the  eclamptic  convul- 
sions of  infancy  than  in  the  epileptic  fits  of  later  life.  Frequent 
convulsions  may  readily  cause  fatal  exhaustion  in  a  young  and  feeble 
child.  The  actual  prognosis  must  be  founded  on  the  severity  and 
frequency  of  the  fits,  and  on  the  strength  of  the  patient.  If  convul- 
sions continue  for  some  months,  the  prognostic  question  arises — Will 
the  disease  go  on  to  epilepsy?  The  danger  is  considei'able,  and  it 
increases  the  longer  the  fits  continue.  But  even  after  they  have 
lasted  for  a  year,  there  is  a  fair  chance  of  arrest. 

Treatment. — In  the  treatment  of  the  convulsions  of  children,  the 
first  important  measure  is  to  search  for  their  cause,  and,  if  possible,, 
to  remove  it  by  treatment.  This  is  especially  important  in  the  ease 
of  rickets,  in  which  the  mere  treatment  of  the  attacks  may  have  little 
influence  if  their  cause  is  allowed  to  continue  unchecked,  whereas  the 
treatment  of  the  underlying  diathetic  state,  by  cod-liver  oil  and  steel 
wine,  may  alone  speedily  stop  the  fits.  The  attacks  themselves,  whether 
general  convulsions  or  the  local  laryngeal  spasm,  are  generally  amen- 
able to  bromide  of  potassium,  but  it  is  necessary  to  give  this  in  ade- 
quate doses,  three  grains  to  a  child  under  six  months ;  five  grains  to 
one  between  six  and  sixteen  months,  and  still  larger  doses  to  older 
children.  Two  or  three  doses  may  be  given  in  the  day.  Severe 
attacks  may  need  the  inhalation  of  chloroform,  which  is  almost  always 
effective,  but  may  have  to  be  repeated  two  or  three  times  before  the 
bromide  that  is  given  can  assert  its  influence. 

It  was  formerly  the  custom  to  treat  infantile  eclampsia  by  warm 
baths  and  by  applications  designed  to  draw  the  blood  to  the  skin,  on 
the  theory  that  the  convulsions  were  the  result  of  cerebral  congestion. 
Grey  powder  was  given,  in  frequent  doses,  to  combat  the  supposed 
local  condition.  Indeed,  the  fact  of  a  patient  having  suffered  from 
infantile  convulsions  may  still  often  be  correctly  surmised  from  the 


PUERPERAL   CONVULSIONS.  773 

indications  presented  by  the  permanent  teeth  of  the  influence  of  the 
mercury  in  early  life.  The  theory  was  certainly  erroneous,  and  it  is 
doubtful  whether  the  treatment  did  any  good.  I  remember,  when  a 
pupil  in  the  country,  spending  the  greater  part  of  a  day  watching  in 
vain  for  the  expected  effect  of  repeated  warm  baths  on  the  almost 
continuous  tonic  convulsion  from  which  a  rickety  child  was  suffering. 
Certainly,  unless  a  warm  bath  has  an  immediate  effect,  it  is  useless  to 
repeat  it. 

The  dentition  theory  of  the  origin  of  the  convulsions  led  to  the 
almost  universal  adoption  of  the  practice  of  lancing  the  gum  over  a 
coming  tooth  to  lessen  the  irritation.  As  the  sole  or  even  the  chief 
element  in  the  treatment,  the  measure  is  a  mistake,  since  it  deals  with 
the  least  important,  and  often  quite  unimportant,  element  in  the 
causation  of  the  convulsions.  It  is,  however,  probable  that  the 
measure  does  sometimes  facilitate  the  eruption  of  the  tooth,  and  may 
thus  lessen  any  irritation  that  exists. 

Puerperal  Convulsions  :  Puerperal  Eclampsia. 

Etiology. — Towards  the  end  of  pregnancy,  during  labour,  and  after 
labour,  women  sometimes  suffer  from  severe  convulsions,  and  of  those 
thus  attacked,  many  die — from  20  to  30  per  cent.  Women  who  are 
pregnant  for  the  first  time,  and  those  who  are  comparatively  young, 
are  the  most  prone  to  suffer,  and  in  them  the  malady  is  most  fatal. 
A  few  of  the  patients  have  been  epileptic,  and  the  fits  are  simply 
those  to  which  they  have  long  been  liable.  In  most  cases  of  epilepsy, 
however,  the  attacks  do  not  occur  during  the  puerperal  period.  In 
some  other  cases,  very  rare,  there  has  been  evidence  of  no  other 
causal  condition  than  an  over-excitable  state  of  the  nervous  system, 
and  the  convulsions  were  distinctly  excited  by  the  pains  of  labour,  or 
by  the  irritation  of  digital  examinations.  In  the  vast  majority  of 
cases,  however,  puerperal  convulsions  are  associated  with  the  presence 
of  a  large  quantity  of  albumen  in  the  urine,  in  which  casts  also  are 
found,  and  urea  is  deficient  in  quantity.  In  fatal  cases,  the  kidnevs 
present  indications  of  prolonged  congestion,  and  often  a  condition  that 
has  been  generally  regarded  as  one  of  nephritis.  These  signs  of 
kidney  disease  may  be  accompanied  by  distinct  oedema  of  the  sub- 
cutaneous tissue.  The  association  of  puerperal  convulsions  with  such 
evidence  of  altered  function  of  the  kidneys  is  too  frequent  to  be 
without  very  strong  significance,  and  the  balance  of  evidence  is  strongly 
in  favour  of  the  common  inference  that  has  been  drawn  from  the  asso- 
ciation— that  puerperal  convulsions  are  really  uraemic  convulsions, 
or  at  least  due  to  the  retention  in  the  blood  of  material  that  should 
be  eliminated  by  the  kidneys.  They  differ  from  such  convulsions 
under  other  circumstances  in  the  common  absence  of  pronounced 
uraemic  coma,  but  they  differ  also  in  another  fact,  which  exj)lains  to 
some  extent  the  absence  of  coma — the  presence  of  a  powerful  cause  of 


77-i  PUERPERAL    CONVULSIONS. 

reflex  irritation,  which,  as  we  have  just  seen,  may  excite  convulsions 
apart  from  any  toxaeinic  influence,  and  when  no  other  predisposition 
exists  than  an  undue  central  excitability  of  the  nervous  system.  We 
must  remember,  also,  that  the  condition  of  pregnancy  itself  involves 
an  abnormal  state  of  the  nerve-centres,  as  is  clearly  shown  by  the 
occurrence  of  many  functional  disorders,  such  as  chorea  and  tetauy. 
Thus  the  influence  of  the  blood-state  is  exerted  on  predisposed  centres, 
and  is  aided  by  peripheral  irritation,  which  is,  under  the  circumstances, 
peculiarly  powerful.  Moreover,  even  when  other  signs  of  ura3inia 
are  absent,  albuminuric  retinitis  often  testifies  to  the  intensity  of  the 
influence  on  the  system  exerted  by  the  renal  disease,  and  is  a  proof  of 
the  essential  correspondence  of  the  state  with  that  of  Bright's  disease, 
which  has  been  overlooked  by  many  writers. 

The  evidence  is  so  conclusive  that  it  seems  hardly  worth  while  to 
mention  the  objections  that  have  been  raised  to  the  theory,  or  the 
hypotheses  that  have  been  put  forward  to  take  its  place.  In  addition 
to  the  absence  of  other  signs  of  uraemia,  which  has  been  already  dis- 
cussed, it  has  been  alleged  that  albumen  is  to  be  found  in  so  large  a 
proportion  of  pregnant  and  puerperal  women  that  its  coincidence  with 
convulsions  has  no  significance.  But  it  is  a  question  not  of  the  mere 
presence  of  albumen,  but  of  its  amount,  and  the  amount  that  is 
common  apart  from  convulsions  is  trifling  and  without  significance.* 
On  the  other  hand,  clinical  experience  shows  that  whenever  a  woman, 
at  or  near  labour,  presents  much  albumen  in  the  urine,  with  other 
signs  of  nephritis,  she  is  in  imminent  danger  of  convulsions.  The 
chief  other  theory  that  has  been  put  forward  is,  that  there  is  anaemia 
of  the  brain,  the  result  of  a  watery  state  of  the  blood  and  of  vaso- 
motor spasm,  which  is  itself  due  to  the  influence  of  irritation  of  the 
uterine  nerves  or  of  the  nerves  of  the  sacral  plexus.  To  render  this 
theory  tenable  it  has  yet  to  be  proved,  first,  that  there  is  more  vaso- 
motor spasm  than  frequently  exists  in  various  conditions  without 
convulsions  ;  and  secondly,  that  vaso-motor  spasm  ever  yet  gave  rise 
to  a  fit.  The  only  hypothesis  that  deserves  future  attention  is  that 
the  renal  condition,  and  perhaps  the  convulsions  also,  are  due  to 
microbial  infection  of  the  blood.  This  has  been  supposed  to  be  due  to 
infarction  of  the  placenta,  in  which  white  nodules  have  been  found,  con- 
taining bacilli  that  are  said  to  cause  convulsions  in  pregnant  animals. 
But  more  facts  are  needed  to  put  the  theory  on  a  current  footing. 

Symptoms. — Puerperal  convulsions  occur  during,  before,  or  after 
labour.  They  may  not  only  be  distinctly  excited  by  the  local  irritation, 
but  are  sometimes  set  up  by  other  causes,  as  a  blow  on  the  head  (Eng- 
stroni),  while  the  depression  of  anxiety  and  fear  seems  sometimes  to 
aid  in  their  production.     In  addition  to  the  oedema  already  mentioned, 

*  This  point  has  heen  ably  and  conclusively  discussed  by  Galabin,  '  British  Med. 
Journ.,'  Aug.  30tb,  1880. 


TREATMENT.  775 

their  onset  is  often  heralded  by  severe  headache,  precordial  pain,  or 
sudden  amaurosis,  the  latter  certainly  and  the  others  probably  ursemic 
in  origin.  The  onset  is  usually  sudden,  and  the  convulsions  generally 
resemble  closely  those  of  epilepsy.  There  is  absolute  unconsciousness, 
the  tongue  is  frequently  bitten,  and  the  bladder  and  rectum  may  be 
emptied  during  the  fit.  One  difference  from  ordinary  epileptic  fits  is, 
that  very  frequently  the  affection  of  the  two  sides  is  not  simultaneous, 
but  successive.  The  eyes  are  often  conspicuously  involved.  In  one 
case  in  which  the  character  of  the  fits  was  very  carefully  noted*  each 
began  with  nystagmus,  lateral  and  to  the  left.  Then  first  the  eyes 
and  afterwards  the  head  were  strongly  turned  to  the  left,  and  clonic 
spasm  came  on  in  both  eyelids,  with  tonic  contraction  of  the  left  side 
of  the  face,  and  the  left  arm  and  leg.  First  the  wrist  was  extended, 
then  strongly  flexed  and  pronated.  Subsequently  the  eyes  and  head 
turned  to  the  right,  and  the  right  arm  and  leg  were  rigid  like  the  left, 
so  that  tonic  spasm  became  universal,  and  the  tongue  was  thrust  out 
of  the  mouth;  then  general  clonic  spasm  set  in,  with  horizontal  nys- 
tagmic movement  of  the  eyes.  The  spasm  ceased  on  the  left  side 
soouer  than  on  the  right.  During  the  coma  that  followed,  the  eyes 
were  rolled  upwards.  All  the  fits  were  the  same,  save  that  in  the 
earlier  attacks  there  was  opisthotonos,  and  the  later  fits,  as  the  patient 
became  exhausted,  were  limited  to  the  face,  involving  especially  the 
frontales.  The  patient  was  a  youug  married  woman  aged  eighteen, 
who  had  an  intense  dread  of  parturition.  The  first  fit  commenced  soon 
after  labour  set  in,  and  each  pain  excited  a  convulsion.  She  was 
delivered  with  the  forceps,  but  the  fits  continued,  with  an  interval 
after  labour  of  four  hours,  and  she  died  forty-eight  hours  from  the 
onset.  The  temperature  rose  to  103°,  and  continued  at  that  point. 
The  urine,  when  heated,  became  solid  from  albumen,  and  the  kidneys 
after  death  presented  the  characteristic  signs,  naked-eye  and  micro- 
scopic, of  acute  inflammation.  In  some  cases,  in  which  the  convul- 
sions are  very  severe,  the  temperature  rises  to  108°  or  109°,  as  it 
may  do  in  the  status  epilepticus.  The  average  mortality  in  puerperal 
convulsions  is  about  30  per  cent.f 

Treatment. — The  treatment  is  in  part  obstetrical,  the  most  impor- 
tant element  being  the  termination  of  pregnancy;  and  the  problem  of 
waiting  for  the  child  to  be  capable  of  living,  and  at  the  same  time 
avoiding  undue  risk  to  the  life  of  the  mother,  is  one  of  the  most 
delicate  and  difficult  tasks  in  obstetric  pi-actice.  For  the  convulsions 
themselves,  venesection  was  formerly  employed,  and  when  much 
blood  had  flowed,  the  fits  usually  ceased ;  but  the  consequent  exhaus- 
tion of  the  patient,  and  the  discovery  of  the  coincident  kidney  disease, 

*  By  Dr.  Hyde  Marriott,  formerly  of  University  College  Hospital,  to  whom  I  am 
indebted  for  the  report  of  the  case. 

t  Of  62  cases  in  the  Konigsberg  Hospital  Eeconls,  the  percentage  mortality  of 
mothers  was  2y,  and  of  children  38  per  cent.  (Gettkant,  '  Diss.  Konigsb.,'  1884). 


776  UREMIC    CONVULSIONS. 

have  led  to  the  abandonment  of  this  practice,  especially  in  view  of  the 
fact  that  inhalations  of  chloroform  are  usually  successful  in  arresting 
each  convulsion.  As  long  as  the  inhalation  is  kept  up,  the  convul- 
sions mav  cease,  but  when  it  is  discontinued  they  too  often  return. 
The  treatment  of  the  blood-state  is  necessarily  limited  under  the  cir- 
cumstances of  parturition,  and  yet  it  is  unquestionably  most  impor- 
tant. Vapour-baths  have  been  employed,  and  so  have  pilocarpine 
and  nitrite  of  atnyl,  sometimes  with  success.  Theoretically,  vene- 
section and  transfusion  might  be  expected  to  afford  more  chance  of 
recoverv  to  a  desperate  case  than  any  other  measure.  For  further 
details  of  treatment  the  reader  is  referred  to  works  on  obstetric 
medicine.* 


TJb.smic  Convulsions. 

The  nature  and  precise  cause  of  the  convulsions  of  uraemia  are 
topics  berond  the  province  of:  this  work,  but  it  may  be  convenient 
brieflv  to  describe  their  characters.  They  occur  only  when  the  kidney 
disease  has  profoundly  affected  the  system  and  has  altered  the  state  of 
the  blood;  in  chronic  kidney  disease  there  are  usually  other  indica- 
tions of  this  effect  in  hypertrophy  of  the  heart  and  albuminuric 
retinitis. 

TJrsemic  convulsions  usually  set  in  suddenly,  and  there  may  be  no 
preceding  symptoms  to  indicate  what  is  coming.  In  some  cases,  how- 
ever, they  are  preceded  by  other  symptoms  of  uraemia,  as  coma  or  amau- 
rosis. The  tits  are  seldom  isolated ;  usually  several  occur  in  a  short 
time,  sometimes  in  the  course  of  an  honr,  sometimes  at  intervals  of 
several  hours. 

The  convulsion  usually  resembles  very  closely  an  epileptic  fit,  con- 
sisting of  tonic  and  clonic  spasm.  The  preponderance  of  the  spasm 
on  one  side  is  generally  well  marked,  and  causes  a  strong  deviation  of 
the  head  and  eyes  to  one  side.  Occasionally  the  convulsion  is  uni- 
lateral, but  the  affection  of  one  side  is  not  constant, — the  side  involved 
varies  in  different  fits.  Another  occasional  characteristic  is  a  special 
affection  of  the  muscles  of  the  face,  which  may  be  bilateral,  as 
was  conspicuous  in  the  case  of  puerperal  convulsions  described  above. 
Nystagmus,  as  in  that  case,  is  sometimes  observed,  the  quick  move- 
ment being  to  the  side  towards  which  the  head  deviates.  The  convul- 
sions often  begin  locally,  now  in  one  part,  now  in  another,  but 
quickly  spread.  The  pupils  are  usually  dilated  during  the  fit,  and 
do  not  act  to  light,  but  I  have  known  them  to  be  contracted,  and 
to  dilate  afterwards.  In  severe  convulsions  the  interference  with 
respiration  is  very  marked,  and  the  tongue  may  be  bitten.  Immedi- 
atelv  after  the  fit,  the  knee-jerk  may  not  be  obtained.     The  patient 

*  Many  papers  relating  to  this  affection,  by  Galabin,  Banner,  and  others,  will  be 
founl  in  the  '  Brit.  Med.  Journ.,'  1891,  vol.  ii. 


VERTIGO.  777 

may  sleep  for  a  time  after  the  attack,  as  after  an  epileptic  fit,  or  may- 
pass  into  a  state  of  coma,  or  may  be  merely  drowsy. 

The  treatment  of  uraBinic  convulsions  is  that  of  the  blood-state. 


VERTIGO. 

The  term  "  vertigo  "  means,  by  derivation,  a  "  turning,"  and  is  used 
as  a  designation  for  any  movement  or  sense  of  movement,  either  in 
the  individual  himself  or  in  external  objects,  that  involves  a  defect, 
real  or  seeming,  in  the  equilibrium  of  the  body.  The  word  "  giddi- 
ness "  is  used  as  a  popular  synonym  for  vertigo.  An  exact  and 
•complete  appreciation  of  the  relation  of  the  body  to  its  physical 
surroundings  is  involved  in  the  mental  state  that  we  call  "  conscious- 
ness." If  that  appreciation  is  incorrect  in  any  degree — and  it  is 
rendered  incorrect  by  a  false  sense  of  movement — to  that  degree  the 
sense  of  perfect  consciousness  is  interfered  with.  Hence  vertigo 
always  involves  a  slight  interference  with  consciousness.  This  fact 
influences  the  popular  use  of  the  term  "  giddiness,"  which  is  some- 
times used  to  designate  a  mental  state  of  imperfect  consciousness 
when  there  is  no  sense  of  movement,  and  in  which  there  is  nothing 
that  would  be  termed  "  vertigo  "  in  the  strict  medical  use  of  the  word. 
The  word  "  dizziness  "  is  more  often  used  in  the  sense  of  imperfect 
consciousness,  but  it  is  also  sometimes  used  as  a  loose  synonym  foi 
"  giddiness."* 

Vertigo  is  a  common  symptom  of  organic  brain  disease,  but  in  such 
■cases  it  is  associated  with  other  distinct  symptoms  of  its  cause,  and 
has  been  already  considered  (p.  97).  In  all  cases,  indeed,  it  is  merely 
a  symptom  of  some  definite  morbid  state,  but  in  many  conditions  it  is 
a  symptom  that  is  far  more  obtrusive  than  its  cause.  Hence  it  has 
become  customary  to  describe  vertigo  as  if  it  were  a  definite  disease, 
and  the  method  has  considerable  practical  convenience,  although  it  is 
not  logically  correct. 

Before  describing  the  special  forms  presented  by  vertigo,  it  is 
desirable  to  consider  what  is  known  of  the  symptom  and  its  origin. 
The  subject  involves  a  very  obscure  branch  of  the  pathological 
ph v siology  of  the  nervous  system.  Vertigo  is  essentially  a  sense  of 
involuntary  movement,  but  it  may  be  perceived  only  as  an  apparent 
movement  of  external  objects, — "  subjective,"  and  "objective"  vertigo. 
It  involves  a  sense  of  defective  equilibrium,  and  it  is  necessarv  to 
consider,  first,  what  we  know  of  the  way  in  which  equilibrium  is 
maintained  under  normal  circumstances. 

*  The  origiual  meaning  of  "  giddy"  was  mirthful  (a  sense  still  extant),  and  that 
of  "  dizzy  "  was  foolish  or  dull. 


778  VERTIGO. 

The  maintenance  of  equilibrium  is  effected,  except  when  the  body  is 
at  rest,  by  the  activity  of  the  muscles,  influenced  by  the  brain.  When 
the  body  is  at  rest,  the  equilibrium  is  permitted  by  the  absence  of 
muscular  contraction.  The  action  of  the  brain  is  in  some  way  deter- 
mined by  certain  centripetal  impressions,  which  give  information  to 
the  cerebral  centres  as  to  the  relation  of  the  body  to  external  objects, 
as  to  the  manner  in  which  the  body  is  supported,  and  as  to  its  posi- 
tion. (1)  Sensory  impressions  come  from  the  skin,  &c,  of  the  parts 
on  which  the  body  is  resting.  (2)  Centripetal  impressions  reach  the 
brain  (probably  in  part  through  the  cerebellum)  from  these  muscles, 
the  contraction  of  which  determines  the  posture  of  the  body  and  its 
support ;  the  most  important  of  these  are  from  the  muscles  of  the 
legs  and  lower  part  of  the  trunk.  (3)  Information  as  to  the  position 
of  the  eyes  and  head  shows  the  relation  of  seen  objects  to  the  body; 
this  information  is  chiefly  derived  from  the  sense  of  the  active  inner- 
vation of  the  muscles  (see  p.  173),  probably  aided  by  centripetal 
impressions  from  them.  (4)  Impressions  from  the  semicircular  canals 
of  the  internal  ear,  which  are  apparently  due  to  the  pressure  of  the 
endolymph,  under  the  influence  of  gravitation  and  of  movement 
(Flourens,  G-oltz,  Cyon,*  &c).  We  shall  have  to  consider  these  in 
greater  detail  presently. 

Of  these  various  impressions,  which  are  doubtless  always  acting  on 
the  intra-cranial  centres,  only  those  of  the  first  class  are  felt  as  sensa- 
tions ;  the  others  seem  to  give  rise,  in  some  way,  to  perceptions — of 
posture,  &c, — which  are  not  true  sensations.  They  apparently  act 
on  some  centre  through  which  equilibrium  is  maintained,  and  which 
in  some  way  regulates  the  outgoing  currents  of  nerve-force,  probably 
the  middle  lobe  of  the  cerebellum.  We  can  trace  a  connection 
between  it  and  many  of  the  afferent  paths  concerned.  It  may  merely 
co-ordinate  these  impressions,  and  influence,  according  to  them,  the 
cerebral  centres  whence  the  outgoing  currents  proceed,  and  the  states 
of  these  motor  cerebral  centres,  thus  induced,  may  influence  con- 
sciousness as  the  "  perceptions "  alluded  to.f  This  idea  harmonises 
the  various  facts  better  than  the  assumption  that  the  outgoing 
impulses  proceed  directly  downwards  from  the  cerebellar  centre,  of 
which  there  is  no  evidence,  direct  or  indirect. 

If  any  one  of  the  centripetal  impressions  that  regulate  equilibrial 
co-ordination  is  imperfect,  we  are  chiefly  conscious  of  the  effect  on  the 
action  of  the  centre,  not  of  the  imperfection  itself.     It  is  thus  that 

*  The  various  experiments  on  the  subject  are  described  in  most  text-books  of 
physiology.  Their  details,  however  interesting,  have  not  such  a  direct  bearing  on 
the  medical  aspect  of  vertigo  to  make  it  worth  while  to  describe  them  here. 

f  What  may  be  termed  the  perceptive  character  of  the  influence  on  consciousness 
— its  origin  in  processes  not  felt  directly — is  illustrated  by  the  fact  that  there  is 
sometimes  a  feeling  that  objects  are  moving,  combined  with  a  consciousness  that 
they  are  not.  Some  patients  describe  a  feeling  of  impending  giddiness  as  being  as 
distressing  as  actual  giddiness. 


VERTIGO.  779 

"  vertigo  "  seems  to  arise,  at  least  in  many  conditions.  That  vertigo 
is  commonly  a  disturbance  of  the  action  of  some  centre,  and  is  not  a 
mere  consciousness  of  the  defective  centripetal  impression,  is  shown 
by  the  fact  that,  when  well  marked,  it  is  clearly  a  sensation  of  a  motor 
process.*  There  may  be  merely  a  sense  of  movement,  but  if  the 
sensation  is  intense,  there  is  actual  movement,  and  this  is  in  the  same 
direction  as  the  sensation  of  movement. f  From  this  it  appears  that 
the  sensation  felt  is  the  result  of  the  process  which,  in  greater  degree, 
causes  the  movement,  i.  e.  it  is  due  to  a  motor  process.  Even  when 
the  apparent  movement  is  in  external  objects,  the  same  correspondence 
is  often  observed  ;  if  the  patient  moves,  or  seems  to  move,  it  is  often 
in  the  same  direction  as  that  in  which  objects  appear  to  move.  This 
is  intelligible  only  on  the  assumption  that  the  sensation  is  due  to  a 
motor  process.  If  a  person  actually  moves,  and  an  object  remains 
opposite  his  face  (in  the  centre  of  his  field  of  vision),  he  rightly  infers 
that  it  has  moved.  The  subjective  process  in  vertigo  leads  to  the 
same  inference.  Sometimes,  however,  objects  appear  to  move  in  the 
opposite  direction  to  that  of  the  sense  of  subjective  movement;  to 
this  we  shall  presently  return. 

These  statements  apply  to  what  may  be  termed  typical  vertigo  from 
derangement  of  guiding  impulses.  But  vertigo  may  be  due  to  other 
causes.  We  have  seen  that  it  is  common  in  epilepsy  as  the  warning 
of  severe,  and  the  sensation  in  slight,  attacks.  We  can  understand 
its  occurrence  in  these  cases  on  the  theory  just  described.  In  epilepsy 
there  is  a  spontaneous  motor  dischaige,  which  may  be  one-sided,  or 
merely  greater  on  one  side  than  on  the  other ;  in  either  case  there  will 
be  a  tendency  to  lateral  movement,  which  is  actually  seen  in  the 
deviation  of  the  head  and  eyes,  and  may  give  rise  to  positive  rotation. 
This  motor  process  may  be  felt  as  vertigo  before  it  causes  movement, 
or  when  it  is  too  slight  to  cause  movement.  Hence,  too,  we  can 
understand  that  many  organic  lesions  of  the  brain  should  cause 
vertigo  at  the  time  of  their  occurrence,  just  as  they  may  also  cause 
convulsion. 

But  the  sensation  is  not  always  thus  definite,  and  does  not  always 
correspond  to  the  motor  process.  It  may  be  merely  a  vague  sense  of 
unsteadiness  or  uncertainty.     It  is  possible  that  in  some  cases  it  may 

*  This  fact  has  been  repeatedly  insisted  on,  as  of  paramount  importance,  by  Dr. 
Hughliugs  Jackson.  It  was  also  pointed  out,  long  ago,  by  Dr.  Russell  Reynolds : 
"  The  feeling  of  equilibrium  results  from  the  harmony  of  our  different  sensations 
among  themselves,  and  with  the  motor  impulse  which  is  their  combined  effect. 
When  any  one  group  of  the  sensorial  impressions  is  distorted  or  removed,  the  balance 
is  disturbed,  and  as  these  impressions  are  themselves  the  stimuli  of  muscular  action 
attempts  are  made  for  its  restoration,  ....  producing  vertiginous  or  allied  move- 
ments."— Russell  Reynolds,  '  Vertigo,'  London,  Churchill,  1854, — a  paper  in  which 
are  collected  all  the  older  facts  and  opinions  on  the  subject. 

t  It  may  be  partial,  as  in  a  patient  in  whom  a  tendency,  in  walking,  to  deviate  to 
the  left  was  accompanied  by  an  irresistible  impulse  to  put  the  right  leg  across  the 
left,  which  often  caused  a  fall. 


760  VEKTIGO. 

be  a  more  direct  effect  of  the  dei'anged  aud  discordant  centripetal 
processes,  or  the  vagueness  of  the  seusation  may  be  due  to  the  trifling 
character  of  the  motor  disturbance,  or  elements  in  its  production 
which  we  cannot  yet  clearly  discern. 

The  mechanism  of  vertigo  is  thus  so  complex,  and  our  knowledge  of 
it  is  so  fragmentary,  that  we  may  easily  go  very  far  wrong  if  we 
endeavour  to  formulate  the  precise  mode  in  which  any  given  sensation 
is  produced,  or  the  actual  disturbance  that  exists  in  any  given  case. 
But  at  the  same  time  we  may  note  the  apparent  suggestiveness  of 
some  of  the  phenomena,  in  considering  their  features.  The  exact 
character  of  the  sensation  experienced  is  often  very  difficult  to  ascer- 
tain ;  and  this  is  not  surprising,  for  the  movement  is  one  of  intense 
mental  confusion,  in  which  accurate  observation  is  most  difficult. 

The  apparent  movement  of  the  individual  himself,  the  subjective 
vertigo,  as  we  have  seen,  varies  much  in  different  cases.  "When  it  is 
definite  in  character,  its  direction  is  often  emphasised  by  the  fact  that 
the  patient  falls  or  tends  to  fall  in  the  same  direction.  There  may  be 
a  tendency  to  incline  to  the  right  or  left,  or  to  turn  towai'ds  right  or 
left,  but  more  often  this  is  combined  with  a  movement  forwards  or 
backwards.  Sometimes  there  is  a  sense  of  going  downwards — of 
sinking.  One  patient  described  it  as  if  there  were  a  powerful  magnet 
in  the  earth,  drawing  him  towards  its  centre  ;  another,  as  if  there 
were  a  huge  weight  on  his  head,  pressing  him  downwards.  A  sense 
of  falling  from  a  height  is  also  common,  and  is  probably  familiar  to 
most  persons  as  a  sleep-sensation,  the  cause  of  which  will  be  con- 
sidered presently.  It  is  noteworthy  that  the  sense  of  going  down- 
wards towards  the  earth  may  have  the  same  character,  whether  the 
patient  is  standing  or  lying.  This  sensation  is  occasionally  felt  when 
there  is  disease  of  the  semicircular  canals,  and  it  appears,  therefore, 
as  if  the  precise  direction  of  the  false  sensation  were  determined  by 
the  true  sensations  engendered  by  the  posture  of  the  body.  The 
patient  who  feels  as  if  he  were  sinking  into  the  earth  when  he  is 
standing,  feels  as  if  he  were  sinking  through  the  bed  when  he  is  lying. 
The  opposite  sensation,  that  of  rising,  is  uncommon,  but  one  form 
has  been  described  to  me  as  a  sense  of  "  walking  on  the  air,"  or  as  if, 
when  sitting,  the  body  scarcely  touched  the  chair. 

The  apparent  movement  of  objects,  objective  vertigo,  may  be  an 
impression  that  they  are  passing  before  the  patient  in  a  given  manner, 
lateral,  upwards,  or  downwards,  as  we  have  seen,  which  usually 
corresponds  to  that  in  which  the  patient  seems  to  move.  It  is  usually 
combined  with  subjective  vertigo,  and  intensifies  the  distress,  so  that 
the  eyes  have  to  be  kept  closed  in  severe  cases.*  In  some  instances, 
however,  the  direction  in  which  objects  seem  to  move  is  opposite  to 
that  of  the  subjective  movement.     The  explanation  of  this  is  difficult, 

*  Even  opening  the  eyes  in  the  dark,  when  no  object  can  he  seen,  may  intensify 
the  vertigo,  au  illustration  of  the  closeness  and  extent  of  the  association  oi  the  use 
of  the  eyes  and  the  maintenance  of  equilibrium. 


VEB1IG0.  781 

and  oiav  not  be  always  the  same.  In  some  cases  the  disturbance 
may  not  involve  the  visual  centres  in  such  a  way  as  to  give  rise  to  the 
error  of  inference,  which  causes  the  apparent  movement  of  objects  in 
the  same  direction  as  the  subjective  movement.  If  a  person  in  health 
turns  round,  objects  seem  to  move  in  the  opposite  direction,  because 
their  images  move  across  the  retina ;  in  some  cases  of  vertigo  there 
may  be  a  false  impression  of  such  a  reverse  movement,  although  there 
is  no  movement  of  the  images  on  the  retina.*  In  the  same  way,  to  a. 
patient  who  fell  forward,  it  seemed  that  the  ground  rose  up  to  meet 
him,  while  to  one  who,  in  bed,  felt  as  if  rolling  over  to  the  left,  the 
left  side  of  the  bed  on  which  he  was  lying  seemed  to  be  rising  up. 
This  condition,  in  which  objects  seem  to  move,  as  they  would  seem  if 
the  person  moved  but  the  objects  did  not,  is  perhaps  a  less  complete 
form  of  vertigo  than  that  in  which  objects  seem  to  move  with  the 
individual. 

In  other  cases  again,  objects  before  the  eyes  seem  to  move  in  a 
manner  that  has  no  exact  parallel  in  the  subjective  vertigo.  Every 
object  may  seem  to  be  rotating  on  its  own  axis,  or  all  the  objects  may 
seem  to  rotate  around  a  fixed  point  ;  rarely  objects  rotate  towards 
the  patient.  In  these  cases  the  subjective  movement  may  be  a  simple 
one  to  right  or  left,  or  there  may  be  no  subjective  vertigo ;  the- 
apparent  rotation  of  external  objects  may  be  the  only  sensation  of 
which  the  patient  is  conscious.  The  disturbance,  in  such  cases,  is 
probably  complex,  and  we  cannot  yet  discern  its  possible  mechanism. 

There  seems  to  be  a  special  relation  between  the  labyrinthine 
impressions  and  the  movements  of  the  eye,  and  in  labyrinthine  vertigo- 
there  may  be  an  actual  involuntary  movement  of  the  eyes.  This  is 
probably  the  slightest  degree  of  the  actual  movement  which,  as  we- 
have  seen,  occurs  in  many  cases,  and  involves  the  whole  body ;  when- 
ever there  is  actual  rotation,  the  eyes  and  head  lead  the  way. 

There  is  a  close  association  of  vertigo  with  vomiting,  and  often  also 
with  disturbance  of  the  vaso-motor  system ;  in  vomiting  from  any 
cause  there  is  often  a  "cold  perspiration."  Intense  giddiness  almost 
always  causes  vomiting.  It  is  probable  that  the  gastric  fibres  of  the 
vagus  have  a  connection  with  the  middle  lobe  of  the  cerebellum, 
disease  of  which  so  frequently  causes  vomiting.  It  is  more  probable 
that  the  symptom  is  thus  produced  than  that  it  is  due  to  a  direct 
connection  between  the  auditory  and  vagal  nuclei.  It  has  also  an 
obverse  side  in  the  influence  of  gastric  derangement  in  exciting  vertigo, 
which  we  shall  consider  presently. f 

*  Objects  are  not  then  involved,  in  the  false  inference,  as  in  the  vertigo  described  as 
typical,  but  there  is,  as  it  were,  a  subsidiary  false  inference  of  their  movement  in  the 
opposite  direction.  Another  possible  explanation  is  that  the  apparent  movement  of 
objects  is  the  result  of  compensatory  processes  to  maintain  the  disturbed  equilibrium. 

t  It  probably  underlies  the  pathology  of  sea-sickness,  in  which  the  vomiting  may 
be  simply  a  reflex  effect  of  the  unaccustomed  oscillations  of  the  endolymph  in  the 
semicircular  canals. 


782  OCCLAE    VERTIGO AURAL   VERTIGO. 


Ocular  Vertigo. 

Ocular  Tertigo  is  a  rare  form ;  it  is  due  to  weakness  of  an  ocular 
muscle,  and  depends  on  the  erroneous  projection  of  the  visual  field 
(see  p.  172).  There  is  an  error  in  the  unconscious  inference  of  the 
relation  of  the  body  to  seen  objects,  and  this  element  in  the  impres- 
sions that  influence  the  equilibrial  centre  is  at  variance  with  others, 
and  either  the  discord  or  the  disturbance  of  the  cerebral  motor  centres 
induces  giddiness.  The  sensation  is  seldom  intense,  and  is  not 
independently  paroxysmal ;  it  occurs  only  when  the  affected  muscle 
is  put  in  action.  In  most  cases  it  is  slight  and  transient,  as  the 
cerebral  centres  learn  to  neglect  the  error.  Barely  it  continues  for  a 
long  time.  It  is  chiefly  important  in  respect  to  diagnosis.  The 
treatment  of  the  ocular  palsy  soon  removes  the  vertigo,  but  if  its 
cause  is  not  discovered,  the  patient  may  be  put  through  long  courses 
of  useless  treatment. 


Aural  Vertigo  ;  Labyrinthine  Vertigo  ;  Meniere's  Disease. 

The  vertigo  that  depends  on  disease  of  the  semicircular  canals  is 
sometimes  termed  "  aural  "  or  "  auditory  vertigo,"  sometimes  "  laby- 
rinthine vertigo,"  sometimes  "  Meniere's  disease."  It  always  depends 
on  derangement  of  the  auditory  nerve,  commonly  on  disease  of  the 
nerve-endings  in  the  labyrinth  (or  of  their  disturbance  by  disease  of 
the  middle  ear),  rarely  on  disease  of  the  fibres  of  the  nerve  in  its 
trunk  or  origin.  Attention  was  first  drawn  to  this  cause  of  vertigo 
by  a  description  given  by  Meniere*  of  some  cases  in  which  very  violent 
disturbance  was  produced  by  a  sudden  lesion  of  the  labyrinth.  Such 
cases  came  to  be  termed  "Meniere's  disease" — the  great  frequency 
with  which  slight  disease  causes  slighter  symptoms  was  not  at  first 
recognised.  This  name  has  been  since  applied,  by  some,  to  all  forms, 
slight  and  severe ;  by  others  it  has  been  more  wisely  restricted  to  the 
severer  cases. 

This  labyrinthine  form  is  by  far  the  commonest  of  all  varieties  of 
vertigo.  In  nine  cases  out  of  ten  in  which  there  is  definite  giddiness, 
not  epileptic  in  nature  or  obviously  due  to  organic  brain  disease,  it  is 
due  to  a  morbid  state  of  the  labyrinth  or  auditory  nerve-endings.  It 
has  been  doubted  by  some  whether  this  opinion  is  justified,  whether 
undue  significance  is  not  given  to  the  association  of  slight  deafness  with 
the  vertigo  ;  but  the  evidence,  considered  as  a  whole,  is  very  strong.  In 
the  first  place,  Ave  have  the  undoubted  fact  that  violent  vertigo  may 
result  from  acute  lesions  of  the  labyrinth.     Secondly,  progressive  dis- 

*  Before  the  Academie  de  Med.  of  Paris,  in  1861.  The  association  of  tinnitus 
auriurn  and  vertigo  was  noted  by  Burns  in  1809  (f  Obs.  on  Dis.  of  the  Heart/  p.  75). 


AURAL    VERTIGO.  783 

ease  of  the  labyrinth  may  be  attended  with  severe  vertigo,  which  may 
cease  when  the  progress  of  the  disease  has  produced  complete  deaf- 
ness. These  two  facts  suggest  that  the  vertigo  is  the  result  rather  of 
the  irritation  of  the  nerve  than  of  its  loss  of  function.  Thirdly,  in  the 
majority  of  cases  of  definite  vertigo,  slight  or  considerable,  tinnitus  is 
present,  and  is  evidence  of  a  process  of  irritation  of  the  fibres  of  the 
part  of  the  nerve  concerned  in  hearing.  Fourthly,  slight  loss  of 
hearing,  tinnitus,  and  vertigo  may  be  observed  not  only  to  come  on 
together,  but  to  pass  away  together.  Lastly,  the  frequency  with 
which  symptoms  of  labyrinthine  disease  are  found  in  cases  of  vertigo 
is  itself  a  fact  of  very  great  significance.  Of  106  consecutive  cases 
in  which  definite  vertigo  made  the  patient  seek  advice,  in  no  less  than 
ninety-four,  ear  symptoms  were  present,  tinnitus  or  deafness,  or 
more  often  both ;  defect  of  hearing  through  the  bone  always  existed, 
and  in  almost  all  cases  in  which  it  was  slight,  a  distinct  difference 
between  the  two  sides  emphasised  its  pathological  character.  In  con- 
junction with  these  facts  we  have  the  experimental  evidence  that 
vertiginous  movements  result  in  animals  from  lesions  of  the  semi- 
circular canals.* 

The  coincidence  of  auditory  symptoms  with  vertigo  depends  on  the 
fact  that  the  lining  membrane  of  all  parts  of  the  labyrinth  is  con- 
tinuous, and  so  also  is  its  cavity.  The  two  sets  of  symptoms  depend 
on  the  affection  of  adjacent  structures,  which  commonly  suffer  together; 
but  since  they  are  distinct,  it  is  conceivable  that  labyrinthine  vertigo 
may  occur  without  any  auditory  symptoms.  I  have  seen  two  or 
three  cases  in  which  definite  giddiness  existed  alone,  and  in  which 
auditory  symptoms  came  on  later,  and  many  in  which  the  defect  was 
limited  to  inability  (on  one  side  only)  to  hear  the  high-pitched  notes 
of  G-alton's  whistle,  or  to  perceive  the  sound  of  a  watch  through  the 
bone.  From  this  consideration  it  is  easy  to  understand  that  there  is 
no  necessary  proportion  between  the  disturbance  of  hearing  and  of 
equilibrium. 

The  central  relations  of  the  two  parts  of  the  auditory  nerves  have 
been  already  described  (p.  47).  The  stimulation  of  the  nerve-fibres  of 
the  semicircular  canals  is  believed  to  be  through  the  pressure  of  the 
endolymph  on  the  hairs  within  the  ampullae  acting  on  the  epithelioid 
elements  in  which  the  nerve-fibres  end.  The  three  canals  are  arranged 
at  right  angles  ;  the  horizontal  and  transverse  canals  have  their 
ampullae  at  the  outer  ends,  while  that  on  the  vertical  canal  is  at  its 
antero -inferior  extremity.  If  movements  stimulate  the  nerves  by 
increasing  the  pressure  in  the  ampullae,  the  fibres  of  the  transverse 
canal  will  be  excited  by  an  inclination  of  the  head  to  the  opposite  side, 

*  The  literature  of  aural  vertigo  is  exceedingly  voluminous.  Among  the  more 
important  papers  are  those  of  Knapp  and  Brunner,  'Arch,  of  Oph.  and  Otol./ 
vol.  ii ;  Hughlings  Jackson,  'Mel.  Times  and  Gaz.,' 1872,  'Med.  Record,'  vol.  ii, 
and  '  Lancet/  18S0,  Oct.  2nd ;  Charcot,  '  Prog,  med.,'  1874 ;  Buzzard,  '  Lancet/ 
1890. 


784  AURAL    VERTIGO. 

as  in  falling  in  that  direction  ;  those  of  the  horizontal  canal  by  a 
rotation  of  the  head  towards  the  side  of  the  canal  concerned  ;  those  of 
the  vertical  canal  by  a  forward  movement.  Irritation  of  the  canals  by 
disease  may  be  expected  to  give  rise  to  corresponding  sensations  of 
movement.  But  it  is  probable  that,  in  most  cases,  the  condition  is  a 
complex  one,  and  the  disturbance  is  seldom  the  result  of  the  irritation 
of  a  single  canal. 

On  account  of  the  frequency  with  which  vertigo  seems  to  the  patient 
himself  to  preponderate  over  the  auditory  symptoms,  a  large  propor- 
tion of  the  sufferers  seek  the  advice  of  physicians  rather  than  of  aural 
surgeons,  and  most  text-books  of  diseases  of  the  ear  give  a  very  im- 
perfect representation  of  the  malady.  The  following  account  is  based 
upon  about  150  cases  in  which  the  affection  was  distinct. 

Etiology. — Aural  vertigo  seems  to  result  from  almost  any  of  the 
many  morbid  processes  that  involve  the  labyrinth  and  the  nerve- 
endings  it  contains.  As  a  chronic  symptom,  however,  it  seldom 
results  from  inflammation  of  the  middle  ear  or  caries,  such  as  are  so 
common  in  childhood.  It  is  a  well-known  fact  that  in  these  cases  the 
labyrinth  usually  escapes.*  In  most  cases  there  are  no  signs  of  mis- 
chief in  the  middle  ear ;  the  affection  seems  to  be  confined  to  the 
labyrinth.  Chronic  slightly  irritative  disease  is  that  which  seems  most 
frequently  to  cause  it,  and  such  disease  is  most  common  in  the  second 
half  of  adult  life.  It  is  met  with  very  seldom  under  twenty,  occa- 
sionally between  twenty  and  thirty,  and  frequently  after  thirty.  In 
four  fifths  of  the  cases  the  symptoms  commence  between  thirty  and 
sixtv.  For  some  reason,  it  is  more  common  in  men  than  in  women,  in 
the  proportion  of  about  two  to  one. 

The  nature  of  the  change  in  the  labyrinth  is  necessarily  a  matter  of 
conjecture.  In  a  few  cases  the  symptoms  came  on  after  exposure  to 
cold,  and  inflammation  is  the  probable  lesion.  Such  inflammation  is 
generally  chronic  or  subacute,  but  in  one  of  Meniere's  cases,  due  to 
cold,  it  was  so  intensely  acute  that  the  patient  died  in  a  few  days 
from  the  severity  of  the  cerebral  derangement  produced.  In.  many 
cases  the  mischief  seems  to  be  the  result  of  gout,  acquired  or 
inherited,  and  it  is  highly  probable  that  the  labyrinthine  membrane 
rnav  suffer  from  this  cause,  as  other  membranes  do  that  are  connected 
with  bones.  I  have  more  than  once  known  all  symptoms  to  pass 
away  under  the  influence  of  treatment  directed  to  the  gouty  state. 
Occasionally  a  syphilitic  inflammation  is  suggested  by  the  presence  of 
the  constitutional  disease,  and  labyrinthine  lesions  have  been  proved 
to  occur  from  this  cause. f     In  other  cases,  again,  the  slow  progressive 

*  In  a  curious  case  reported  by  Mac  Bride  the  symptoms  were  caused  by  disease  of 
the  middle  ear  through  the  agency  of  defective  pressure  in  the  tympanum,  and  were  at 
once  relieved  by  inflation.     (Quoted  by  Grainger  Stewart,  'On  Vertigo,'  1884,  p.  20.) 

f  As  in  a  case  of  acute  deafness  and  giddiness  in  a  syphilitic  subject  (recorded  by 
Moos,  '  Virchow's  Archiv,'  Bd.  lxix),  in  which  the  whole  labyrinth  was  occupied 
by  semi-solid  inflammatory  material. 


AURAL    VERTIGO.  785 

character  of  the  symptoms  suggests  that  they  are  due  to  degenera- 
tive changes  in  the  membrane,  either  senile  in  character  or  allied  to 
senile  changes.  Atrophy  of  the  nerve  may  be  a  cause,  but  exists 
more  rarely  than  symptoms  suggest  (see  p.  262).  It  is  sometimes 
met  with,  in  characteristic  foi*m,  in  tabes.  Very  acute  inflammation 
or  haemorrhage,  such  as  gave  rise  to  the  intense  symptoms  of  the 
cases  described  by  Meniere,  is  certainly  most  rare.  Another  very  rare 
cause  is  a  lesion  at  the  base  of  the  brain,  damaging  both  the  auditory 
and  facial  nerves,  but  such  cases  do  not  come  into  the  class  now  under 
consideration,  in  which  the  vertigo  itself  is  the  chief  symptom.  It 
should  be  noted  that  attacks  may  be  excited  by  almost  any  depressing 
influence  in  a  predisposed  subject.  The  effect  of  stomach  derange- 
ment will  be  again  considered,  and,  in  addition  to  this,  I  have  known 
attacks  to  be  brought  on  by  fatigue,  by  excitement  of  various  kinds, 
and  by  pain,  such  as  toothache. 

Symptoms. — The  vertigo  in  these  cases  presents  very  great  variation 
in  its  character.  It  is  almost  always  paroxysmal,  but  there  is  often  con- 
tinuous slighter  vertigo,  sometimes  vague,  often  of  the  same  character 
as  that  in  the  attacks.  Less  commonly  there  is  no  vertigo  except 
during  the  paroxysms,  or  for  a  few  hours  or  a  few  days  afterwards. 
The  attacks  may  occur  at  intervals  of  a  few  days  or  of  several  weeks 
or  months  ;  sometimes  many  attacks  occur  daily.  They  may  come  on 
spontaneously,  or  be  excited  by  some  sudden  movement,  occasionally 
by  coughing  or  sneezing.  Some  of  these  patients  can  never  blow 
the  nose  without  reeling.  An  attack  may  come  on  during  sleep,  and 
wake  the  patient. 

The  vertigo  may  be  subjective  or  objective,  or  both.  "When  the 
patient  feels  as  if  turning  or  falling,  there  is  often  an  actual  tendency 
to  turn  or  fall  in  the  same  direction  during  the  severe  attacks.  A 
tendency  to  go  forwards  or  backwards  is  very  common,  with  or  without 
a  lateral  tendency.  A  sense  of  movement  in  external  objects  is  also 
frequent,  and  this  may  present  all  the  varieties  desciibed  at  p.  780. 
When  both  phenomena  are  combined,  it  is  far  more  common  for  the  two 
movements  -to  correspond  in  their  direction  than  for  them  to  be  in 
opposite  directions.  The  other  aural  symptoms  are  often  one-sided,  or 
are  much  greater  on  one  side  than  on  the  other  ;  in  such  cases  the  sense 
of  movement  may  be  either  towards  or  from  the  ear  most  affected,  but 
when  the  subjective  and  objective  movements  correspond  indirection, 
they  are  more  often  towards  the  affected  ear  than  from  it.  In  one 
case  of  actual  movement  from  the  affected  side,  there  was  a  sense  of 
compulsion  which  could  not  be  resisted.  When  they  differ,  it  is 
about  equally  common  for  the  subjective  movement  to  be  either 
towards  or  from  the  ear  affected,  and  this  is  also  true  of  the  apparent 
movement  of  objects.  It  must  be  remembered  that  when  there  is  not 
much  difference  in  the  auditory  symptoms  on  the  two  sides,  the  excess 
does  not  furnish  any  strong  ground  for  inferring  that  the  cause  of  the 

vol.  n.  50 


786  AUliAL  VERTIGO. 

vertigo  is  greater  on  that  side,  because  the  derangement  of  the  canals 
niay  be  greater  on  the  side  ou  which  the  cochlea  is  less  affected. 

The  paroxysms  of  vertigo  are  generally  sufficiently  severe  to  make 
it  difficult  or  impossible  for  the  patient  to  stand,  and  in  many  in- 
stances he  occasionally  falls.  Sometimes,  indeed,  the  sufferer  is 
hurled  to  the  ground  with  violence,  as  if  by  some  unseen  power, 
much  to  his  own  astonishment  and  alarm.  In  one  woman,  the  attacks 
began  with  a  sudden  irresistible  impulse  to  run  forwards  a  few  yards 
and  then  to  turn  to  the  right,  which  made  her  fall  to  the  ground,  and 
for  two  hours  there  was  a  sense  of  movements  of  herself  and  objects 
to  the  right  (the  deaf  side).  Occasionally  there  is  a  sensation  as  of  a 
blow  behiud  the  ear.  A  patient  who  felt  as  if  rapidly  whirled  round 
from  the  deaf  side  had  also  a  sense  of  pressure  on  the  side  of  the  head, 
seeming  to  make  her  turn.  When  the  sufferer  falls,  it  may  be  impos- 
sible for  him  to  rise,  so  intense  is  the  giddiness.  In  some  very  severe 
attacks  there  is  a  moment's  loss  of  consciousness,  as  might  be 
expected  from  the  intense  derangement  of  the  functions  of  the  brain. 
This  occurs  chiefly  in  attacks  that  are  very  sudden  in  onset,  and  in 
which  the  subjective  giddiness  is  very  intense.  There  is  no  suc- 
ceeding "dazed"  feeling  as  in  epilepsy,  but  the  vertigo  continues, 
often  for  hours.  In  other  cases,  sight  may  be  indistinct  for  a  few 
minutes.  After  severe  vertigo  has  lasted  for  a  short  time,  nausea 
comes  on,  followed  by  vomiting ;  the  patient  becomes  pale,  and  a  cold 
sweat  breaks  out.  The  pallor  and  physical  depression  are  often 
extreme,  and  very  alarming  in  aspect.  If  the  giddiness  persists,  the 
vomiting  may  go  on  for  some  hours,  and  after  the  stomach  has  been 
emptied,  bile  is  brought  up,  as  is  usual  in  continued  vomiting ;  this 
is  popularly  regarded  as  conclusive  proof  that  the  attack  was  due  to 
"  biliousness."  The  vertigo  is  often  increased  by  any  movement  of 
the  head,  and  the  patient  may  be  unable  to  raise  the  head  from  the 
pillow  without  being  sick.  Gradually,  however,  the  attack  passes 
away,  but  for  a  few  days  the  patient  experiences  more  than  the 
ordinary  amount  of  vertigo,  and  the  interference  with  the  functions 
of  the  stomach  occasions  some  indigestion,  and  especially  some  diar- 
rhoea. Vaso-motor  disturbance  sometimes  precedes  the  onset,  and 
connected  with  it  are  various  cephalic  sensations,  from  general 
pulsation,  greatest  in  the  head,  or  a  "  rushing  to  the  head,"  to  a 
sense  of  "  something  passing  over  the  brain,"  and  other  allied 
sensations. 

Often  the  paroxysms  are  much  slighter  in  character,  and  are 
unattended  by  vomiting,  or  even  by  nausea.  There  may  be  merely 
a  sudden  tendency  to  fall,  or  sudden  movement  of  objects,  or  a 
tendency  to  deviate  to  one  side  in  walking.  Attacks  sometimes  come 
on  at  night,  and  may  be  distinctly  related  to  the  horizontal  posture, 
so  that  the  patient  has  to  sit  up  from  time  to  time  to  get  rid  of  the 
giddiness.  This  is  probably  related  to  an  affection  of  a  special  part 
of  the  semicircular  canals.     Paroxysms  may  also  occur  during  sleep, 


AURAL   VEKTIGO.  787 

and  wake  the  patient.  The  duration  of  the  paroxysms  varies  from  a 
few  minutes  to  several  hours,  and  bears  a  general  correspondence  to 
their  severity.  Severe  attacks  may  occur  at  intervals  of  a  few  weeks  or 
months,  or  even  years.  Between  them  there  is  often  slight  persistent 
unsteadiness,  or  occasional  periods  of  slight  vertigo,  or  the  patient 
may  be  perfectly  free  from  giddiness. 

Ocular  symptoms,  secondary  in  origin,  are  present  in  some  instances.* 
In  cases  of  ear  disease,  an  increase  of  pressure  within  the  ear,  as  by 
pressing  firmly  the  antitragus  over  the  opening  of  the  meatus,  may 
cause  nystagmus.  During  paroxysms  of  vertigo  the  patient  may  be 
conscious  of  a  jerky  movement  of  objects,  a  quick  motion  in  one 
direction  and  slow  return,  like  that  sometimes  produced  by  nystagmus, 
and  I  have  known  it  to  correspond  with  intermitting  tinnitus.  This 
apparent  movement  may  sometimes  alone  be  caused  by  pressure 
on  the  meatus  ;f  and  nystagmus  may  be  produced,  with  vertigo,  by 
disease  of  the  middle  ear,  of  course  through  the  secondary  affec- 
tion of  the  labyrinth.  It  has  been  known  to  persist  after  the  ear 
disease  was  cured,  even  for  ten  years. J  I  have  several  times  known 
double  vision  to  occur  during  or  after  a  paroxysm :  in  one  case  of  pure 
aural  vertigo,  each  attack  was  followed  by  double  vision,  jerky  move- 
ment of  objects,  and  distinct  erroneous  projection  in  the  direction  of 
the  movement,  so  that,  if  the  patient  attempted  to  touch  an  object, 
the  hand  went  too  far  in  that  direction.  Slight  diplopia  is  sometimes 
due  to  nystagmus  that  is  not  quite  equal  in  the  two  eyes.  It  is  apt  to 
cause  an  error  in  diagnosis. 

In  most  of  the  cases  the  auditory  symptoms  comprise  both  tinnitus 
and  deafness.  These  correspond  in  side,  except  in  rare  cases  in  which 
one  is  bilateral.  The'  deafness  may  present  any  degree  of  intensity, 
but  is  generally  sufficient  to  be  a  source  of  trouble  to  the  patient,  and 
always  involves  hearing  through  the  bone  (see  p.  263).  In  the  cases 
in  which  the  loss  of  hearing  is  slight,  and  unknown  to  the  patient,  it 
is  generally  one-sided  ;  the  watch  can  be  heard  loudly  through  the 
bone  on  one  side,  and  not  at  all  on  the  other,  or  the  notes  of  G-alton's 
whistle  (very  high-pitched  sounds)  are  inaudible  on  one  side,  and  the 
loss  is  emphasised  by  corresponding  tinnitus.     On  the  other  hand, 

*  According  to  Cyon,  irritation  of  each  of  the  semicircular  canals  produces  its 
own  special  effect  on  the  position  of  the  eyes. 

f  In  '  Brain,'  vol.  iii,  Dr.  Hughlings  Jackson  describes  a  case  of  aural  vertigo  in 
which  objects  appeared  to  move  from  the  affected  ear  in  nystagmic  jerks,  and  quotes 
a  case  of  ear  disease.in  which  pressure  caused  objects  to  appear  to  move  towards  the 
affected  ear.  In  several  cases  a  similar  spontaneous  movement  has  been  described  to 
me,  and  cases  are  not  at  all  rare  in  which  it  can  be  produced  by  pressure. 

J  Urbantschitch,  188i.  In  this  association  it  is  instructive  to  note  that  in  one 
case  a  pulsating  tinnitus,  without  vertigo,  was  associated  with  jerking  movements  of 
the  body  and  head,  the  result,  as  it  seemed  to  the  patientj  of  an  irresistible  impulse 
induced  by  the  sound.  It  doubtless  depended  on  the  influence  of  conjoined  disturb- 
ance of  the  semicircular  canals  on  the  motor  centres,  and  presents,  as  it  were,  a 
general  extension  of  the  tendency  to  nystagmus. 


783  AURAL    VERTIGO. 

absolute  deafness  is  scarcely  ever  met  with,  perhaps  because  when  all 
hearing  is  lost  vertigo  usually  ceases. 

Tinnitus  is  present,  at  some  time,  in  the  vast  majority  of  the  cases, 
and  in  almost  all  is  persistent.  It  may  present  most  of  the  variations 
described  at  p.  270.  A  continuous  sound  is  the  most  common ;  pulsat- 
ing sounds  are  occasionally  described,  but  are  less  frequent  than  in 
the  tinnitus  that  occurs  without  vertigo.  The  intensity  of  the  sound 
is  usually  moderate,  and  sometimes  slight,  but  it  often  becomes  more 
intense  at  the  onset  of  a  paroxysm  of  vertigo,  and  may  then  become 
very  loud.  Thus  one  patient,  who  habitually  heard  a  noise  like  a. 
distant  waterfall,  said  that  with  the  vertigo  it  rapidly  increased  in 
loudness,  and  was  like  an  express  train  coming  past  a  station,  and  as 
it  became  loudest  "it  seemed  to  force  on  the  giddiness."  It  is  ex- 
ceedingly rare  for  the  noise  to  be  confined  to  the  paroxysms  of  vertigo. 
On  the  other  hand,  it  is  not  at  all  uncommon  for  no  increase  of  the 
tinnitus  to  take  place  on  the  occurrence  of  the  giddiness,  and  paroxysms 
of  tinnitus  may  not  coincide  with  those  of  vertigo. 

An  attack  of  vertigo,  however  severe  and  however  alarming  it  may 
be  to  the  sufferer,  is  attended  with  little  danger.  Nevertheless  it  is 
possible  that,  in  a  patient  with  a  feeble  heart,  the  prostration  may  go 
on  to  fatal  syncope.  The  chief  danger,  however,  is  in  the  cases, 
fortunately  extremely  rare,  in  which  the  labyrinthine  lesion  is 
intensely  irritating,  and  the  cerebral  disturbance  induced  is  so 
intense  as  to  lead  to  fatal  exhaustion. 

Among  the  complications  of  the  affection  we  can  scarcely  reckon 
the  signs  of  labyrinthine  disturbance,  since  these  are  really  part  of  it. 
Many  sufferers  present  varied  indications  of  nerve  weakness,  partly 
secondary  to  the  vertigo  and  to  the  tinnitus  (q.  v.)  which  so  often 
attends  it,  partly  associated,  and  disposing  the  centres  to  greater 
derangement  under  the  influence  of  the  peripheral  disorder.  Other 
neurotic  affections  sometimes  co-exist ;  true  epilepsy  may  accompany 
independent  aural  vertigo,  and  the  affection  is  sometimes  met  with 
in  the  subjects  of  migraine.  These  diseases  may  also  aid  in  intensi- 
fying the  central  disturbance.  Disorders  of  the  digestive  system  are 
common,  and  both  excite,  and  result  from,  the  attacks,  while  some 
patients  present  conspicuous  evidence  of  gout. 

The  course  of  aural  vertigo  varies  according  to  the  nature  of  the 
morbid  process.  If  this  is  steadily  progressive,  the  symptoms  may 
only  cease  when  all  hearing  power  is  destroyed.  Happily,  however, 
these  cases  are  rare  ;  in  the  majority,  either  the  changes  in  the  laby- 
rinth are  not  progressive,  and  the  tendency  to  giddiness  lessens  in  the 
course  of  time,  or  else  the  tendency  can  be  kept  down  by  treatment. 
I  have  known  perfect  recovery  to  occur  in  many  cases  in  which  the 
attacks  of  giddiness  were  most  severe. 

Pathology. — The  chief  facts  regarding  the  pathology  of  laby- 
rinthine vertigo  have  been  alreadv  mentioned,  but  one  or  two  other 


AURAL   VERTIGO.  789 

points  remain  for  consideration.  We  must  refer  the  vertigo  to 
changes  in  the  semicircular  canals,  but  we  must  bear  in  mind  the 
fact  that  it  must  always  be  perceived  through  the  medium  of  cortical 
centres,  influenced  by  the  derangement  of  lower  mechanisms.  The 
readiness  with  which  these  are  disturbed  must  influence  the  result. 
The  precise  mode  in  which  the  affected  labyrinth  acts  on  the  centres 
is  still  unknown.  It  probably  varies  much,  but  is  more  often  by  the 
stimulation  of  the  fibres,  rather  than  by  simple  diminution  of  func- 
tion. This  conclusion  is  suggested  by  the  results  of  experiments  on 
animals,  and  is  in  harmony  with  the  fact  that  there  may  be  gradual 
loss  of  function,  to  judge  by  progressive  deafness,  without  vertigo. 
Thus  the  morbid  process  is  more  nearly  allied  to  the  irritation  which 
causes  tinnitus  than  to  that  which  causes  deafness.  Loss  of  function 
seems  chiefly  effective  when  on  one  side  only,  and  vertigo  from  bilateral 
destruction  of  the  labyrinth  is  commonly  transient. 

It  is  doubtful  whether  we  can  refer  the  paroxysmal  character  of  the 
affection  directly  to  the  labyrinthine  disease.  The  labyrinthine 
irritation  probably  brings  the  centre  for  equilibration  (or  the  centre 
in  which  the  centripetal  influences  are  co-ordinated)  into  a  state  of 
instability,  in  which  a  sudden  violent  derangement  may  occur  on  some 
.slight  exciting  influence,  or  even  without  any  excitant  that  can  be 
traced.  This  conclusion  is  indicated  by  the  extreme  intensity  of 
many  paroxysms,  in  which  the  sufferer  is  hurled  to  the  ground  with 
convulsive  violence,  without  any  coincident  indication  of  special 
aural  disturbance.  In  some  cases  a  slight  aural  disturbance  may 
perhaps  excite  the  paroxysm,  but  even  when  a  sudden  loud  subjective 
sound  occurs  as  the  vertigo  comes  on,  we  cannot  take  this  as  proof  of 
a  labyrinthine  irritation  of  corresponding  intensity,  because  it  is 
possible,  and  even  probable,  that  the  sound  associated  with  the  vertigo 
may  be  of  central  origin,  due  to  the  extension  of  the  central  disturb- 
ance to  the  centres  for  hearing.  Through  these,  of  course,  simple 
tinnitus  is  perceived,  and  their  over-action  must  cause  subjective 
sensations  precisely  like  those  produced  in  the  labyrinth.  The  sound 
may  thus  be  rather  part  of  the  attack  than  an  indication  of  its  cause. 
This  view  of  the  nature  of  the  symptoms  enables  us  to  understand 
that  severe  paroxysms  may  occur  when  the  labyrinthine  change  is 
apparently  slight,  and  also  the  co-operation  of  stomach  disturbance  in 
exciting  the  paroxysms. 

Diagnosis. — The  diagnosis  of  labyrinthine  vertigo  depends  on  the 
coincidence  of  vertigo  of  definite  character  with  indications  of  derange- 
ment of  the  functions  of  the  labyrinth, — tinnitus,  and  deafness  not 
due  merely  to  impairment  of  the  conduction  through  the  external 
meatus  or  middle  ear.  The  indications  of  this  have  been  already 
described  (p.  263).  If  the  loss  of  hearing  is  trifling,  its  significance 
is  greater  if  it  is  one-sided.  It  must  be  remembered  that  the  fact 
that  paroxysms  are  excited  by  stomach  disturbance  does  not  prove 


790  AURAL    VERTIGO. 

that  the  vertigo  is  simply  gastric.  A  gentleman  had  always  been, 
liable  to  attacks  of  acute  dyspepsia,  but  they  were  never  attended  with 
giddiness  until  he  became  deaf;  afterwards,  each  dyspeptic  attack 
was  accompanied  by  severe  vertigo.  The  diagnosis  of  aural  vertigo 
is  occasionally  helped  by  the  fact  that  giddiness  may  be  brought  on 
by  a  sudden  movement  of  the  head  in  one  direction  and  not  in  another, 
or  by  suddenly  increasing  the  pressure  in  one  ear. 

Cases  of  epilepsy,  in  which  the  aura  is  an  auditory  sensation  accom- 
panied by  giddiness,  may  be  mistaken  for  labyrinthine  vertigo.  The 
distinction  depends  on  the  fact  that  in  the  latter  there  is  usually 
persistent  tinnitus,  impaired  audition,  and  more  or  less  constant  slight 
vertigo,  while  loss  of  consciousness  is  extremely  rare,  and  is  confined 
to  an  occasional  very  violent  paroxysm.  Such  a  pai*oxysm  is  followed 
by  vomiting  and  by  prolonged  giddiness.  In  epilepsy,  loss  of  con- 
sciousness is  the  rule ;  there  is  no  subsequent  vertigo,  but  a  slow 
return  of  normal  consciousness,  and  indications  of  a  convulsive  seizm-e 
can  usually  be  ascertained.  It  must  be  remembered  that  the  twa 
diseases  sometimes  co-exist. 

It  is  a  very  common  thing  for  aural  vertigo  to  be  mistaken  for  a, 
slight  attack  of  organic  cerebral  disease,  congestion,  or  an  actual  vas- 
cular lesion.  The  error  is  the  more  easy  because  both  classes  of 
disease  are  common  in  the  degenerative  period  of  life ;  but  it  gene- 
rally arises  from  ignorance  of  the  occurrence  and  frequency  of  laby- 
rinthine vertigo.  It  is  a  mistake  the  more  easily  made,  because  the 
prostration  and  pallor  that  are  the  consequence  of  the  giddiness  are 
very  like  those  that  result  from  a  cerebral  lesion.  The  diagnosis 
rests  on  the  absence  of  other  symptoms.of  such  a  lesion  on  the  one 
hand,  and  on  the  presence  of  aural  symptoms  on  the  other ;  while  in 
most  cases  the  decision  is  much  helped  by  the  fact  that  the  patient 
has  had  other  attacks  of  simple  giddiness,  which  are  as  significant  if 
they  have  been  slight  as  if  they  have  been  severe.  In  a  cerebral 
attack,  loss  of  consciousness  is  out  of  proj^ortion  to  the  vertigo, 
whereas  in  the  other  it  is  slight,  often  imperfect,  and  clearly  subor- 
dinate to  the  intensity  of  the  giddiness. 

Peognosis. — The  prognosis  is  distinctly  serious  chiefly  in  cases  of 
steadily  progressive  disease  of  the  labyrinth,  in  which  the  symptoms 
may  persist  in  spite  of  all  treatment,  until  complete  destruction  of  the 
nerve-endings  brings  a  cessation  alike  of  the  giddiness  and  of  the 
power  of  hearing.  It  is  still  more  grave  in  the  case  of  extreme  severity 
from  acute  lesions,  but  these  are  so  rare  that  they  scarcely  influence 
the  genei'al  prognosis.  In  most  other  cases,  the  prognosis,  although 
uncertain,  is  not  definitely  bad ;  improvement  is  exceedingly  common, 
and  in  many  cases  goes  on  to  recovery,  if  careful  and  persistent  treat- 
ment can  be  secured. 

Teeatment. — In  the  treatment  of  aural  vertigo  we  must  recognise 


AUiiAL    VERTIGO.  791 

the  double  element  in  the  pathology  of  the  disease,  the  labyrinthine 
irritation,  and  the  central  instability  induced  by  the  irritation ; 
the  latter  may  be  to  some  extent  in  excess  of  its  cause.  The 
central  disturbance  is  lessened  by  bromide,  which  almost  always 
reduces  the  tendency  to  vertigo,  and,  when  this  is  slight,  may  remove 
it  altogether.  Twenty  grains  should  be  given  two  or  three  times 
a  day,  and  the  addition  to  each  dose  of  a  few  minims  of  tincture 
of  belladonna  seems  to  increase  its  effect.  Hydrobromic  acid  has 
been  recommended,  but  must  be  converted  into  bromide  in  the  blood, 
and  only  a  quite  inadequate  dose  of  bromide  can  be  given  in  the  acid 
form.  But  it  is  also  important  to  strengthen  any  weakness  of  the 
nervous  system  that  can  be  traced. 

The  local  irritability  is  commonly  lessened  by  counter- irritation, 
whether  the  lesion  is  inflammatory  or  degenerative.  The  most  effec- 
tive counter-irritant  is  a  small  blister  over  the  mastoid  process.  It 
is  remarkable  how  rapid  and  marked  may  be  the  effect  of  a  blister  on 
all  the  symptoms,  especially  in  recent  cases.  Drugs,  unfortunately, 
have  very  little  influence  over  morbid  processes  in  the  labyrinth, 
unless  these  are  of  a  specific  nature.  Syphilitic  inflammation  can  be 
readily  removed,  and  the  more  common  gouty  changes  can  be  lessened 
in  a  very  marked  degree  by  appropriate  treatment.  In  the  latter  class 
I  have  several  times  known  treatment  remove  not  only  the  vertigo, 
but  the  tinnitus  and  the  deafness,  so  that  even  the  power  of  hearing 
through  the  bone,  before  completely  lost,  became  normal.  Purgatives, 
alkalies,  and  colchicum  were  the  effective  agents,  but  it  is  desirable 
to  employ  also  counter-irritation,  and  at  first  to  give  bromide  also,  in 
order  to  lessen  the  morbid  irritability  of  the  centre.  The  bromide 
of  lithium  is  a  convenient  salt  to  use  in  these  cases,  and  some  citrate 
of  lithia  may  be  added.  It  must  be  remembered,  however,  that  de- 
generative changes  occur  earlier  and  progress  more  speedily  in  gouty 
subjects  than  in  others,  and  hence,  in  such  patients,  the  change  in 
the  labyrinth  does  not  always  prove  amenable  to  the  special  treat- 
ment. 

We  can  get  little  help  from  drugs  in  dealing  with  other  chronic 
changes  in  the  labyrinth.  Charcot  first  suggested  that  agents  which 
have  a  special  action  on  this  structure  may  possibly  exert  an  influence 
antagonistic  to  the  morbid  process.  With  this  object  he  gave  large 
doses  of  quinine,  so  as  to  produce  cinchonism.  The  patients  were 
worse  for  the  time  being,  but  when  the  influence  of  the  quinine  had 
passed  away,  some  of  them  were  distinctly  better.  I  have  not 
found  the  effect  of  quinine  so  satisfactory  as  that  of  salicylate  of 
soda,  and  I  think  that  more  good  is  done  by  giving  it  in  moderate 
doses,  five  grains  three  times  a  day,  than  by  administering  it  in  such 
quantities  as  to  produce  toxic  ear-symptoms.  In  several  cases  in 
which  other  treatment  had  failed,  the  moderate  doses  of  salicylate 
rendered  both  the  vertigo  and  tinnitus  less  troublesome.  In  all  cases 
the  conditions  that  lessen  the  tinnitus  should  be  ascertained,  and 


792  VEliTIGO. 

as  far  as  possible  their  co-operation  should  be  secured,  since  they  may 
also  exert  a  similar  effect  on  the  uerves  concerned  in  causing  vertigo. 

It  is  important  to  treat  any  morbid  influence  that  may  co-operate 
in  exciting  the  vertigo.  The  general  health  must  be  improved  by 
tonics ;  exposure  of  the  head  to  cold  should  be  avoided,  and  the  bowels 
should  be  kept  open.  Of  special  importance  is  the  treatment  of  the 
dyspepsia  which  often  co-exists,  and  has  a  very  powerful  influence  in 
exciting  the  giddiness.  As  far  as  practicable,  patients  who  are  liaMe 
to  vertigo  should  avoid  stooping,  and  sudden  movements  of  the  head. 

Nocturnal  Vertigo. — Most  persons,  perhaps  all,  have  been  occasion- 
ally disturbed  when  falling  asleep,  or  just  after  going  to  sleep,  by  a 
sudden  sensation  of  falling  from  a  height.  Sometimes  it  is  accom- 
panied by  a  dream.  I  believe  that  this  is  really  slight  labyrinthine 
vertigo,  due  to  spasmodic  contraction  of  a  tympanic  muscle,  which 
suddenly  changes  the  pressure  within  the  labyrinth.  Those  who 
wake  up  quickly  during  this  sensation  may  distinctly  hear  the  peculiar 
vibratory  sound  characteristic  of  intra-aural  muscular  contraction. 
It  is  identical  in  character  with  that  which  many  persons  may  produce 
at  will  by  contracting  the  orbiculares  palbebrarum,  and  at  the  same 
time  turning  the  eyeballs  upwards.  What  muscle  contracts  is  un- 
certain ;  it  is  perhaps  the  stapedius,  which  would  suddenly  lessen  the 
pressure. in  the  labyrinth.  As  soon  as  the  sound  of  the  contraction 
ceases,  the  sense  of  falling  ceases  also.  These  attacks  may  be  pre- 
vented by  a  dose  of  bromide. 

Other  Forms  of  Vertigo. 

We  have  seen  that  it  is  exceedingly  rare  for  definite  vertigo  to  occur 
apart  from  aural  symptoms,  and  it  is  certain  that,  in  the  majority  of 
cases  in  which  such  vertigo  has  been  ascribed  to  other  causes,  these 
have  only  had  an  exciting  influence,  and  the  symptom  has  been  essen- 
tially due  to  the  effect  of  unobtrusive  labyrinthine  disease,  bringing 
the  centre  into  an  unstable  condition.  This  is  certainly  true  of  the 
majority  of  cases  of  gastric  vertigo,  which  was  formerly  thought  to  be 
so  common;  the  mere  presence  of  dyspepsia  was  regarded  as  a  suffi- 
cient explanation  of  the  giddiness.  Certainly  vertigo  of  purely  gastric 
origin  does  not  constitute  more  than  5  per  cent,  of  the  cases  in  which 
definite  giddiness  is  the  prominent  symptom.*  The  giddiness 
met  with  in  such  cases  is  similar  to  that  above  described  as  met 
with  in  the  aural  form.      The  diagnosis  rests  on  the  fact  that   it 

*  I  do  not  think  it  is  quite  certain  that  there  is  such  a  tiling  as  definite  vertigo 
of  purely  gastric  origin.  Thirty  years  ago  80  per  cent,  of  cases  of  giddiness 
were  supposed  to  be  due  solely  to  the  stomach.  But  we  now  know  that  in  90  per 
cent,  of  the  cases  of  definite  giddiness  a  morbid  state  of  the  labyrinth  is  the  real 
cause  of  the  vertigo.  It  is  possible  that  in  the  small  remainder,  of  apparently 
gastric  giddiness,  there  is  some  other  influence  that  is  the  real  cause,  e.g.  a  morbid 
state  of  the  semicircular  canals  causing  no  auditory  symptoms,  and  so  not  to  be 
detected  save  by  its  effects. 


VERTIGO.  793 

distinctly  follows  stomach  disturbance,  and  no  other  cause  can  be  dis- 
covered. The  treatment  needed  is,  first,  that  for  the  gastric  disorder, 
and.  secondly,  the  reduction  of  the  central  irritability  by  bromide. 

Vertigo  occurs,  in  slight  and  vague  form — a  mere  sense  of  unsteadi- 
ness— as  a  symptom  of  many  morbid  conditions,  in  which,  however, 
it  is  subordinate  to  other  more  characteristic  symptoms.  Thus  it  is 
met  with  in  anaemia,  in  hysteria,  and  in  various  conditions  of  nervous 
weakness.  It  is  met  with,  although  rarely,  as  part  of  an  attack  of 
migraine.  It  occurs  also  in  the  old  whose  brains  are  ill-nourished,  in 
•consequence  especially  of  arterial  degeneration,  and  also  at  the  onset  of 
various  vascular  lesions  of  the  brain,  of  which  it  may  be  a  premonitory 
symptom.  The  subjects  of  senile  atheroma  may  suffer  from  occasional 
severe  or  constant  slight  vertigo,  usually  vague  in  character.  The 
symptom,  occurring  in  the  old  apart  from  distinct  cause,  is  thus  some- 
times of  serious  significance,  especially  when  it  is  paroxysmal  and 
when  headache  is  associated  with  it.  It  seems  to  be  the  result  of  the 
local  interference  with  the  blood  supply,  and  suggests  that  an  attack 
of  hemiplegia  is  not  unlikely.  But  care  must  be  taken  not  to  mistake 
for  this  the  vertigo  that  is  due  to  labyrinthine  degeneration,  senile  or 
gouty.  Many  of  those  who  suffer  from  this  comparatively  unimportant 
form  are  alarmed,  and  indeed  injured,  by  groundless  apprehensions  of 
apoplexy.  Vertigo  is  a  prominent  symptom  in  some  cases  of  intra- 
cranial tumour,  especially  in  tumours  of  the  cerebellum  or  of  the  pons 
Varolii  (see  pp.  98  and  322),  and  it  is  very  intense  in  lesions  of  the 
middle  peduncle  of  the  cerebellum. 

Epileptic  vertigo  is  a  common  form;  the  sensation,  in  all  its  varieties, 
occurs  as  the  first  symptom  of  the  epileptic  attack,  and  may  be  due 
to  the  inequality  in  the  motor  discharge  in  the  two  hemispheres  that 
causes  the  initial  deviation  of  the  head  and  eyes,  and  sometimes  a 
definite  rotation  of  the  body,  but  pronounced  examples  are  occasionally 
met  with. 

Definite  vertigo  is  occasionally  met  with  apart  from  any  recognisable 
morbid  state,  aural,  gastric,  or  other,  to  which  it  can  be  ascribed. 
This  form,  in  ignorance  of  its  nature,  has  been  termed  essential  vertigo. 
Most  cases  so  described  are  labyrinthine,  and  those  that  can  be 
regarded  as  independent  of  the  common  causes  are  so  rare  that  we 
have  little  definite  knowledge  of  their  characters  or  nature. 

One  peculiar  variety  is,  however,  unconnected  with  the  common 
causes  of  giddiness,  and  from  its  features  may  be  termed  epileptoid 
vertigo,  if  it  is  recognised  that  the  name  does  not  involve  any  actual 
connection  with  epilepsy.  In  this  form  sudden  attacks  of  severe 
vertigo  recur  for  months  or  years,  with  or  without  vomiting  or  vaso- 
motor disturbance,  but  with  perfect  freedom  in  the  intervals.  In  the 
suddenness  of  the  attacks,  their  independence  and  recurrence,  they 
resemble  epilepsy,  but  they  exhibit  no  tendency  to  pass  into  this 
disease.  They  differ,  moreover,  in  their  frequent  excitation  by  fatigue, 
and  in  the  long  duration  of  the  symptom,  often  for  half  an  hour  or 


794  ASTASIA — ABASIA. 

even  one  or  two  hours.  The  sensation  may  be  objective  or  subjective, 
or  both;  objects  sometimes  seem  to  rotate  rapidly  round  a  central 
point.  The  vertigo  may  or  may  not  induce  vomiting.  Young  adults 
have  been  the  subjects  in  the  few  eases  I  have  seen.  The  occurrence 
of  the  attacks  is  facilitated  by  fatigue  and  whatever  depresses  the 
nervous  system.  Mental  tranquillity  and  physical  rest  are  important 
elements  in  the  treatment,  and  I  have  found  the  administration  of 
nitro- glycerine  in  alcoholic  solution,  with  a  little  hydrobromic  acid, 
and  sometimes  also  some  bromide,  particularly  effective.  It  should 
be  given  regularly  three  times  a  day  after  food. 


ASTASIA-ABASIA. 


Not  far  removed  from  vertigo,  at  least  in  some  of  its  features,  is  a 
peculiar  symptom  which  has  been  recently  described  under  this  name, 
but  is  certainly  much  less  rare  than  the  unfamiliar  character  of  the 
term  might  suggest.  The  sufferer  from  it,  when  walking,  will  suddenly 
fall  to  the  ground  (astasia),  often  forwards  ;  it  seems  to  him  his  legs 
give  way.  "When  sitting,  he  will  suddenly  bend  forwards,  his  head 
dropping  on  his  chest,  and  his  body  seeming  to  lose  its  power  of  support 
(abasia).  In  either  case,  in  a  minute  or  two,  normal  strength  returns, 
and  he  is  able  to  proceed  as  before  the  curious  attack.  There  is  never 
loss  of  consciousness.  Rarely  there  has  been  a  sensation  of  slight 
vague  "  giddiness  "  at  the  onset,  but  it  is  a  symptom  quite  distinct 
from  vertigo.  Occasionally  the  fall  has  been  preceded  by  a  sensation 
as  if  struck  by  a  hammer  on  the  back  of  the  neck.  It  occurs  chiefly 
in  persons  past  middle  life,  especially  in  the  gouty  and  in  those  who 
have  degenerated  vessels.  It  has  been  thought  to  be  of  grave  signi- 
ficance, but  is  certainly  far  less  serious  than  the  somewhat  analogous 
paroxysmal  dyslexia  (see  p.  116).  In  the  cases  I  have  seen  the  sym- 
ptom has  passed  away  under  the  influence  of  nervine  and  cardiac 
tonics,  and  the  treatment  and  regimen  suited  for  the  constitutional 
condition.  The  symptoms  must  not  be  confounded  with  the  "  giving 
■way  of  the  legs"  met  with  in  hysteria,  nor  with  the  similar  attack, 
accompanied  by  transient  loss  or  obscuration  of  consciousness,  of 
minor  epilepsy. 


NEURALGIA. 


The  -word  "  neuralgia  "  means  simply  "  nerve  pain  ;  "  such  pain 
may  be  due  to  actual  disease  of  a  nerve-trunk,  by  which  its  fibres  are 
irritated,  or  it  may  occur  without  auy  organic  lesion.  It  is  true  that 
the  absence  of  such  morbid  change  cannot  often  be  proved  by  actual 
microscopical  examination,  but  the  transient  character  of  the  pain, 


NEUKALGIA.  795 

and  its  migration  from  one  part  to  another,  frequently  afford  strong 
confirmation  of  the  opinion  that,  in  a  large  number  of  the  cases  of 
local  nerve  pain,  the  symptoms  are  not  due  to  actual  organic  change. 
Two  classes  of  neuralgias  have  been  distinguished, — "  symptomatic," 
in  which  the  pain  is  a  symptom  of  organic  disease  of  the  nerves  ;  and 
**  idiopathic,"  in  which  the  malady,  in  the  first  instance  at  least, 
.  consists  only  in  functional  disturbance.  Both  of  these  forms  have 
been  called  "  neuralgia  "  by  some  writers.  By  others,  however,  the 
term  is  restricted  to  the  idiopathic  class,  and  this  seems  to  be  the  only 
logical  course.  It  is  manifestly  unreasonable  to  describe  inflamma- 
tion of  nerves  as  "  neuralgia  "  when  it  causes  much  pain  and  few 
other  symptoms,  and  as  "  neuritis  "  when  other  symptoms  predomi- 
nate over  pain.  But  the  distinction  of  the  two  forms  of  nerve  pain  is 
often  very  difficult  in  practice.  In  some  forms  described  as  neuralgia 
the  pain  has  certainly  been  generally  the  result  of  neuritis.  This  is 
the  case,  for  instance,  with  sciatica,  which,  as  stated  in  the  account  of 
the  disease  in  the  first  volume,  is  generally  an  inflammation  of  the 
nerve.  Yet  not  only  has  the  common  form  of  sciatica  been  described 
as  a  neuralgia,  but  its  symptoms  have  been  allowed  to  influence  the 
description  of  neuralgia  in  general.  In  ascertaining  the  clinical 
history  of  neuralgia  it  is,  therefore,  of  great  importance  that  only 
cases  should  be  used  in  which  a  primary  organic  lesion  of  the  nerve 
trunk  or  centres  can  be  excluded  with  reasonable  confidence.  But  we 
have  practically  to  include  under  the  term  those  cases  in  which  an 
organic  process  causes  pains  that  persist  longer  than  their  cause,  or 
extend  far  beyond  its  range  of  direct  influence. 

The  subject  of  neuralgia  is  a  very  large  one,  so  numerous  are  the 
forms  of  the  disease,  and  so  varied  its  characters.  It  will  be  most  in- 
structive to  consider  the  general  causes  and  symptoms  of  the  affection,. 
and  also  its  general  pathology,  before  describing  its  special  varieties. 

Etiology. — Neuralgia  is  essentially  a  disease  of  adult  life.  It  is 
rare  before  puberty,  and  is  not  common  in  extreme  old  age,  although, 
when  the  disease  does  commence  late  in  life,  it  is  often  very  severe 
and  intractable.  Most  cases  commence  between  twenty  and  sixty 
years.  Children  enjoy  an  almost  complete  immunity  from  true 
neuralgia,  although  very  liable  to  certain  headaches  which  do  not  come 
into  this  category.  Women  are  more  prone  to  neuralgia  than  men, 
but  the  degree  of  their  liability  has  often  been  over-estimated,  and  the 
excess  of  females  among  the  sufferers  disappears  in  the  second  half  of 
life.  Moreover,  the  relative  liability  of  the  sexes  is  not  the  same  in 
the  several  varieties.  The  tendency  to  neuralgia  is  often  hereditary, 
although  not  so  frequently  as  in  the  case  of  migraine.  Anstie  found 
evidence  of  heredity  in  only  one  quarter  of  his  cases.  Sometimes  the 
inherited  tendency  is  not  special  but  general,  indicated  by  the  occur- 
rence in  ancestors  or  collaterals  of  epilepsy,  insanity,  and  other 
neuroses.     This  is  not  surprising  when  we  remember  that  the  chief 


796  NEURALGIA. 

-element  in  the  affection  seems  often  to  be  an  excessive  action  of  the 
central  sensory  cells,  arising  in  them  or  induced  from  the  periphery, 
bnt  analogous  to  that  which,  in  the  motor  and  other  cells  of  the  brain, 
gives  rise  to  the  various  forms  of  epilepsy. 

The  subjects  of  neuralgia  often  present  a  peculiar  temperament. 
They  are  what  is  popularly  called  "  nervous," — excitable,  often  irri- 
table, anxious,  worrying  over  the  trifling  ills  of  life,  sleeping  badly, 
and  are  often  extremely  liable  to  headaches  not  distinctly  neuralgic 
in  character.  In  many  patients  the  neuralgic  tendency  is  deeply 
rooted ;  they  suffer  from  neuralgia  first  in  one  situation  and  then  in 
-another  during  the  course  of  years.  Some  forms  are  especially  common 
in  those  who  present  the  symptom  of  "  hysteria,"  but  whose  sufferings 
from  the  pain  are  not  the  less  genuine.  Other  varieties  of  neuralgia 
may  also  occur  in  such  patients,  by  a  coincidence  which  has  only  the 
■connection  of  a  common  cause.  The  disease  is  more  frequent  in 
those  of  weakly  constitution  than  in  the  robust,  but  the  latter  do  not 
enjoy  complete  immunity.  Among  the  constitutional  relations  of 
neuralgia,  those  to  rheumatism  and  gout  are  especially  important. 
"The  connection  with  rheumatism  is  often  conspicuous,  and  is  seen  in 
-several  aspects.  Persons  who  are  liable  to  rheumatism  of  the  fibrous 
tissues  sometimes  suffer  from  pains  which  have  both  rheumatic  and 
neuralgic  characters, — not  specially  related  to  the  nerves  in  situation, 
■and  yet  paroxysmal  and  unconnected  with  movement.  Such  pains 
are  especially  frequent  in  the  limbs  and  back.  Women  who  suffer 
from  rheumatoid  arthritis  are  often  also  liable  to  true  neuralgias 
-of  great  severity.  A  young  lady,  for  instance,  suffered  for  several 
months  from  severe  paroxysms  of  pain  in  one  shoulder  and  the  dorsal 
spine,  apparently  neuralgic ;  these  ceased,  and  she  was  immediately 
■attacked  by  subacute  rheumatoid  arthritis.  Lastly,  both  rheumatic 
affections  and  neuralgia  are  certainly  sometimes  due  to  gout,  and 
probably  not  unfrequently  to  inherited  gout. 

Among  the  exciting  causes  of  neuralgia,  as  among  those  that  are 
remote,  impairment  of  general  health  takes  the  first  place.  The 
affection  may  be  excited  by  any  kind  of  debilitating  influence :  over- 
work of  mind  or  body,  over-lactation,  prolonged  fatigue,  and  anaemia 
of  every  degree  and  causation,  are  frequently  met  with  as  its  immediate 
-antecedents.  Certain  forms  of  sensory  fatigue,  as  over- stimulation  of 
the  eyes,  sometimes  seem  to  have  a  special  influence.  Severe  emotion, 
or  its  physical  analogue,  mechanical  concussion,  are  also  occasional 
exciting  causes ;  the  former  is  often  combined  with  the  latter.  As 
examples  of  the  influence  of  emotion  two  cases  may  be  mentioned,  one 
of  slight,  the  other  of  severe  neuralgia,  thus  induced.  A  lady  was 
intensely  distressed  after  parting  with  her  husband,  who  was  going  to 
America.  She  felt  on  the  point  of  bursting  into  tears,  and  as  if  the 
tears  would  give  her  relief.  Her  sister  said,  "  Do  not  cry  ;  you  shall 
not  cry."  By  an  effort  she  succeeded  in  restraining  her  tears,  but  was 
immediately  conscious  of  a  sense  of  intense  pressure  above  the  eye- 


ETIOLOGY.  797 

brows,  and  a  few  days  later  severe  supra-orbital  neuralgia  came  on 
upon  the  left  side,  and  lasted  for  several  weeks.  A  girl  of  eighteen 
was  much  startled  and  alarmed  by  the  unexpected  discharge  of  a  gun 
close  beside  her.  The  same  evening  facial  neuralgic  pain  came  on,  and 
continued  for  five  years  in  most  violent  paroxysms,  sometimes  on  one- 
side,  sometimes  on  the  other.  In  this  connection  it  may  be  noted  that 
the  fifth  nerve  is  especially  related  to  emotion,  both  by  influencing  the 
secretion  of  tears  and  also  as  the  sensory  nerve  of  the  chief  region  of 
emotional  display — the  face. 

~No  single  actual  excitant  of  neuralgia  is  so  frequent  as  exposure  to 
cold,  sometimes  general,  sometimes  local  and  affecting  the  part  in 
which  the  neuralgia  is  felt.  Valleix  found  a  history  of  exposure  to- 
cold  in  one  third  of  his  cases.  Cold  may  not  only  produce  neuralgia, 
but  may  also  excite  paroxysms  of  pain  when  the  neuralgia  is  due  to 
some  other  cause.  Another  frequent  cause  is  the  irritation  of  nerves, 
especially  near  their  peripheral  distribution,  which  induces  pain  ex- 
tending far  beyond  the  area  supplied  by  the  irritated  nerve.  A  com- 
mon example  is  the  wide-spread  pain  that  may  result  from  the  irritation 
of  a  carious  tooth  ;  the  pain  may  extend  into  other  divisions  of  the  fifth 
nerve,  and  even  into  the  region  of  the  cervical  plexus.  Moreover,  the 
pain  may  be  felt  only  or  chiefly  in  some  other  region  than  that  in 
which  it  is  produced.  Thus  I  have  known  severe  neuralgia  confined 
to  the  second  division  of  the  fifth  to  be  due  to  a  carious  tooth  in  the 
lower  jaw,  and  cease  entirely  when  this  was  extracted.  Every  form 
of  neuritis,  except  that  of  purely  motor  nerves  or  branches,  may  have, 
as  its  sequel,  pain  of  long  duration,  which  may  be  regarded  as  a. 
secondary  neuralgia.  Brachial  and  sciatic  neuritis,  either,  primary 
or  traumatic,  local  or  migratory,  are  common  causes  of  this  form. 
Another  is  the  peculiar  neuritis  that  is  manifested  by  herpes  zoster. 
The  severity  and  duration  of  the  subsequent  pain  is  chiefly  serious  in 
late  life,  when  it  may  continue  even  for  one  or  two  years,  and  be  most 
distressing  in  severity.  Traumatic  lesions  of  nerves  without  any 
preponderating  neuritis,  constitute  another  cause,  and  often  give  rise  to 
pain  that  is  extremely  obstinate. 

Toxic  influences  often  induce  neuralgia.  The  most  frequent  are- 
alcoholism,  lead-poisoning,  and  the  presence  of  an  excess  of  sugar  in 
the  blood.  But  these  causes  also  produce  neuritis,  of  which  pain  and 
tenderness  may  be  the  only  evidence,  and  it  is  often  difficult  to 
exclude  actual  inflammation  of  the  nerve.  At  the  same  time,  an  agent 
which  causes  neuritis  may  sometimes  merely  irritate  the  sensory 
structures  and  produce  neuralgia.  This  statement  is  also  applicable  to 
gout,  the  influence  of  which  has  been  already  mentioned.  Both 
neuritis  and  neuralgia  may  unquestionably  result  from  acquired  and 
inherited  gout.  Malaria  is  another  powerful  cause,  but  its  influence 
is  seldom  seen  in  this  country,  except  in  those  who  have  been 
abroad.  Neuralgia  is  an  occasional  sequel  of  various  acute  diseases 
which  depress  the  nervous  system,  but  it  follows  none  so  often  as 


798  NEUKALGIA. 

influenza.  It  may  then  occur  in  any  locality,  sometimes  after  a 
trifling  exciting  influence,  and  may  last  for  weeks  or  months  ;  in  some 
cases  it  probably  succeeds  an  initial  neuritis.  The  syphilitic  poison 
has  been  thought,  by  some,  to  cause  true  neuralgia  during  its  active 
stage,  but  the  evidence  is  not  strong.  Occasionally,  those  who  have 
had  syphilis  long  before  are  the  subjects  of  paroxysmal  pains,  in 
character  and  course  identical  with  those  of  tabes,  but  yet  present  no 
other  indication  of  this  disorder.  It  is  possible  that  this  is  a  "  tabetic 
neuralgia,"  due  to  degeneration  in  the  sensory  nerves,  such  as  occurs 
in  tabes,  but  sparing  the  muscle  nerves,  in  which  it  causes  ataxy. 

Symptoms  generally. — The  great  symptom  of  neuralgia  is  pain, 
spontaneous,  paroxysmal,  and  felt  in  certain  regions  of  nerve  distri- 
bution. It  is  usually  unilateral ;  when  bilateral  it  is  almost  always 
symmetrical  in  distribution.  Usually  the  pain  is  constant  in  seat  for 
a  time,  it  may  be  for  many  years.  In  other  cases  it  changes,  now  in 
one  part,  now  in  another.  Thus  a  girl  aged  fifteen  had  suffered 
for  two  years  from  paroxysms  of  intense  pain  in  various  parts,  arms, 
legs,  back,  different  parts  of  the  head,  and  occasionally  universal. 

The  pain  is  never  constant  in  degree  ;  there  are  paroxysms  with 
intervals  of  complete  freedom,  or  there  is  a  slight  continuous  pain 
with  intense  exacerbations.  Continuous  pain  may  be  merely  a  dull 
ache,  but  it  is  generally  acute  and  sharp  during  the  paroxysms,  and 
is  described  as  "  darting,"  "  stabbing,"  "  boring,"  "  burning,"  &c. ; 
often  the  sufferer  can  find  no  words  to  express  its  exact  character. 
The  sharp  pain  generally  has  a  darting  character.  A  series  of 
sudden  sharp  pains  occurs  every  few  minutes  ;  the  series  of  successive 
pains  constitutes  a  paroxysm,  and  a  series  of  paroxysms  an  attack. 
The  intervals  between  the  attacks  present  extreme  variation,  and  are 
sometimes  remarkably  long  in  proportion  to  the  severity  of  the  pain. 
Thus  one  patient  will  have  attacks  daily  during  several  years,  while 
in  another  (as  in  an  actual  instance)  intervals  of  many  months  sepa- 
rate groups  of  attacks  of  most  intense  pain,  each  group  lasting  only 
a  few  days.  In  such  paroxysms  it  is  usual  tor  the  pains  to  commence 
suddenly,  but  they  are  rarely  as  severe  at  first  as  they  subsequently 
become.  Sometimes  a  peculiar  sensation,  such  as  throbbing,  heralds 
each  attack  of  pain.  The  attacks  gradually  increase  in  intensity,  and 
in  each  attack  the  separate  paroxysms  may  present  a  characteristic 
augmentation  and  decrease. 

The  pain  is  seldom  referred  to  the  skin ;  usually  it  is  more  deeply 
seated,  and  often  corresponds  to  the  position  of  a  nerve-trunk  and  its 
branches — a  fact  of  some  diagnostic  importance.  The  throbs  of  pain 
sometimes,  but  seldom,  coincide  with  the  arterial  pulsations.  There 
is  often  a  darting  movement  of  the  pain,  usually  towards  the  peri- 
phery— centrifugal ;  less  commonly  from  the  periphery — centripetal ; 
still  less  commonly  the  pain  darts  alternately  in  both  directions. 
Sometimes  it  seems  to  be  localised  in  a  single  point,  and  then  has 


STMPTOMS.  799 

usually"  a  "boring  character.  When  most  intense  the  darting  pain 
radiates  to  other  nerve-regions  adjacent  to  that  in  which  it  is 
chiefly  felt. 

The  duration  of  each,  attack  varies  according  to  the  numher  of 
paroxysms  and  their  length.  Rarely  there  is  a  single  brief,  intense 
pain  ;  more  often  an  attack  lasts  several  hours.  In  the  intervals  there 
may  be  slighter  pain,  or  a  peculiar  sensation  in  the  part,  or  freedom. 
The  intervals  vary  from  a  few  hours  to  several  months.  Often 
periodicity  exists  ;  it  may  be  exact  in  malarial  cases,  in  which  the 
pain  may  commence  at  the  same  hour  each  day,  or  at  intervals  of  two 
or  three  days.  Now  and  then  the  periodicity  is  exact  in  cases  that 
ai-e  not  malarial.  The  pain  may  be  worse  at  the  catamenial  periods, 
and  may  even  occur  only  at  those  times.  When  there  is  continuous 
pain  in  the  intervals  between  the  paroxysms,  it  is  moderate  in  degree, 
but  often  troublesome  by  disturbing  rest. 

The  paroxysms  and  attacks  are  often  induced  by  certain  influences, 
external  or  internal,  such  as  by  exposure  to  cold,  sometimes  by  warmth, 
by  movement,  posture,  or  emotion.  In  some  cases  there  is  remarkable 
sensitiveness  to  atmospheric  influences.  When  the  paroxysms  occur 
at  regular  intervals,  an  influence  that  will  induce  the  pain  when  it  is 
"due,"  may  be  powerless  immediately  after  an  attack.  During  a 
paroxysm,  the  influences  that  will  bring  it  on  usually  intensify  the 
pain.  Movement  is  especially  influential  in  the  neuralgias  of  the  fifth 
nerve;  the  slightest  motion  of  the  jaws  may  induce  the  pain.  A 
touch  on  the  skin  may  have  the  same  effect;  nevertheless  in  many 
cases,  although  slight  pressure  increases  the  pain,  firm  pressure  gives 
distinct  relief ;  even  when  mere  contact  with  the  skin  causes  an 
exacerbation,  rough  rubbing  may  distinctly  relieve  the  suffering.  This 
difference,  however,  is  not  always  to  be  observed.  In  some  cases 
alcohol,  even  in  small  quantities,  invariably  intensifies  or  induces  the 
pain ;  in  other  cases  it  gives  relief.* 

This  increased  sensitiveness  of  the  skin  is  a  very  common  accom- 
paniment of  the  pain.  It  may  involve  all  forms  of  sensation,  although 
thermic  impressions  much  less  commonly  occasion  pain  than  does  a 
touch.  Sometimes  the  tactile  impression  seems  to  be  felt  as  pain; 
more  often  it  excites  an  increase  in  the  true  neuralgic  pain.  The 
hyperesthesia,  or  hyperalgesia,  is  usually  limited  to  the  region  in 
which  the  spontaneous  pain  is  felt.  When  this  pain  follows  the 
course  of  a  nerve  it  is  commonly  most  intense  at  certain  spots,  and  at 
these  places  pressure  may  cause  a  special  increase  in  the  suffering. 
In  the  intervals  between  the  paroxysms  these  spots  may  remain 
tender,  and  pressure  upon  them  may  induce  a  paroxysm.     They  are 

*  Very  curious  facts  are  sometimes  met  with  in  regard  to  the  induction  of  the 
pain.  Thus  in  one  patient  intense  fronto-occipital  neuralgic  pain  was  excited  by 
every  act  of  defsecation.  This  action,  in  some  cases,  has  a  very  peculiar  influence 
on  the  nervous  system,  and  so  has  micturition,  as  the  familiar  shiver  shows.  I  have 
known  micturition  to  be  attended  with  a  moment's  loss  of  consciousness. 


800  NEUKALGIA. 

not  usually  present  until  the  disease  has  lasted  for  some  time.  In 
recent  cases,  and  when  the  attacks  occur  only  at  long  intervals, 
although  there  is  no  persistent  tenderness,  the  pain  may  be  increased 
during  the  paroxysm  by  pressure  on  certain  places.  The  tender 
points  were  first  studied  by  Yalleix,  and  hence  are  often  called  after 
him.  They  are  tolerably  uniform  in  their  position,  and  for  the  most 
part  correspond  either  to  the  place  at  which  a  nerve-trunk  emerges 
from  a  bony  canal,  passes  over  a  hard  structure,  or  passes  through  a 
fascia  to  become  superficial,  or  to  the  point  of  division  of  a  nerve- 
trunk,  or  to  an  anastomosis  of  two  nerve-trunks.  They  are  present 
in  about  half  the  cases  ;  when  absent  there  is  sometimes  ill-defined 
tenderness  in  certain  areas. 

There  is  occasionally  tenderness  of  the  vertebral  spine  corresponding 
to  the  origin  of  the  painful  nerve,  the  point  apophysaire  of  Trousseau. 
It  is  probable,  as  Anstie  pointed  out,  that  the  relation  of  this  to- 
neuralgia  has  been  exaggerated.  The  tenderness  of  certain  vertebral 
spines  is  common  apart  from  neuralgia,  and  there  is  not  always  a 
close  correspondence  between  the  position  of  the  spinal  tenderness 
and  the  seat  of  the  neuralgia.  In  bigeminal  neuralgia,  for  instance, 
there  may  be  tenderness  of  the  cervical  spines. 

Other  sensory  disturbances  are  occasionally  observed  in  neuralgia, 
The  onset  of  the  pain  is  sometimes  preceded  by  numbness,  tingling, 
&c.,.  in  the  affected  area,  but  less  frequently  than  in  neuritis. 
Occasionally  the  attack  of  pain  is  followed  by  transient  anaesthesia. 
Persistent  diminution  of  sensibility  is  only  met  with  in  cases  of 
"  symptomatic  neuralgia,"  in  which  there  are  structural  changes  in 
the  nerves.  Increased  sensitiveness  to  pain  (hyperalgesia),  in  the 
whole  area  of  the  neuralgia,  is  not  uncommon.  Yomiting  is  rarely 
associated  with  simple  neuralgia,  although  so  common  in  migraine, 
in  which  the  pain  may  bear  a  superficial  resemblance  to  that  of 
neuralgia.  But  I  have  met  with  vomiting  in  two  cases  of  neuralgia ; 
one,  bilateral,  in  the  anterior  branches  of  the  cervical  plexus,  and  the 
other  in  the  two  upper  divisions  of  one  fifth  nerve.  Severe  attacka 
in  women  often  cause  hysterical  symptoms  as  the  pain  is  subsiding. 

Muscular  spasm  may  be  excited  by  the  acute  paroxysms  of  pain, 
evidently  in  a  reflex  manner.  It  is  usually  confined  to  the  motor  nerve 
related  to  that  which  is  the  seat  of  the  pain,  but  sometimes  spreads 
to  adjacent  areas,  very  rarely  passing  into  a  general  convulsion.  In 
a  case  of  cranio-spinal  neuralgia  each  paroxysm  was  attended  by  opis- 
thotonos so  severe  that  the  patient  rested  on  the  head  and  the  heels. 
The  exacerbation  of  the  pain  by  movement  may  lead  to  temporary 
diminution  of  mobility,  partly  voluntary,  partly  of  inhibitory  origin. 

Trophic  and  vaso-motor  disturbance  sometimes  results  from  the 
deranged  nerve-influence.  Skin  eruptions  are  rare  ;  herpes  is  seldom, 
if  ever,  a  consequence  of  true  neuralgia,  although  neuralgic  pain 
so  often  accompanies  and  follows  herpes.  The  hair  of  the  part 
may  undergo  changes :   it   may  lose  its  pigment,  fall  off,   or  very 


PATHOLOGY.  801 

rarely  overgrow.  Anstie  observed  temporary  greyness  of  a  lock  of 
hair  after  each  attack,  followed  at  last  by  permanent  change.*  I 
have  seen,  in  a  girl  of  eighteen,  loss  of  pigment  in  the  hair  above 
and  behind  each  ear,  following  neuralgic  pain  there  of  some  months' 
duration.  Yaso-motor  disturbance  often  accompanies  a  paroxysm. 
The  first  effect  of  the  pain  is  usually  to  cause  a  constriction  of  the 
vessels  of  the  part,  but  this  is  often  followed  by  their  relaxation  ; 
flushing  of  the  skin  results,  and  the  throbbing  of  the  arteries  may 
considerably  intensify  the  pain.  The  arterial  dilatation  may  be 
general,  and  be  demonstrable  bv  sphygmograpbic  tracings  (Anstie). 
In  one  case  of  trigeminal  neuralgia  all  the  veins  of  that  side  of  the 
face  became  distended  during  the  paroxysm,  and  as  the  pain  subsided 
pallor  replaced  the  flushing.  The  local  vascular  disturbance  may 
cause  local  sweating  or  local  oedema,  or  even  erythema,  sometimes 
mistaken  for  erysipelas.  The  oedema  thus  produced  is  occasionally 
considerable,,;  I  have  known  each  attack  of  cranial  neuralgia  to  be 
accompanied  by  great  swelling  of  the  whole  scalp,  due  to  this  con- 
dition, -which  slowly  disappeared  some  hours  after  the  cessation  of  the 
pain.  In  another  curious  case,  attacks  of  pain  in  the  tongue  and  face 
were  attended  by  swelling  of  each  part,  which  usually  came  on  during 
the  night,  and  sometimes  occurred  with  very  little  pain.  Repeated 
attacks  of  such  vaso-motor  disturbance  may  lead  to  permanent  dila- 
tation of  the  vessels  of  the  surface,  and,  after  a  time,  to  thickening  of 
the  cellular  tissue,  periosteum,  and  other  structures. 

Pathology. — Few  questions  have  been  the  subject  of  more  con- 
troversy than  the  pathology  of  neuralgia.  The  difference  of  opinion 
is  largely  due  to  the  different  senses  in  which,  as  we  have  seen,  the 
word  has  been  used.  The  problem  of  pathology  is,  What  is  the  nature 
of  nerve- pain  that  has  no  known  organic  cause  ? 

In  neuralgia  we  have  two  symptoms  ;  first,  spontaneous  pain,  and 
secondly,  " hyperaesthesia "  (more  properly  hyperalgesia),  i.e.  the 
production  of  pain  by  sensory  impressions  that  are  not  usually  pain- 
ful :  the  former  includes  the  latter,  and  therefore  must  be  first  con- 
sidered. Spontaneous  pain  means  the  action  of  sensory  nerve- 
elements  apart  from  local  external  stimulation.  The  pain  corre- 
sponds to  certain  peripheral  nerve-areas,  and  we  must  therefore 
look  for  its  cause  to  the  elements  constituting  a  peripheral  nerve- 
structure.  These  are  the  nerve -fibres,  their  peripheral  end-organs, 
and  the  central  cells  with  which  the  fibres  are  connected.  To  which 
of  these  can  we  ascribe  a  functional  activity  independent  of  external 
stimulation  ?  We  know  nothing  of  a  capacity  for  such  action  on 
the  part  of  nerve-fibres.     They  possess  a  limited  power  of  trans- 

*  A  very  remarkable  case  lias  been  recorded  by  Raymond,  in  which,  at  the  time 
neuralgic  pain  in  the  head  was  most  intense,  all  the  hair  of  the  patient  (a  woman 
aged  thirty-eight)  changed  colour  from  black  to  red,  and  in  a  few  days  to  white,  and 
then,  in  the  course  of  fourteen  days,  fell  off  ('  Revue  de  Med.,'  Sept.,  1882). 

VOL.  II.  51 


802  NEUKALGIA. 

forming  external  energy  into  nerve-force,  -which  constitutes  their 
"excitability,"  and  they  "conduct"  nerve-force;  but  there  is  no 
evidence  to  show  that,  apart  from  external  influences,  they  are  capable 
of  producing  nerve-force.  Nor  are  any  facts  known  which  would 
suggest  that  the  peripheral  end-organs  of  the  sensory  nerves  are  the 
seat  of  the  primary  disturbance  in  simple  neuralgia.  It  is  true 
that,  in  tabes  and  degenerative  peripheral  neuritis,  changes  in  the 
nutrition,  and  sometimes  in  the  structure  of  the  nerve-endings  seem, 
in  many  cases,  to  cause  the  acute  pains  of  these  disorders.  The 
function  of  these  structures,  transforming  mechanical  into  nerve 
energy,  must  involve  a  delicate  organisation,  susceptible  of  almost 
spontaneous  over-action  ;  but  the  features  of  true  neuralgia  differ 
from  those  produced  by  disease  of  the  nerve-endings.  We  are  thus 
led  to  look  to  the  central  terminations  of  the  nerve-fibres  as  the 
source  of  the  pain  in  idiopathic  neuralgia.*  The  fibres  end  in 
nerve-cells,  and  nerve-cells  are  the  elements  chiefly  capable  of  the 
production  of  nerve  energy,  in  apparent  independence,  and  certainly 
in  excess,  of  the  stimuli  applied  to  them.  *  When  au  external  cause 
(e.  g.  an  injury  of  the  nerve)  gives  rise  to  pain,  the  sensation  is  due 
to  the  stimulation  of  these  cells,  and  the  pain  which  results  from 
their  spontaneous  "  discharge  "  is  necessarily  referred  to  the  region 
from  which  their  fibres  convey  impressions. 

The  sensory  fibres  end  in  two  sets  of  cells,  those  of  the  ganglia 
on  the  posterior  roots,  and  those  within  the  spinal  cord,  chiefly  in  the 
posterior  coruua.  There  is  no  direct  evidence  to  show  which  of  these 
series  of  cells  is  concerned  in  neuralgia.  But  we  know  nothing  of 
any  sensory  function  of  the  ganglia,  and  we  are  therefore  justified  in 
looking  to  the  nerve-cells  within  the  cerebro- spinal  axis  as  the  seat  of 
the  morbid  process. 

This  conclusion  is  supported  by  the  symptoms  of  many  cases  of 
neuralgia.  Especially  significant  are  the  following — (1)  The  fact 
that  the  pain  may  occupy  adjacent  parts  of  several  nerve-regions. 
For  instance,  in  one  patient  the  pain  extended  on  both  sides  from 
the  seventh  cervical  vertebra,  over  the  whole  occiput  and  vertex 
to  the  coronal  suture.  (2)  The  phenomenon  of  radiation  of  slighter 
pain  into  adjacent  nerve-regions  during  severe  paroxysms.  (3)  The 
phenomena  of  reflex  neuralgia,  in  which  the  pain  is  felt  in  another 
region  than  that  of  the  nerve  irritated.  All  these  are  explicable 
only  on  the  theory  that  the  morbid  action,  felt  as  pain,  is  in  the 
central  cells,  which  are  no  doubt  connected  according  to  the  re- 
lations of  the  surface  regions  from  which  they  receive  impressions, 
and  to  which  their  disturbance  is  subjectively  referred. 

The  same  conclusion,  the  central  nature  of  neuralgia,  is  also 
indirectly  confirmed  by  facts  of  pathology  of  another   kind    which 

*  The  central  theory  has  been  adopted,  amongst  others,  by  Vulpian,  Anstie, 
Clifford  Allbutt,  and  Vanlair,  although  the  theories  of  these  authors  differ  somewhat 
in  their  details. 


PATHOLOGY.  803 

prove  that  pain  of  neuralgic  character  may  be  produced  by  an  organic 
lesion  in  the  grey  matter  which  is  here  supposed  to  be  deranged  in  idio- 
pathic neuralgia.  The  lesion,  for  instance,  involving  part  of  the 
sensory  nucleus  of  the  fifth  nerve,  shown  in  Fig.  53  (B  x),  p.  69, 
caused  severe  neuralgic  pain  in  the  face. 

If,  therefore,  we  regard  idiopathic  neuralgia  as  the  result  of  the  j 
over-action,  the  "  discharge,"  of  the  nerve-cells  constituting  the  proxi- 
mate centre  of  the  nerve,  the  question  still  remains — to  what  is  this 
discharge  due  ?     It  is  often  ascribed  to  hypersemia  of  the  centre,  due  ' 
to  dilatation  of  its  vessels.     The  possibility  of  this  cause  cannot  be 
denied,  but  neither  can  its  efficiency  be  proved.     It  is  an  hypothesis, 
moreover,  which   only  solves   one  problem   by  the  introduction   of 
another.     Vaso-motor  disturbance  means  the  deranged  action  of  the 
vaso-motor  centre  for  that  territory,  and  it  is  as  difficult  to  explain 
tbe  disturbed  action  of  the  vaso-motor  cells  as  of  the  sensory  cells. 
All  cells  possess  the  power  of  evolving  force ;  the  discharge  of  the 
sensory  cells  is  that  alone  of  which  we  have  evidence,  and  it  seems 
unjustifiable  to  assume  the  intervention  of    other  cells  for  its  pro- 
duction.    But  it  is  highly  probable  that  secondary  vaso-motor  dis- 
turbance results.     We  know  that  in  all  organs  vascular  dilatation 
attends  functional  activity.     If  the  cerebral  cortex  is  stimulated  by 
electricity,  local  dilatation  of  vessels  quickly  follows.     It  is  probable 
that  such  secondary  central  hyperemia  may  result  from  the  discharge 
of  sensory  centres,  and  when  established,  may  increase  the  disturbance. 
The  over-action  of  the  cells  in  idiopathic  neuralgia  has  been  spoken 
of  as  "  independent."     It  is  independent  so  far  as  our  means  of  obser- 
vation go.     But  we  cannot  tell  to  what  extent  the  unstable  cells  may 
be  excited  to  discharge  by  stimulation  of  which  we  are  unconscious. 
"We  know  that   some  influences  of  this  kind  (cold  or  pressure)  are 
effective  in  exciting  attacks.     It  is  highly  probable  that  the  afferent 
impressions  which  we  perceive  bear  but  a  small  proportion  to  those  of 
which  we  are  unconscious ;  these,  continuous  or  intermittent,  are  due 
to  slight  cutaneous  impressions,  to  the  movement  of  the  blood,  and  to 
the  nutritional  processes  in  the  tissues.     It  is  quite  possible  that  such 
afferent  impulses,  too  trifling  to  affect  our  consciousness  even  when 
aided  by  attention,  may  excite  the  discharge  of  the  unstable  cells. 
That  a  strong  sensory  impression  (e.  g.  painful  pressure  on  the  nerve) 
may  sometimes  relieve  the  pain  is  quite  in  harmony  with  familiar  facts 
as  to  the  effect  of  sensory  stimulation  ;  a  strong  stimulus  may  inhibit 
the  reflex  action  that  may  be  excited  by  a  slighter  stimulus  in  the 
same  nerve-region;  sometimes  pressure  may  arrest  exciting  impulses. 
These  two  facts  deprive  of  much  of  its  force  an  objection  which  has  been 
often  urged  against  the  central  theory  of  neuralgia,  that  the  disease 
may  sometimes  be  permanently  cured  by  division  of  the  nerve ;  the 
significance  of  this  will  be  considered  in  connection  with  treatment. 

We  are  accustomed  to  think  of  the  sensory  nerves  as  distributed 
chiefly  to  the  skin,  but  the  pain  in  neuralgia  is  rarely  confined  to  the 


804  NEURALGIA. 

skin.  It  appears  to  the  sufferer  to  be  more  deeply  seated,  and  often 
corresponds  in  position  to  the  nerve-trunk  and  branches.  The  fibrous 
sheaths  of  both  are  abundantly  supplied  with  nerves, — the  nervi 
nervorum*  which  ramify  and  end  in  the  sheath,  without  penetrating 
the  interfascicular  septa.  If  a  nerve  is  compressed  (as  the  ulnar  at 
the  elbow)  the  first  sensation  experienced  is  a  pain  at  the  spot,  from 
the  stimulation  of  the  sheath-nerves ;  if  the  pressure  is  continued, 
there  is  also  a  sensation  (tingling)  referred  to  the  peripheral  distribu- 
tion of  the  nerve  in  the  hand,  due  to  the  stimulation  of  the  fibres  of 
the  nerve  itself.  In  neuralgia,  the  central  cells  of  the  sheath-fibres 
seem  often  to  be  disturbed  in  function  more  than  those  of  the  fibres 
of  the  nerve  itself ;  the  pain  is  referred  to  the  nerve-trunk  rather  than 
to  the  skin. 

The  fact  that  the  pain  seems  to  dart  along  the  nerve  must  be  due 
to  the  spread  of  the  discharge  in  the  centre  in  a  certain  order  from 
cell  to  cell.  We  cannot  at  present  say  precisely  on  what  this  depends, 
or  why  the  pain  seems  sometimes  to  dart  towards  and  sometimes 
from  the  periphery. f 

The  irradiation  of  the  pain,  in  severe  attacks,  to  neighbouring 
nerve-areas  is  clearly,  as  already  mentioned,  a  central  phenomenon. 
An  intense  discharge  always  tends  to  spread  to  other  connected  cells,. 
in  proportion  to  its  intensity,  as  the  phenomena  of  epilepsy  abun- 
dantly illustrate. 

The  origin  of  the  tender  points  is  obscure,  and  has  been  the  subject 
of   much   speculation. J      Their  localisation  to  the  places  at  which 

*  Sappey  ('  Journal  de  l'Anat.  et  de  la  Physiologic,'  vol.  i,  1868,  p.  47)  has  demon- 
strated their  existence  in  the  sheath  of  the  optic  nerve,  and  the  fact  mentioned  in 
the  text  admits  of  no  other  explanation  than  the  existence  of  similar  nerves  in  all 
nerve-sheaths,  which  has,  indeed,  been  demonstrated  by  Horsley  ('  Proc.  Roy.  Med. 
and  Chir.  Soc./  1884,  and  Appendix  to  Marshall's  'Bradshaw  Lecture,'  1887). 

t  An  ingenious  hypothesis  has  been  formulated  by  Vanlair,  which  may  be  men- 
tioned. According  to  Pierret  there  is  a  relation  between  the  length  of  a  nerve-fibre 
and  the  size  of  its  cell.  The  sheath-nerves  will  vary  in  length  according  to  the  dis- 
tance from  the  centre  at  which  they  terminate.  If  the  cells  discharge  in  the  order 
of  their  size,  beginning  with  the  smallest,  the  sensation  will  seem  to  dart  centri- 
fugally.  For  the  apparently  centripetal  direction  a  still  more  complex  hypothesis 
has  been  suggested.  Most  nerves  contain  recurrent  fibres,  which  proceed  from  adja- 
cent nerves  (Magendie,  Arloing,  and  Tripier).  These  recurrent  fibres  ascend  the 
branches  and  trunk,  but  all  cease  before  the  foramina  of  exit  are  reached.  If  these 
end  in  the  ner%Te-sheath,  the  same  hypothesis  applied  to  the  recurrent  fibres  will 
serve  to  explain  the  centripetal  darting;  the  longest  fibres,  which  end  nearest  the 
centre,  will  have  the  largest  cells,  and  discharge  last.  Unfortunately  we  do  not 
know  that  any  of  the  recurrent  fibres  end  in  the  nerve-sheath,  and  if  they  do,  it  is 
probable  that  their  central  connection  is  the  same  as  that  of  the  direct  fibres.  It 
seems  more  probable  that  the  arrangement  of  the  cells  in  the  centre  depends  on  the 
distribution  of  the  fibres  in  the  sheath,  and  that  this  arrangement,  and  not  the  size 
of  the  cells,  determines  the  order  of  the  discharge,  which  may  traverse  the  centre  in 
opposite  directions  in  different  cases,  just  as  in  one  epileptic  an  aura  may  pass  down, 
|  and  in  another  up,  the  arm. 

J  The  hypothesis  (of  Cartaz  aud  others)  which  connects  these  tender  points  with 


VARIOUS    FORMS.  805 

■nerves  emerge  from  deeper  structures,  or  divide,  suggests  their 
dependence  on  mechanical  causes.  Accidental  pressure,  and  traction 
in  movement,  will  have  most  influence  on  the  nerves  at  such  places, 
and  cause  there  a  greater  degree  of  stimulation  of  the  nervi  nervorum 
(Vanlair).  Many  phenomena  of  neuralgia  suggest,  moreover,  that  a 
neuralgia  which  is  at  first  purely  central  may  not  remain  so.  We 
have  seen  that  the  pain  often  causes  secondary  vascular  disturbance 
in  the  territory  of  the  nerve.  It  is  most  unlikely  that  such  disturb- 
ance, conspicuous  in  the  skin,  is  confined  to  the  surface.  It  probably 
involves  also  the  deeper  structures,  and  especially  the  nerve-sheaths, 
in  which  the  pain  is  especially  localised.  Such  secondary  vascular 
•disturbance,  and  the  tissue  changes  to  which  it  ultimately  leads,  must 
■constitute  a  source  of  irritation  of  the  nervi  nervorum,  and,  in  a  truly 
"vicious  circle,"  must  intensify  the  malady,  which,  at  first  central, 
may  be  thus,  at  last,  peripheral  also.  It  is  probable  that  this  me- 
chanism takes  an  important  share  in  the  production  of  the  tender 
points,  and  is  also  the  cause  of  the  intractability  of  some  neuralgias. 

Not  only  is  it  probable  that  peripheral  disturbance  takes  part  in 
the  pathogenesis  of  central  neuralgia,  but  it  is  certain  that  central 
•disturbance  is  concerned  in  some  neuralgias  of  peripheral  origin.  A 
traumatic  cause,  an  injury  to  a  nerve- branch,  may  induce  pain  far 
wider  in  area  than  the  distribution  of  the  injured  branch,  or  even  of 
the  nerve  from  which  it  comes.  In  some  cases,  again,  the  pain  is  felt 
not  in  the  area  of  the  nerve  injured,  but  in  that  of  some  other  nerve 
(reflex  neuralgia).  An  interval  usually  elapses  after  the  injury 
before  the  pain  is  felt.  Lastly,  in  some  traumatic  cases,  division  of 
the  nerve  does  not  cure  the  neuralgia.  These  facts  can  only  be  ex- 
plained by  assuming  that  the  chief  cause  of  the  pain  is  a  morbid 
state  of  the  central  cells,  excited  by,  but  to  some  extent  independent 
of,  the  peripheral  lesion.  Doubtless  in  all  neuralgias  of  "  sym- 
ptomatic "  character  the  symptoms  depend,  in  varying  degree,  on  an 
induced  central  disturbance. 

Various  Forms. — Cases  of  neuralgia  differ  much  according  to 
their  situation,  character,  and  cause,  and  hence  it  is  necessary  to 
describe  in  some  detail  the  varieties  of  the  disease.  According  to 
situation,  we  have  to  consider  separately  those  which  occupy  the 
head,  neck,  arm,  trunk,  and  leg.  According  to  character,  we  have 
"epileptiform  neuralgia,"  and  "  reflex  "  or  "  sympathetic  neuralgia;" 
while  of  those  which  depend  on  special  causes  the  most  important  are 
the  traumatic,  herpetic,  anaemic,  malarial,  syphilitic,  and  diabetic 
forms. 

It  is  important  to  remember  that  neuralgia  is  often  not  confined  to 
a  single  nerve.     Those  who  are  liable  to  the  affection  in  a  high  degree 

the  distribution  of  the  recurrent  nerves,  rests  on  too  many  unprovable  assumptions 
to  deserve  detailed  description. 


80(3  NEURALGIA. 

sometimes  suffer  from  neuralgia  in  many  situations,  simultaneously 
or  in  succession. 

Varieties  depending  on  Situation. — Neuralgia  of  the  Fifth  Nerve. 
Trifacial  or  Trigeminal  Neuralgia ;  Tic  Douloureux ;  Prosopalgia. — 
Under  these  various  designations  the  most  common  form  of  neuralgia 
has  been  described.  Neuralgia  of  the  fifth  is  probably  more  frequent 
than  all  the  other  varieties  together,  and  it  presents,  in  most  typical 
form,  the  characteristic  symptoms  of  the  disease.  Nor  is  this  surprising 
when  we  consider  that  the  fifth  is  incomparably  the  most  important 
nerve  of  common  sensibility  in  the  body. 

The  causes  of  this  form  are  all  those  that  have  been  described  in  the 
section  on  etiology ;  indeed,  the  general  history  of  neuralgia  is,  to  a 
large  extent,  based  on  the  symptoms  of  this  variety.  It  is  equally 
common  on  the  two  sides.  The  seat  of  the  pain  may  be  in  any  of  the 
three  divisions  of  the  nerve ;  and  it  more  commonly  occupies  one  or 
two  of  the  divisions  than  all  three.  The  tender  points  are  often  well 
marked,  and  in  them  the  pain  has  its  chief  intensity. 

Neuralgia  of  the  first  division  is  felt  chiefly  in  the  supra-orbital 
branch,  and  hence  is  often  called  supra-orbital  neuralgia.  The  fre- 
quency with  which  it  was  formerly  due  to  malaria  has  left  for  it  the 
popular  name  of  "  brow-ague,"  althoiagh  this  cause  is  now  rarely  ope- 
rative in  this  country.  The  pain  radiates  from  the  supra-orbital  notch 
over  the  anterior  half  of  the  head,  and  is  often  felt  in  the  eyelids  and 
even  in  the  eye,  and  in  the  side  of  the  nose.  The  most  important 
tender  points  are  the  supra-orbital  just  above  the  notch  or  foramen  of 
that  name,  a  palpebral  in  the  outer  part  of  the  upper  eyelid,  a  nasal 
at  the  emergence  of  the  nasal  branch  at  the  lower  edge  of  this 
bone,  and  sometimes  an  ocular  within  the  eyeball.  Pain  felt  just  above 
the  eyebrows  is  sometimes  due  to  a  morbid  state  of  the  frontal  sinuses, 
but  pain  from  this  cause  is  generally  double,  and  is  often  secondary  to 
coiyza.  The  lining  membrane  of  the  sinus  is  supplied  by  the  fifth 
nerve,  and  it  has  been  conjectured  that  the  pain  occurs  when  the  small 
openiug  of  the  sinus  into  the  nasal  cavity  becomes  closed.  Seelig- 
miiller  thinks  that  this  is  the  cause  of  the  pain  even  in  malarial  cases. 
But  the  nerves  of  the  sinus  (or  their  centres)  seem  to  he  particularly 
obnoxious  to  cei'tain  influences,  as  is  shown  by  the  peculiar  pain,  evi- 
dently referred  to  these  sinuses,  which  many  persons  experience  after 
eating  ices.  "We  cannot,  therefore,  conclude  that  because  the  pain 
occupies  this  situation,  it  is  necessarily  due  to  a  local  cause.  The 
supra-orbital  region  is  a  not  uncommon  seat  of  localised  pain  that  is 
apparently  neuralgic.  This  does  not  follow  the  course  of  the  nerves,, 
but  it  may  be  felt  sometimes  over  one  eye,  sometimes  over  both. 

Ocular  Neuralgia. — The  eyeball  is  an  occasional  seat  of  neuralgic 
pain,  often  of  considerable  severity.  This  is  sometimes  associated  with 
some  error  of  refraction,  especially  hypermetropia,  but  occurs  also 
independently  of  any  abnormality  of  the  eye  itself.     Either  one  or 


VARIETIES    DEPENDING    ON    SITUATION.  807 

both  eyes  may  be  affected.  The  pain  may  occur  spontaneously,  or 
may  be  brought  on  by  use  of  the  eyes ;  it  is  not  often  accompanied 
by  photophobia.  When  severe,  there  is  occasionally  dimness  of  sight, 
apparently  of  inhibitory  origin,  and  the  amblyopia  may  be  accom- 
panied by  a  peripheral  restriction  of  the  field  of  vision.  Ocular 
neuralgia  may  exist  alone,  or  be  associated  with  pain  in  adjacent  parts, 
and  sometimes  with  pain  that  extends  far  beyond  the  limits  of  the 
fifth  nerve.  Bilateral  pain  sometimes  passes  from  the  eyes  over  or 
through  the  head  to  the  occipital  region,  and  even  down  the  neck. 
Anaemic  girls  often  complain  of  a  peculiar  dragging  pain  at  the  back  of 
the  eyes,  increased  by  their  use.  Ocular  pain  is  often  associated 
with  rheumatism ;  the  subjects  of  rheumatic  iritis  may  be  liable  to 
pain  in  the  eyeballs,  which  seems  to  be  neuralgic  in  character. 

In  neuralgia  of  the  second  division,  infra-orbital  neuralgia,  the  pain 
occupies  the  area  between  the  orbit  and  the  mouth  and  extends  over 
a  great  part  of  the  cheek,  and  to  the  ala  nasi.  The  chief  foci  of  pain 
and  tender  points  are  an  infra-orbital,  at  the  emergence  of  the  nerve 
beneath  the  orbit ;  a  nasal,  at  the  side  of  the  nose  ;  a  malar  over  the 
most  prominent  part  of  that  bone,  and  a  gingival  line  below  that  bone, 
along  the  line  of  the  gums  of  the  upper  jaw:  very  rarely  there  is  a 
point  in  the  palate  or  in  the  upper  lip.  The  most  acute  pain  is  often 
felt  only  in  one  portion  of  the  nerve,  as,  for  instance,  the  side  of  the 
nose  ;  but  it  usually  radiates,  in  a  slighter  degree,  over  a  wider  extent. 

When  the  third  division  is  affected,  the  pain  often  extends  over  a 
large  area,  occupying  the  parietal  eminence  and  the  temple,  the  ear, 
the  lower  jaw,  and  the  tongue.  The  chief  tender  points  are  the 
inferior  dental,  at  the  foramen  of  that  name  ;  the  temporal,  in  the 
posterior  part  of  the  temple  on  the  auriculo-temporal  branch  ;  it  may 
be  a  little  lower  down,  just  above  the  zygoma,  in  front  of  the  ear,  and 
is  a  very  common  focus.  The  parietal,  over  the  parietal  eminence,  is 
common  to  this  and  to  occipital  neuralgias.  Sometimes  there  is  a 
focus  of  pain  in  the  tongue.  Separate  portions  of  this  branch  are 
sometimes  affected  alone,  especially  the  inferior  dental  and  the  auri- 
culo-temporal. A  boring  pain  limited  to  the  temporal  point  is  espe- 
cially common.  Most  intense  neuralgia  is  sometimes  confined  to  the 
lingual  branch.  Occasionally  a  tender  point  exists  in  the  cervical  spines 
at  the  first  two  or  at  the  fifth ;  its  exact  cause  is  obscure. 

The  pain  in  trigeminal  neuralgia  is  often  peculiarly  intense,  and 
presents  every  variety.  It  may  radiate  from  one  part  of  the  fifth 
nerve  to  the  next,  and  even  to  other  nerve-regions.  Thus,  in  one  case 
of  violent  neuralgia  of  the  second  division  of  the  fifth,  the  pain  often 
radiated  to  the  occipital  region,  and  sometimes  to  the  shoulder  on  that 
side.  The  effect  of  cold  and  contact  in  exciting  the  pain  are  well 
marked,  and  it  is  often  increased  by  movement  of  the  face  or  jaw,  so 
that,  in  severe  cases,  mastication  may  be  impossible,  and  it  may  be 
difficult  to  give  sufficient  food.  If  the  ear  is  the  seat  of  pain,  either 
alone  or  with  other  parts,  the  attack  may  be  accompanied  or  followed 


808  NEURALGIA. 

by  auditory  hyperesthesia.  When  the  pain  is  very  acute  and  sudden, 
reflex  muscular  spasm  may  occur  in  the  face  (the  "tic  convulsif  "  of 
the  French).  Paralytic  phenomena  are  rare,  but  transient  paralysis 
of  the  third  nerve  has  been  observed  to  follow  each  paroxysm  of  pain 
in  the  supra-orbital  branch.  Sometimes  paroxysms  of  severe  pain  in 
the  fifth  nerve  are  accompanied  by  subjective  flashes  of  light,  especially 
■when  the  eyeballs  are  the  seat  of  pain.  The  vaso-rnotor  disturbance 
already  described  is  frequently  seen,  flushing,  sweating,  permanent 
dilatation  of  the  vessels  (often  conspicuous  on  the  eye),  salivation, 
increased  secretion  of  mucus  in  the  nose,  lacrymation.  Trophic 
disturbances  occasionally  occur, — acute,  as  erythema,  or  chronic,  as 
thickening  of  the  periosteum,  loss  of  hair,  or  local  greyness.  Even 
unilateral  atrophy  of  the  face  has  been  met  with.  It  is  probable 
that  in  many  of  these  cases  the  pain  has  been  the  result  of  actual 
changes  in  the  nerves.  The  course  of  the  fifth  in  the  base  of  the  skull, 
through  the  membranes  and  bony  foramina,  exposes  it  to  damage  from 
many  morbid  processes,  and  causes  its  fibres  to  suffer  when  there  is 
any  inflammatory  swelling  of  the  sheath. 

Occasionally,  migratory  pains  are  felt  in  various  parts  of  the  scalp, 
sometimes  on  one  side,  sometimes  on  the  other,  without  any  distinct 
relation  to  the  nerve-trunks.  There  may  be  tenderness  of  the  skin 
during  and  after  the  paroxysms  of  pain.  This  form  is  sometimes 
more  closely  allied  to  rheumatism  than  is  ordinary  neuralgia.  Rarely 
there  is  neuralgic  pain  over  the  whole  scalp  at  the  same  timei  so  that, 
as  one  patient  expressed  it,  there  is  "  a  cap  of  pain  on  the  head." 
Pain  at  the  vertex  is  a  common  form  of  headache,  sometimes  closely 
allied  to  neuralgia,  and  it  may  alternate  with  characteristic  neuralgic 
pains  in  other  situations. 

Cervico-occijrital  Netiralgia. — The  pain  is  felt  in  the  region  of  the 
neck  supplied  by  the  first  four  cervical  nerves,  and  in  the  posterior 
portion  of  the  head,  chiefly  along  the  course  of  the  great  occipital  nerve. 
Thus  the  pain  may  extend  over  the  greater  part  of  the  neck  as  well  as 
over  the  head,  as  far  forward  as  the  parietal  eminence  and  the  ear. 
It  is  occasionally  confined  to  the  posterior  branches,  extending  over 
the  back  of  the  neck  and  occiput.  The  most  important  tender  points 
are  (1)  about  midway  between  the  mastoid  process  and  the  spine,  at 
the  point  at  which  the  great  occipital  nerve  becomes  superficial,  (2) 
over  the  branches  of  the  cervical  plexus  between  the  sterno-mastoid 
and  trapezius,  and  (3)  just  above  the  parietal  eminence,  the  focus 
common  to  occipital  and  trigeminal  neuralgia.  Fusiou  of  these  two 
forms  of  neuralgia  occurs,  not  only  above  but  also  below,  where 
the  distribution  of  the  cervical  nerves  blends  with  that  of  the  third 
division  of  the  fifth  over  the  lower  jaw.  A  primary  cervical  neuralgia 
may  extend  into  this  region  of  the  fifth  ;  doubtless  the  centres  blend 
as  does  the  distribution.  It  is  probable  that  cervico-occipital  neuralgia 
is  more  often  bilateral  thau  any  other  foi-tn,  especially  when  confined 
to  the  occipital  region.     I  have  known  most  severe  bilateral  neuralgia 


VARIETIES    DEPENDING   ON   SITUATION.  809 

to  be  limited  to  the  anterior  cervical  i-egion,  from  the  jaw  to  the  upper 
part  of  the  thorax  on  each  side.  The  pain  in  cervico-occipital  neuralgia 
is  rarely  intermitting  ;  there  is  more  or  less  dull  constant  pain  with 
occasional  exacerbations,  less  violent  than  in  the  trigeminal  form. 
The  scalp  may  become  extremely  tendei*,  so  that,  during  the  pain,  the 
patient  cannot  bear  the  hairs  to  be  touched.  This  form  of  neuralgia 
is  not  common,  and  Anstie  believed  that  it  occurs  especially  in  those 
who  have  suffered  from  other  forms. 

Cervico-brachial  and  brachial  neuralgia  include  those  forms  in  which 
the  pain  is  referred  to  the  region  supplied  by  the  four  lower  cervical 
and  the  first  dorsal  nerves.  The  pain  may  be  felt  in  the  lower 
and  posterior  part  of  the  neck,  or  any  part  of  the  arm  and  hand,  but  is 
commonly  most  intense  in  the  axilla,  at  the  brachial  plexus,  and 
along  the  course  of  the  ulnar  nerve.  The  region  of  the  last  is  a 
very  frequent  seat,  but  sometimes  the  pain  is  referred  to  other  nerves. 
It  is  commonly  increased  by  movement,  and  may  render  the  arm 
almost  useless.  It  is  often  excited  by  writing,  and  this  may  give  rise 
to  an  erroneous  impression  that  it  is  connected  with  the  act  of  writing. 
Some  severe  forms  of  brachial  neuralgia,  indeed,  have  their  origin  in 
•a  sensory  occupation-neurosis,  but  this  variety  has  been  separately 
described  (p.  710).  The  most  common  tender  points  in  brachial 
neuralgia  are  the  axillary ;  the  circumflex,  at  the  posterior  border  of  the 
deltoid ;  a  superior  ulnar  behind  the  elbow,  and  an  inferior  ulnar  in 
front  of  the  wrist.  The  latter  is  the  most  frequent  of  all  the  brachial 
foci.  Others  occasionally  met  with  are  the  vertebral,  by  the  side  of  the 
lower  cervical  spines  ;  a  scapular,  at  the  inferior  angle  of  that  bone;  an 
external  humeral,  on  the  outer  side  of  the  arm  three  inches  above  the 
condyle,  over  the  musculo-spiral  nerve  ;  and  a  radial,  in  the  lower  and 
outer  part  of  the  forearm.  There  is  usually  some  constant  pain  in 
addition  to  the  acute  paroxysms.  Occasionally  it  may  radiate  to  the 
side  of  the  chest,  and  then,  if  on  the  left  side,  may  simulate  angina 
pectoris.  The  pain  is  almost  always  intensified  by  movement.  Trophic 
disturbance  in  the  arm  is  very  rare  in  cases  of  true  neuralgia,  and, 
indeed,  probably  always  indicates  neuritis.  When  the  pain  starts  from 
the  fingers,  it  may  begin  with  some  sensation  other  than  pain,  such  as 
tingling,  which  changes  to  pain  as  it  passes  up  the  arm.  In  some 
patients  with  brachial  neuralgia  the  arm  is  peculiarly  liable  to  be  the 
seat  of  tingling  at  night.  Brachial  neuralgia  is  not  often  due  to 
diathetic  causes,  with  the  exception  of  rheumatism,  with  which  it  is 
often  associated  even  when  there  is  no  suspicion  of  neuritis.  On  the 
other  hand,  it  is  more  frequently  than  any  other  the  result  of  injury. 
Probably  many  cases  of  supposed  neuralgia  are  really  cases  of  neuritis 
of  the  brachial  plexus,  which  may  arise  by  migratory  inflammation. 
But  true  neuralgia  of  the  arm,  widely  spread,  may  be  set  up  by  a  slight 
injury,  as  a  blow,  which  does  not  apparently  cause  neuritis.  Brachial 
neuralgia  is  occasionally  associated  with  neuralgia  of  the  fifth,  and  this 
when  there  is  no  connecting  pain  in  the  neck. 


810  NEUEALGIA. 

Trunk  Neuralgia. — Of  the  neuralgias  of  the  trunk,  we  have,  first,  the 
dorso -inter costal  forms,  which  occupy  the  intercostal  nerves,  from  the 
third  to  the  ninth,  characterised  by  pain  coursing  along  the  intercostal 
spaces  or  parts  of  them.  It  is  sometimes  bilateral  and  symmetrical. 
There  is  usually  a  constant  dull  pain,  with  acute  stabbing  exacerba- 
tions, but  sometimes  the  continuous  pain  exists  alone,  or  the  sharper 
pains  are  excited  only  by  movement,  respiratory  or  other.  There  are 
foci  of  intensity  and  tender  points  at  the  emergence  of  the  three- 
branches  of  the  intercostal  nerve, — beside  the  vertebrae,  near  the 
middle  line  in  front,  and  midway  between  these  two  points  in  the 
mid-axillary  line.  Intercostal  neuralgia  is  most  frequently  due  te 
cold,  or  to  injury,  such  as  a  contusion.  It  is  sometimes  extremely 
obstinate  and  of  long  duration. 

The  thoracic  wall  is  also  the  seat  of  more  trifling  neuralgic  pains  j 
one  of  these  is  pleurodynia,  which  differs  from  true  intercostal 
neuralgia  in  being  usually  localised  at  some  spot  not  corresponding  to 
the  course  or  exit  of  the  intercostal  nerves.  It  appears  to  be  a  true 
neuralgia,  distinguished  from  myalgia  by  the  fact  that  it  is  local,  very 
acute  in  character,  and  is  excited  by  expansion  of  the  thorax  rather 
than  by  lateral  movements  of  the  trunk.  The  theory  that  it  is  a  neu- 
ralgia of  the  pleural  nerves  has  much  probability.  Another  common 
neuralgia  is  the  infra-mammary  pain  of  anaemic  women.  Very 
limited  in  position,  it  is  more  or  less  constant,  and  is  rarely  increased 
by  respiration  to  such  an  extent  as  to  interfere  with  the  free  expan- 
sion of  the  thorax.  The  relation  between  intercostal  neuralgia  and 
pulmonary  trouble  is  a  difficult  subject,  on  which  satisfactory  facts 
are  difficult  to  obtain,  and  few  observers  have  ventured  to  corroborate 
the  statement  of  WoilJez  that  acute  intercostal  neuralgia  is  always 
accompanied  by  a  secondary  congestion  of  the  lung.  It  is  more 
probable  that  when  this  association  exists,  the  true  relation  is  the 
reverse.  The  intercostal  nerves  are  frequently  also  the  seat  of  herpetie 
neuralgia. 

The  neuralgias  that  occupy  the  lower  half  of  the  trunk  have  been 
grouped  as  lumbo-abdominal.  The  pain  has  a  course  similar  to  that 
of  the  intercostal  form.  Foci  of  pain  and  tender  points  are  found  at 
the  back,  beside  the  vertebrae,  over  the  posterior  branches  ;  at  the 
middle  of  the  iliac  crest  (iliac  point)  ;  at  the  lower  part  of  the  rectus 
(hypogastric  point) ,  while  sometimes  there  is  in  the  male  a  scrotal,  and 
in  the  female,  a  labial  point.  These  pains  are  often  bilateral,  and  may 
change  their  position  from  time  to  time.  They  are  generally  acute 
pains,  but  now  and  then  have  a  constricting  character,  like  the  girdle- 
pain  of  organic  disease,  but  distinguished  from  them  by  their  muta- 
bility. Lumbo-abdominal  neuralgias  seem  to  be  sometimes  secondary 
to  disease  of  the  pelvic  organs,  especially  in  the  female.  Neuralgia  in 
the  penis  has  been  thought  to  result  from  masturbation.  It  may  also 
be  due  to  litbsemia,  and  from  this  cause  I  have  known  it  to  be  most 
severe  and  long  continued. 


VARIETIES    DEPENDING    ON    SITUATION.  811 

The  spinal  column  is  a  very  common  seat  of  neuralgic  pain,  especially 
in  weakly  women  and  after  concussion  of  the  spine.  It  constitutes  one 
of  the  most  troublesome  of  the  many  pains  of  hysteria,  and  one  of  the 
most  enduring  consequences  of  railway  accidents.  The  pain,  in  most 
cases,  is  felt  through  a  considerable  vertical  extent  of  the  spine,  and  is 
specially  intense  in  certain  spots,  usually  in  more  than  one.  The  dorsal 
region  is  the  most  common  seat,  next  the  lower  cervical,  and  least  fre- 
quently the  lumbar  regiom  Sometimes  the  pain  is  localised  on  one  side 
of  the  spine,  close  to  it.  That  which  is  felt  in  the  spine  in  cases  of  gastric 
ulcer  seems  to  be  a  sort  of  reflex  neuralgia.  Often  the  pain  seems  to  pass 
up  to  the  back  of  the  head.  Spinal  neuralgia  may  be  associated  with 
a  similar  pain  in  some  other  part  of  the  trunk,  in  the  shoulder,  arm,  or 
leg.  It  is  usually  accompanied  by  considerable  tenderness,  and  is  in- 
creased by  fatigue,  by  use  of  the  legs,  by  long  sitting  or  standing,  and 
also  by  vibration,  such  as  the  movement  of  a  carriage.  The  latter  point 
is  often  of  considerable  diagnostic  importance,  for  it  is  far  more  marked 
in  neuralgia  than  in  spinal  diseases  causing  pain.  On  the  other  hand, 
the  pain  is  not  increased  by  slight  movement,  as  is  the  pain  of  growths 
and  caries.  It  is  seldom  distinctly  paroxysmal,  but,  as  already  men- 
tioned, in  one  case  paroxysms  of  pain  in  the  cervical  spine  and  vertex 
were  most  intense,  and  each  was  accompanied  by  opisthotonos.  It  is 
uncertain  in  what  structure  this  spinal  neuralgia  is  produced.  It  is 
often  associated  with  neuralgia  elsewhere,  and  also  with  rheumatism 
of  the  fibrous  tissues,  so  that  some  cases  seem  to  be  of  the  nature  of 
rheumatic  neuralgia.  It  has  been  thought  that  the  membranes  are 
the  seat  of  the  pain,  but  there  is  no  real  evidence  for  or  against  the 
theory. 

Another  very  common  seat  of  "neuralgia  is  the  sacral  region,  no 
doubt  in  consequence  of  the  plexus  of  nerves  that  lies  between  the  bone 
and  the  skin.  Pains  of  pelvic  origin  are  often  referred  to  this  region, 
as  those  of  parturition  show.  Occasionally  the  pain  is  felt  chiefly 
about  the  coccyx.  It  must  be  remembered  that  the  fibrous  tissues 
over  the  sacrum  are  sometimes  the  seat  of  acute  rheumatic  pain,  such 
as,  higher  up,  is  termed  lumbago. 

Neuralgia  oftheLeg. — In  the  lower  limb,  neuralgia  is  rare  in  the  region 
supplied  from  the  lumbar  plexus,  although  a  crural  form,  in  which  the 
pain  occupies  chiefly  the  front  of  the  thigh,  is  occasionally  met  with. 
In  most  instances  pain  in  this  region  is  of  secondary  origin,  due  to  a 
lesion  of  the  lumbar  plexus,  as,  for  instance,  from  the  pressure  of  an 
abdominal  tumour,  or  is  due  to  the  extension  of  neuritis  from  the 
sciatic  up  the  lumbo-sacral  cord. 

The  majority  of  neuralgic  pains  in  the  leg  are  in  the  region  of  the 
sciatic  nerve,  and  are  grouped  under  the  designation  of  sciatica.  The 
pain  occupies  especially  the  course  of  the  nerve,  but  tender  foci  are 
met  with  in  certain  spots ; — lumbar,  near  the  spine,  just  above  the 
sacrum;  sacro-iliac,  at  the  articulation  of  the  same  name;  a  gluteal, 
opposite  the  middle  of  the  lower  border  of  the  gluteus  ;  a  series  of  spots, 


812  NEURALGIA. 

varying  in  exact  position,  along  the  course  of  the  nerve  in  the  posterior 
region  of  the  thigh ;  a  peroneal  behind  the  head  of  the  fibula ;  a  malleolar 
behind  the  lower  extremity  of  the  fibula,  and  an  external  plantar  at 
the  outer  border  of  the  foot.  It  is,  however,  certain  that  sciatica  is 
seldom  a  true  neuralgia.  Almost  all  severe  cases  are  due  to  inflam- 
mation of  the  nerve-trunk ;  the  evidence  of  this  has  been  stated  in  the 
account  of  the  disease  in  the  first  volume. 

Lastly,  it  should  be  mentioned  that,  in  rare  cases,  neuralgic 
pains  are  felt  almost  everywhere,  in  the  limbs,  trunk,  and  head,  and 
apparently  constitute  a  sort  of  universal  neuralgia.  The  few  cases 
I  have  seen  have  been  in  adult  men,  and  associated  with  hypochon- 
driasis. 

Varieties  depending  on  Character  and  Cause. — Epileptiform  Neu- 
ralgia.— The  term  is  applied  (according  to  the  example  of  Trousseau) 
to  an  intractable  form,  in  which  each  attack  of  pain  comes  on  very 
suddenly,  with  intense  severity,  and  lasts  usually  less  than  a  minute, 
sometimes  only  a  few  seconds,  rarely  two  or  three  minutes.  The 
frequency  with  which  the  attacks  recur  varies  in  different  cases ;  the 
daily  number  may  be  one,  a  hundred  or  more.  The  paiu  is  most  in- 
tense, so  that  the  patient  stamps  about  the  room  in  agony,  or  tries  to  get 
relief  by  violent  rubbing  or  by  pressure.  Trousseau  relates  the  case 
of  a  lady  whose  malar  bone  was  atrophied  in  consequence  of  the  pres- 
sure, repeated  every  few  minutes  for  years.  The  sufferers  from  this 
terrible  form  are  usually  iu  the  second  half  of  life.  The  pain  is 
invariably  in  the  region  of  the  fifth  nerve,  sometimes  in  the  whole, 
sometimes  in.  part  only,  but  rarely  confined  to  a  single  branch. 
Convulsive  spasm  in  the  face  may  accompany  the  paiu  (convulsive 
•epileptiform  neuralgia) . 

Meflex  or  sympathetic  neuralgias  are  those  in  which  the  pain  is  felt  in 
another  nerve-region  than  that  in  which  its  cause  exists.  To  radi- 
ation of  neuralgic  pain  must,  as  already  stated,  be  ascribed  to  the 
extension  of  the  central  discharge  to  adjacent  centres,  but  the  term 
"  reflex  neuralgia"  is  not  applied  to  such  cases,  but  to  those  either  in 
which  the  pain  exists  only  at  a  distance  from  its  cause,  or  in  which 
the  distant  neuralgia  has  no  sensory  continuity  with  the  primary  pain. 
The  pain  of  a  carious  tooth  may  be  associated  with  a  distant  and 
apparently  disconnected  pain  in  some  other  part  of  the  fifth  nerve,  or 
such  disease  may  cause  only  distant  neuralgia,  and  no  local  pain.  The 
proneness  of  the  fifth  nerve  to  be  affected  in  neuralgia  renders  it  a 
common  seat  of  the  reflex  form.  Tor  instance,  neuralgia  limited  to 
the  fifth  has  been  produced  by  injury  to  the  ulnar  nerve,  and  also  to  the 
occipital  nerve  (Anstie).  Nevertheless,  the  converse  relation  is  some- 
times observed ;  carious  teeth  are  said  occasionally  to  cause  neuralgia 
in  other  parts,  as,  for  instance,  in  the  cervico-brachial  region  (Salter). 
When  no  local  pain  is  felt,  we  must  assume  that  the  centre  to 
•which  the  afferent  impressions  directly  come,  is  not  thus  excitable  to 


VARIETIES  DEPENDING    ON    CHARACTER.  81$ 

painful  activity,  or  even  so  as  to  influence  consciousness,  but  that  it- 
is  in  connection  "with  another  centre,  which,  by  natural  or  acquired 
susceptibility,  is  disposed  to  excessive  action.  Curious  cases  are  on 
record  in  which  the  act  of  micturition  invariably  caused  a  pain  in  the 
region  of  the  arm  supplied  by  the  ulnar  nerve.* 

The  cause  and  seat  of  reflex  neuralgia  may  be  most  varied.  When 
due  to  causes  acting  on  the  cerebro-spinal  nerves,  the  pain  is  usually 
felt  on  the  same  side,  and  rarely  far  distant.  A  most  important  class 
of  reflex  pains  are  those  which  are  produced  by  disease  of  the  internal 
viscera,  such  as  the  spinal  pain  in  ulcer  of  the  stomach,  the  sacral  pain 
in  uterine  disease,  the  scapular  pain  in  affections  of  the  liver,  the  pain 
in  the  testicle  in  renal  colic,  and  pain  in  the  front  of  the  thigh  and 
spine  in  gonorrhoeal  orchitis  (Mauriac).  Many  of  these  are  rather 
reflected  pain  than  neuralgia  properly  so  called,  but  they  occasionally 
persist  when  their  cause  is  removed,  or  assume  disproportionate  inten- 
sity. They  are  of  very  great  practical  importance  on  account  of  the 
readiness  with  which  their  cause  may  escape  attention. 

Traumatic  neuralgias  are  those  that  are  excited  by  injury  to  nerves 
— by  contusion,  and  by  punctured,  lacerated,  or  incised  wounds.  In 
some  instances  the  pain  is  the  result  of  a  neuritis,  set  up  by  the  injury, 
which  may  ascend  the  nerves  and  pass,  at  a  junction,  to  other  trunks. 
But  neuralgia  may  also  be  set  up  when  there  is  no  more  than  the  local 
and  transient  inflammation  at  the  spot  injured.  Such  neuralgias  may 
follow  nerve-lesions  in  any  part  of  the  body,  but  are  especially  frequent 
in  the  arm,  the  nerves  of  which  are  much  exposed  to  injury.  In  the  days 
of  venesection,  a  common  form  of  neuralgia  resulted  from  injury  to  a 
cutaneous  nerve  in  the  operation.  It  may  follow  wounds  of  both  large 
and  small  nerves,  and  by  some  observers  has  been  thought  to  be  more 
frequently  due  to  the  latter,  but  it  must  be  remembered  that  small 
nerves  are  more  often  wounded  than  larger  trunks.  Anstie  believes 
that  neuralgia  is  more  common  from  partial  injuries  than  when  the 
nerves  are  completely  divided.  It  is  a  frequent  consequence  of  gun- 
shot injuries  of  nerves.  In  some  cases  the  disease  is  apparently  due  to- 
the  imphcation  of  nerves  in  a  cicatrix,  and  the  morbid  enlargement  of 
the  nerve-ends  after  amputation,  which  goes  by  the  name  of  "  bulbous 
nerves  "  and  may  cause  much  suffering. 

The  pain  may  commence  a  few  hours  or  days  after  the  injury,  but 
more  frequently  not  until  after  an  interval  of  some  weeks  or  months. 
It  generally  begins  in  the  point  injured,  but  is  rarely  limited  to  this,  or 
even  to  the  part  supplied  by  the  wounded  branch.  It  usually  radiates 
to  adjacent  regions,  and  sometimes  to  parts  supplied  by  other  nerve- 
trunks.  For  instance,  a  woman  received  a  blow  on  the  thorax, 
probably  contusing  an  intercostal  nerve.     The  early  pain  of  the  injury 

*  Several  such  cases  are  given  by  Vanlair  (*  Les  Nevralgies,'  p.  330) ;  one  of 
them  comes  from  a  curious  source, — the  autobiography  of  Clarendon,  Chancellor  to 
Charles  II.     See  note  on  p.  799. 


814  NEURALGIA. 

ceased,  but  two  months  later,  neuralgic  pains  commenced  at  the  spot, 
and  gradually  spread  over  the  whole  region  supplied  by  the  cervical 
and  brachial  plexus  (Ollivier).  The  pain  may  be  less  intense  at  the 
seat  of  the  injury  than  it  is  elsewhere,  and  it  may  even  be  absent 
at  the  former,  and  then  is  of  the  purely  reflex  variety,  instances 
of  which  have  been  already  mentioned.  These  facts,  and  also  the 
circumstance  that  the  paiu  is  not  always  influenced  by  excision  of  the 
injured  nerve,  show  clearly  that  it  is  to  a  large  extent  of  central  origin, 
the  expression  of  a  disturbance  which,  though  excited  by  the  nerve 
injury,  is  to  a  considerable  extent  independent  of  it,  and  doubtless 
due,  not  only  to  the  excitaut,  but  also  to  a  predisposition,  such  as  is 
concerned  in  the  production  of  other  neuralgias.  The  same  fact  is 
seen  even  more  clearly  in  cases  in  which  some  injury  leaves  a  slight 
local  weakness  or  disability,  and,  years  afterwards,  the  part  may  become 
the  seat  of  neuralgic  pain,  under  the  influence  of  a  constitutional 
tendency. 

The  pain  is  usually  intermitting  in  charactei',  but  often  most  intense 
in  degree,  and  causes  profound  depression  of  the  general  system.  It 
may  excite  muscular  spasm,  and  also,  especially  soon  after  the 
injury,  other  reflex  symptoms  such  as  vomiting.  Yaso-motor  dis- 
turbance occasionally  ensues  ;  trophic  changes  in  the  skin  and  joints 
have  been  described,  but  it  is  very  doubtful  whether  nutrition  suffers 
except  in  consequence  of  considerable  secondary  neuritis.  These 
lesions  are  considered  more  fully  in  the  chapter  on  neuritis  in  the 
first  volume.  The  course  of  traumatic  neuralgia  is  often  tedious,  some- 
times most  prolonged,  and  it  has  been  known  to  last  to  the  end  of 
life,  in  spite  of  every  medical  and  surgical  measure  that  could  be 
devised  for  its  relief.  When  it  ceases,  it  is  prone  to  recur  under  the 
influence  of  general  depressing  influences. 

Occupation-Neuralgias. — These  are  pains,  more  or  less  neuralgic  in 
character,  brought  on  by  some  habitual  act.  They  are  the  sensory 
forms  of  occupation- neurosis,  in  the  account  of  which  they  have  been 
fully  described. 

Herpetic  Neuralgia. — Herpes  zoster,  whatever  its  seat,  is  usually 
accompanied  by  pain  of  a  neuralgic  character.  The  explanation  of 
this  is  found  in  the  conclusive  evidence  that  the  eruption  is  the  effect 
of  nerve  irritation,  probably  always  inflammatory  in  character.  It 
corresponds  in  area  to  the  distribution  of  certain  nerves,  and, 
post  mortem,  inflammation  has  been  found  in  the  nerve  (Haight)  and 
-  in  the  ganglia  of  the  posterior  roots  (Barensprung,  Charcot,  &c). 
The  neuralgic  pain  is  thus  "  symptomatic,"  the  result  of  organic 
change  in  the  nerves.  Sometimes  herpes  occurs  in  the  area  of  a 
nerve  which  has  long  been  the  seat  of  neuralgic  pain,  and  hence  is 
regarded  as  an  occasional  trophic  effect  of  neuralgia,  but  it  is  au 
extremely  rare  consequence,  and  probably  only  occurs  in  cases  in 
which  the  pain  is  the  expression  of  organic  changes,  and  is  not  a 
consequence  of  simple  idiopathic  neuralgia. 


VARIETIES    DEPENDING    ON    CHARACTER.  815 

In  cases  of  ordinary  zoster,  pain  may  occur  before  or  after  the 
eruption.  The  initial  pain  precedes  the  appearance  of  the  eruption 
for  a  few  hours  or  days,  is  usually  moderate  in  severity,  and  com- 
monly (but  not  always)  subsides  as  the  cutaneous  lesion  is  developed. 
Sometimes  this  pre-herpetic  pain  is  absent,  especially  in  the  young, 
although  even  then  there  is  usually  an  initial  sensation  of  tingling  in 
the  part.  The  pain  that  succeeds  herpes  is  more  constant.  It  comes 
•on  usually  during  the  decline  of  the  eruption,  and  its  occurrence 
bears  no  relation  to  the  seat  of  the  herpes.  The  sequel  is  most 
frequent  where  herpes  is  most  common, — the  side  of  the  trunk, 
the  forehead,  neck,  and  leg.  The  pain  has  the  distribution  of 
the  eruption,  corresponding  to  the  nerve  or  nerves  affected.  It 
varies  in  degree,  but  is  usually  acute,  lancinating,  and  for  a  time 
severe,  and  is  accompanied  by  great  tenderness  of  the  skin.  The  same 
tender  points  are  met  with  as  in  ordinary  neuralgia  in  the  same 
area.  There  is  an  important  relation  between  the  age  of  the  patient 
and  the  severity  and  duration  of  the  pain.  In  old  persons  it  con- 
stitutes one  of  the  most  severe  and  persistent  forms  of  nerve  pain, 
often  continuing  for  months,  and  even  for  years,  before,  at  last,  it 
slowly  lessens.  Occasionally  it  persists  in  unmitigated  intensity  to  the 
end  of  life.  Sir  William  Jenner,  in  his  lectures,  was  accustomed  to 
illustrate  the  obstinate  persistence  of  this  pain  in  the  old,  by  the 
instance  of  a  man  who,  before  the  days  of  anaesthetics,  endured  the 
excision  of  the  skin  to  which  the  pain  was  referred,  in  the  hope  of 
relief,  but  found  none,  and  then,  unable  to  bear  the  continuous  agony, 
he  shot  himself. 

Hysterical  Neuralgias. — Neuralgic  pains  are  common  in  hysteria, 
but  a  distinction  must  be  drawn  between  those  which  are  merely 
associated  with,  and  those  which  are  due  to,  the  general  neurosis. 
Of  associated  forms,  every  variety  of  true  neuralgia  may  be  met  with, 
due  to  the  neuropathic  disposition,  which  is  also  the  cause  of  the 
hysteria,  and  they  present  the  characteristic  distribution,  tender 
points,  &c,  of  the  ordinary  form.  Anaemic  neuralgias  are  also 
common  in  hysterical  patients,  in  whom  the  nerve  disturbance  is  often 
due  to  poorness  of  blood.  Of  the  neuralgic  pains  that  are  due  to 
hysteria,  some  are  in  the  cerebro-spinal  system,  some  in  that  of  the 
sympathetic.  Certain  local  pains  in  the  head  are  very  common,  but 
these  differ  from  ordinary  neuralgia  in  being  confined  to  one  small 
spot,  instead  of  following  the  course  of  nerves,  and  the  local  pain  has 
a  sharp  stabbing  or  boring  character,  as  if  a  nail  were  being  driven  in, 
and  hence  has  received  the  name  of  "clavus  hystericus."  It  is 
important  to  remember  that  a  similar  pain  may  be  met  with  apart 
from  hysteria,  especially  in  anaemic  persons.  Pains  in  the  spine  are 
also  extremely  common,  sometimes  very  local,  and  of  various  charac- 
ters. Other  pains  referred  to  the  trunk  are  usually  associated  with 
local  tenderness  in  the  so-called  "  hysterogenic  points."  The  most 
important  neuralgias  of  hysteria  are  those  of  the  viscera,  ovarialgia 


816  NEURALGIA. 

(not  necessarily  in  the  ovary  itself)  and  gastralgia  being  the  most 
frequent.  Pains  in  the  joints  and  muscles  are  also  common.  The 
visceral  neuralgias,  and  those  associated  with  parietal  tenderness,  are 
usually  persistent,  but  the  local  boring  pains,  and  those  in  the  joints 
and  muscles,  are  often  fugacious  and  migratory,  and  this  constitutes 
a  diagnostic  point  of  considerable  importance. 

Rheumatic  Neuralgia. — In  a  loose  way,  all  neuralgias  produced  by 
cold  are  sometimes  styled  "rheumatic,"  but  the  mere  causal  relation 
scarcely  warrants  the  epithet.  The  peculiar  affection  termed  "  mus- 
cular rheumatism"  is  also  sometimes  called  a  rheumatic  neuralgia, 
but  this  is  to  extend  the  use  of  the  term  in  a  manner  that  is  scarcely 
justified  or  needed.  Pain  that  occurs  only  on  movement  should 
never  be  called  neuralgia.  Acute  articular  rheumatism  is  rarely 
associated  with  true  neuralgia,  but  some  forms  of  spontaneous  pain 
are  frequently  produced  by  cold  in  those  who  present  what  is  termed 
the  "  rheumatic  diathesis,"  who  perspire  easily,  are  liable  to  catarrh, 
and  whose  urine  readily  becomes  loaded  with  lithates  after  a  chill. 
Such  pains  may  correspond  to  a  certain  nerve,  or  may  occupy  some 
part  of  a  limb,  without  any  definite  relation  to  nerves,  sometimes  with 
a  definite  relation  to  the  muscles  or  fibrous  tracts,  and  are  often 
migratory.  Their  exact  pathology  is  uncertain.  Some  other  facts 
regarding  this  variety  have  been  mentioned  on  p.  796. 

Gouty  Neuralgia. — The  subjects  of  gout  not  nnfrequently  suffer 
from  nerve-pains,  apparently  idiopathic  in  character,  coming  and 
going,  and  sometimes  very  severe.  The  pain  may  disappear  when  an 
attack  of  acute  gout  is  developed.  The  fifth,  the  intercostal,  and  the 
sciatic  nerves  are  those  most  frequently  affected.  Severe  sciatica 
sometimes  occurs  in  the  gouty,  but  is  certainly  due  to  neuritis.  One 
visceral  neuralgia  is  also  sometimes  due  to  gout,  gastralgia. 

Diabetic  Neuralgia. — Patients  with  diabetes  may  suffer  from  neu- 
ralgic pains  that  have  no  special  characters,  but  Worms  has  called 
attention  to  the  symmetry  of  the  pains,  which  occupy  the  same  nerve- 
on  both  sides,  as  a  characteristic  of  diabetic  neuralgia.  The  pain  has 
hitherto  been  observed  chiefly  in  the  third  division  of  the  fifth  nerves 
and  the  sciatics.  It  must  be  remembered,  however,  that  ordinary 
neuralgia  is  occasionally  symmetrical.  The  nerve-pains  met  with  in 
diabetes  are  often  severe  and  obstinate  until  the  cause  is  removed  by 
dietetic  treatment.  They  have  been  observed  to  increase  and  decrease 
with  the  amount  of  sugar  in  the  urine.  They  are  sometimes  the 
result  of  a  peripheral  neuritis. 

Ansemic  Neuralgia. — Anaemia  is  one  of  the  most  powerful  causes 
of  neuralgia  in  all  its  forms,  but  certain  varieties  are  more  frequent 
than  others  in  this  condition,  especially  in  young  women.  One  of 
these  is  situated  in  the  fifth  nerve,  either  in  the  first  division  or  in 
the  auriculo-temporal  branch.  It  is  generally  intermittent  and  is 
increased  by  movement,  while  it  is  lessened  by  the  recumbent  posture. 
Another,  still  more  frequent  and  more  continuous,  is  that  which  is 


VARIETIES    DEPENDING    ON    CHARACTER.  817 

felt  in  the  thorax,  in  the  fifth  and  sixth  interspaces  on  the  left  side, 
the  well-known  infra-mammary  pain.  Gastralgia  is  also  common  apart 
from  ulcer.  Headaches  that  have  no  true  neuralgic  character  are  also 
very  common. 

Neuralgia  of  the  cerebro-spinal  nerves  sometimes  occurs  in  lead- 
poisoning,  but  it  is  often  uncertain  whether  the  pain  is  the  expression 
of  functional  disturbance  or  is  due  to  neuritis.  The  knowledge  of 
this  cause,  however,  is  very  important.  It  has  been  thought  that  lead- 
colic  is  in  part  a  neuralgia  ;  the  evidence  of  this  is  insufficient,  but 
there  may  be  severe  epigastric  pain. 

Malarial  neuralgias  are  not  very  common  even  where  ague  is  fre- 
quent. They  present  nothing  charactei-istic  in  seat,  although  the 
supra-orbital  and  intercostal  forms  are  the  most  frequent ;  nor  is  there 
anything  special  in  the  character  of  the  pain.  Their  chief  feature  is 
regular  periodicity,  the  intervals  between  the  attacks  being  from  one 
to  four  days.  The  periodicity  is  less  characteristic  when  the  attacks 
are  diurnal  than  when  three  or  four  days  intervene.  Occasionally  the 
paroxysms  are  attended  with  slight  symptoms  of  an  ague  fit,  a  trifling 
cold  and  hot  stage  (Anstie) .  These  must  not  be  confounded  with  the 
vaso-motor  phenomena  met  with  in  cases  of  the  ordinary  form.  It  is 
very  doubtful  whether  the  neuralgia  is,  in  most  cases,  a  direct  effect  of 
the  malarial  poison,  in  the  sense  in  which  ague  is.  It  is  probably  an 
indirect  effect,  the  result  of  the  anaemic  and  depressed  state  of  the 
nervous  system  induced  by  malarial  influences,  even  in  those  who  do 
not  suffer  from  intermittent  fever.  Neuralgia,  apparently  due  to 
malarial  causes,  does  not  always  yield  to  quinine,  even  when  given  in 
the  most  approved  manner.  It  is  probable  also  that  the  periodicity 
of  many  malarial  neuralgias  is  the  result  of  the  state  of  the  nervous 
system  produced  by  the  poison,  and  it  does  not  prove  the  neuralgia 
to  be  truly  malarial.  In  some  cases  of  supra-orbital  neuralgia 
with  exact  periodicity,  coming  from  malarial  districts  (recorded  by 
Seeligmiiller),  quinine  failed  entirely  while  other  treatment  was 
quickly  successful. 

Syphilitic  Neuralgia. — The  pains  of  syphilis  constitute  a  prominent 
symptom  of  that  disease,  but,  for  the  most  part,  have  no  correspond- 
ence with  nerve  distribution,  and  can  therefore  be  scarcely  regarded 
as  neuralgic.  Symptomatic  neuralgic  pain  occurs  in  many  syphi- 
litic affections  of  the  nervous  system  which  cause  irritation  of  the 
nerves  or  their  roots,  in  chronic  meningitis,  neuritis,  and  pressure 
from  growths.  One  of  the  most  severe  and  obstinate  cases  of  pain  in 
the  region  of  the  fifth  nerve  I  have  seen,  was  due  to  chronic  syphilitic 
meningitis  at  the  origin  of  the  nerve.  In  such  cases  the  nature  of  the 
lesion  is  usually  clear  from  the  evidence  of  structural  damage  to  the 
nerve-fibres.  In  the  case  just  mentioned,  for  instance,  there  was 
anaesthesia  and  paralysis  of  the  masseter.  Whether  idiopathic  neu- 
ralgia results  from  the  influence  of  the  syphilitic  poison  is  uncertain. 
Fournier  believes  that  such  neuralgia  is  common  during  the  secondary 

vol.   ii.  52 


818  NEURALGIA. 

stage,  but  very  few  conclusive  cases  have  been  recorded.  It  must  be 
remembered  that  in  the  early  stage  of  neuritis,  &c,  pain  may  be  the 
only  symptom,  and,  on  the  other  hand,  the  anaemia  which  results  from 
syphilis  may  be  the  real  cause  of  the  neuralgia.  Anstie  believed  that 
syphilis  does  not  cause  true  neuralgia  although  it  may  recall  a 
neuralgia  which  had  long  ceased.  A  peculiarly  distressing  post-sternal 
pain,  apparently  neuralgic  in  character,  has  been  occasionally 
observed  in  constitutional  syphilis  (Eccheverria,  Buzzard). 

Degenerative  Neuralgia. — In  advanced  life,  and  sometimes  before 
the  senile  period  is  reached,  neuralgia  is  occasionally  met  with,  of 
extreme  obstinacy,  and  associated  with  other  signs  of  degeneration  of 
the  central  nervous  system,  such  as  failure  of  memory  or  persistent 
mental  depression.  The  neuralgia  is  apparently  one  effect  of  the  de- 
generative tendency.  The  affection  has  all  the  characters  of  a  central 
neuralgia.  The  fifth  nerve  is  by  far  the  most  common  seat,  but  the 
pain  sometimes  occurs  in  other  situations. 

Diagnosis. — The  diagnosis  of  neuralgia  rests  on  the  unilateral  situa- 
tion of  the  pain,  on  its  correspondence  to  the  distribution  of  certain 
nerves,  its  intermitting  or  remitting  character  (i.  e.  the  occurrence  of 
paroxysmal  exacerbations),  on  the  fact  that  the  patient  has  suffered 
from  similar  pains  elsewhere,  on  the  variations  in  the  seat  of  the 
pain,  and  on  the  absence  of  any  indications  of  actual  damage  to 
the  nerve-fibres.  The  variability  is  a  symptom  of  great  importance. 
If  the  pain  shifts  about,  now  in  one  spot  and  now  in  another,  it  is 
not  likely  to  be  due  to  an  organic  cause.  For  instance,  a  man  with 
fronto-occipital  neuralgia  had  foci  of  pain  in  the  forehead,  temple, 
and  occiput,  but  he  never  had  pain  at  the  same  time  at  more  than, 
one  of  these  places.  The  last  of  the  above  indications,  however,  is 
the  most  important  element  in  the  distinction  of  neuralgia  from  the 
similar  pains  which  result  from  organic  disease  of  the  nerves  due  to 
external  pressure  or  neuritis.  It  is  in  the  case  of  the  fixed  neuralgias 
(as  distinguished  from  the  migratory  forms)  that  the  distinction  is  of 
chief  importance.  The  diagnosis  is  more  difficult  in  the  case  of  neuritis 
than  of  external  pressure  (tumour,  &c),  because,  in  the  latter  case,  the 
cause  of  the  pressure  usually  produces  other  symptoms,  an"d  the  effect 
of  the  pressure  is  progressive,  so  that  gradually  increasing  signs  of 
a  structural  lesion  are  added  to  the  pain.  But  from  neuritis  the 
distinction  may  be  much  less  easy.  The  difficulty  is  greater,  the 
slighter  the  degree  of  neuritis.  Severe  inflammation  causes  severe, 
constant  pain,  at  first  more  intense  at  its  seat  than  in  the  distribution 
of  the  nerve,  because  the  inflammation  is  most  intense  in  the  nerve- 
sheath,  and  the  sheath-nerves  suffer  first.  In  severe  forms,  however, 
the  proper  fibres  of  the  nerve  are  soon  implicated  to  a  degree  that 
interferes  with  their  conducting  functions,  so  as  to  cause,  first, 
hyperaesthesia,  and  afterwards  areas  of  anaesthesia,  while  if  the  nerve 
is  "  mixed,"  the  muscles  supplied  become  weak,  flabby,  and  rapidly 


DIAGNOSIS.  819 

waste,  with  changes  in  electrical  irritability.  In  slight  cases,  on  the 
other  hand,  the  sheath  chiefly  suffers  ;  there  may  be  no  interference 
with  conduction,  and  the  pain  resembles  neuralgia  more  closely, 
although,  as  a  rule,  it  is  more  continuous  than  in  true  neuralgia.  The 
diagnosis  is  also  difficult  when  the  seat  of  the  neuritis  is  such  as  to 
render  the  nerve  inaccessible  to  direct  examination.  If  it  can  be 
reached,  there  will  be  found,  from  the  first,  local  tenderness  of  the 
nerve.  In  idiopathic  neuralgia,  tenderness  of  the  trunk  in  the  intervals 
is  only  developed  after  the  neuralgia  has  existed  for  some  weeks. 
Moreover,  in  neuritis,  distinct  swelling  of  the  nerve  can  sometimes  be 
felt.  Local  tenderness  is  thus  chiefly  of  significance  in  the  early  stage  of 
the  affection,  or  when  it  occupies  a  considerable  area  of  the  nerve- 
trunk,  and  is  not  confined  to  certain  points. 

If,  therefore,  the  pain  is  migratory,  if  it  is  completely  intermittent, 
especially  if  the  intermissions  are  of  long  duration,  if  the  attacks  are 
induced  by  psychical  influences,  the  suspicion  of  an  organic  cause  will 
scarcely  arise.  If,  on  the  other  hand,  there  is  continuous  pain,  rapidly 
developing  to  a  considerable  degree,  organic  disease  should  be  sus- 
pected, and  the  suspicion  will  be  confirmed  if  there  is  evidence  of 
early  or  considerable  impairment  of  the  conducting  function  of  the 
fibres,  persistent  alteration  of  sensibility,  muscular  wasting  or  altered 
irritability,  or  trophic  changes  in  the  skin.  Great  care  is  necessary, 
however,  in  testing  the  muscles,  because  a  strong  electrical  stimulus 
may  greatly  increase  the  pain.  The  isolated  faradic  shocks  should  be 
employed  rather  than  the  current,  because  they  cause  much  less  pain, 
and  because  they  detect  most  readily  the  earliest  change  produced  by 
neuritis,  a  slight  increase  of  irritability ;  an  altered  reaction  to  voltaism 
will  also  often  be  found.  Early  tenderness  of  the  nerve,  not  merely 
during,  but  between  the  paroxysms,  indicates  neuritis,  but  its  absence 
does  not  exclude  inflammation,  which  may  occupy  an  inaccessible  por- 
tion of  the  nerve.  If  the  symptoms  of  structural  damage  gradually 
increase  and  progress,  and  especially  if  they  involve  the  whole  region 
of  the  distribution  of  the  nerve,  compression  may  be  suspected,  and 
is  confirmed  by  the  discovery  of  any  other  symptoms  indicating 
organic  disease  in  the  vicinity  of  the  nerve-trunk,  such  as,  in  the  case 
of  the  fifth,  damage  to  other  nerves  which  arise  or  pass  near  it.  It 
must  be  remembered  that  in  some  cases  the  differential  diagnosis  of 
slight  inaccessible  neuritis  from  neuralgia  may  be  very  difficult,  because, 
on  the  one  hand,  the  irritation  of  neuritis  may  cause  neuralgic  changes 
in  the  nerve-centre,  and,  on  the  other,  a  primary  functional  neuralgia 
may  cause,  by  reflex  vaso-motor  disturbance,  secondary  changes  in  the 
sheath,  so  that  in  each  case  a  mixed  affection,  partly  functional,  partly 
organic,  is  the  result ;  or,  in  current  terms,  a  neuralgia  which  is  at  first 
either  symptomatic  or  idiopathic  may  ultimately  be  both.  At  the 
same  time,  the  diseases  are  often  confounded  through  simple  ignorance 
or  misconception.  The  latter  cause,  as  we  have  seen,  often  leads 
sciatic  neuritis  to  be  regarded  as  neuralgia ;  and  the  former,  with 


820  NEURALGIA. 

remarkable  constancy,  causes  brachial  neuritis,  severe  and  character- 
istic, to  be  thought  a  mere  neuralgia. 

In  all  forms  the  circumstance  that  the  patient  has  previously  had 
attacks  of  neuralgia  in  other  situations  is  a  very  important  help  in 
diagnosis.  It  does  not,  of  course,  prove  that  a  given  pain  is  of  func- 
tional origin,  but  it  is  proof  of  a  tendency  to  such  pain,  which  may 
justly  be  allowed  considerable  weight  in  the  absence  of  signs  of 
an  organic  lesion.  This  character  is  frequently  of  very  great  prac- 
tical value,  especially  in  cases  of  neuralgic  pain  of  unusual  seat. 
Another  similar  indication  is  furnished  when  the  neuralgia  replaces 
some  other  functional  affection,  as,  for  instance,  migraine  or  melan- 
cholia. 

Special  Diagnosis. — There  are  certain  affections  with  which  the 
several  varieties  of  neuralgia  are  liable  to  be  confounded.  Almost 
any  form  of  neuralgia  may  be  simulated  by  the  pains  of  tabes, 
and  the  possibility  of  this  cause  should  always  be  thought  of, 
especially  in  the  case  of  migratory  pain.  In  some  situations  the 
risk  of  error  is  greater  than  in  others,  and  these  will  be  especially 
mentioned. 

In  neuralgia  of  the  nerves  which  are  distributed  over  the  skull  (fifth 
and  great  occipital)  it  is  often  doubtful  whether  the  affection  should 
be  called  headache  or  neuralgia.  The  former  may  be  local,  e.g.  at  one 
temple,  as  in  migraine.  The  chief  distinction  is  the  correspondence 
to  the  course  of  the  nerves,  or  to  an  entire  nerve-region,  in  neuralgia, 
which  is  absent  in  headache.  But  true  neuralgia  may  induce  a  diffuse 
head-pain  which  may  be  called  "  neuralgic  headache."  The  fifth 
nerve  is  often  damaged  by  organic  intra-cranial  disease,  and  nerve- 
pain,  thus  produced,  is  sometimes  mistaken  for  simple  neui-algia. 
Besides  the  indications  already  described,  organic  disease  often  causes 
deeply  seated  headache  and  various  symptoms,  especially  in  the  func- 
tions of  other  nerves,  optic  neuritis,  and  paralysis  or  convulsion  in  the 
limbs.  The  occurrence  of  herpes  in  the  course  of  a  supposed 
neuralgia  is  also  evidence  of  organic  change  in  the  nerve.  It  must 
not  be  forgotten  that  neuralgic  pains  are  sometimes  the  first  symptom 
of  morbid  growths  in  the  upper  jaw  and  parotid  region. 

The  diagnosis  of  the  cervico-occipital  form  rarely  presents  any 
difficulty.  The  neuralgic  pain  usually  courses  along  the  nerve-trunks, 
but  it  must  be  remembered  that  occipital  neuralgia  is  occasionally 
bilateral.  In  caries  of  the  cervical  vertebrae,  pain  may  be  an  early 
symptom,  but  it  scarcely  ever  spreads  to  the  occiput,  and  the  early 
interference  with  movement  is  usually  characteristic. 

The  neuralgias  of  the  arm  have  to  be  distinguished  chiefly  from 
neuritis  by  the  indications  already  mentioned.  The  diagnosis  is 
seldom  difficult,  because  neuritis  usually  causes  early  tenderness  in 
the  affected  nerve-trunks,  and,  later,  trophic  changes  in  the  muscles 
and  skin. 

A  more  difficult  problem  is  presented  by  the  trunk  neuralgias,. 


DIAGNOSIS.  821 

which  have  to  he  distinguished  from  disease  of  the  internal  viscera, 
and  from  organic  spinal  disease.  Unilateral  pain  is  a  frequent 
accompaniment  of  disease  of  the  organs  in  the  thorax  and  abdomen, 
and  it  is  hardly  necessary  to  point  out  that,  in  every  case,  a  careful 
examination  should  be  made  of  the  organs  adjacent  to  the  seat  of 
pain.  The  greatest  difficulty  arises  in  the  case  of  deeply  seated 
tumours  which  cause  pain  by  nerve-compression,  especially  when,  as  is 
sometimes  the  case,  the  pains  are  "  reflected,"  and  do  not  precisely 
correspond  in  position  to  their  cause.  Aneurism  of  the  aorta,  for 
example,  often  gives  rise  to  such  pain,  especially  when  seated  in  the 
descending  part ;  pain  in  the  course  of  the  nerves  may  be  the  only 
symptom  until  sudden  death  occurs.  The  pain  is  usually  very 
severe,  and  often  burning  in  character,  and  has  not  the  same  foci 
of  intensity  and  tender  points  as  ordinary  neuralgia.  In  severe 
unilateral  (and  even  bilateral)  pain,  persistent  in  occurrence,  whether 
uniform  in  seat  or  not,  this  cause  should  always  be  suspected.  One 
of  the  most  severe  cases  of  neuralgic  pain  I  have  ever  seen — darting, 
stabbing,  burning,  migratory  pains  in  legs,  abdomen,  thorax,  and  left 
arm — was  due  to  an  undiscovered  abdominal  aneurism.  Aneurism  of 
the  ascending  part  of  the  arch  is  now  and  then  accompanied  by  pain 
passing  to  the  arm,  apparently  of  reflex  character.  Intercosto-humeral 
neuralgia  may  simulate  angina  pectoris,  of  which,  indeed,  such 
neuralgia  may  be  said  to  form  part.  The  severity  of  the  paroxysms 
of  angina,  and  the  other  distressing  sensations  which  accompany  the 
pain,  usually  render  the  nature  of  the  attacks  sufficiently  clear. 

The  parietal  pains  which  accompany  disease  of  the  spinal  cord 
rarely  have  the  acute  lancinating  character  of  neuralgia :  they  are 
sensations  of  tightness  or  constriction,  and  the  obtrusive  symptoms  in 
the  legs  indicate  the  nature  of  the  disease.  To  this,  however,  morbid 
growths  in  the  membranes  offer  an  exception,  especially  in  the  early 
stage.  The  pains  may  be  very  severe  and  of  various  character,  but  they 
are  constant  in  seat,  are  increased  by  any  movement,  and,  before  long, 
indications  of  compression  of  the  cord  are  added  to  them.  The 
"  lightning  pains  "  of  tabes  are  sometimes  felt  in  the  trunk,  and  have 
often  been  mistaken  for  neuralgia.  They  are  distinguished  by  their 
changing  seat  and  momentary  duration,  by  the  similar  pains  in  the 
legs,  and  especially  by  diminished  sensibility  over  extensive  areas. 
In  most  cases  there  are  some  pains  in  the  legs  and  the  knee-jerk  is 
lost ;  I  have  seen  one  case  in  which  the  changes  were  confined  to 
the  dorsal  region  of  the  cord,  and  the  knee-jerk  was  normal ;  but  in 
this,  as  in  other  cases  of  the  kind,  the  light-reflex  of  the  iris  was  lost — 
a  symptom  of  great  indirect  diagnostic  importance.  More  constant 
in  seat  and  neuralgic  in  character  are  the  pains  of  pachymeningitis, 
which  are  caused  by  the  compression  of  the  nerve-roots  by  the 
thickened  membrane.  They  are  distinguished  from  neuralgia  by  the 
wide  extent  of  the  pains,  their  bilateral  situation,  by  the  presence  of 
areas  of  anaesthesia  due  to  still  greater  damage  to  the  nerves,  by 


822  NEURALGIA. 

muscular  wasting  in  the  limbs,  and  by  the  symptoms  of  compression 
of  the  cord. 

The  terrible  nerve-pain  which  is  sometimes  produced  by  organic 
disease  of  the  bone  of  the  spinal  column  closely  resembles  neuralgia 
in  its  fixity  of  site  and  unilateral  situation,  but  is  distinguished  by  its 
peculiar  dependence  on  movement  of  the  trunk  (see  vol.  i,  p.  257). 
Leg  symptoms  are  usually  soon  associated  with  it.  The  lumbo-abdo- 
minal  neuralgia  may  be  confounded  with  renal  colic.  The  distinction 
rests  chiefly  on  the  urinary  symptoms  that  accompany  the  latter. 

The  sharp  pains  of  tabes  are  more  frequently  felt  in  the  legs  than 
in  the  trunk,  and  there  also  are  often  mistaken  for  neuralgia,  but  the 
indications  already  mentioned  suffice  to  distinguish  them.  Occasion- 
ally such  pains  are  met  with  apart  from  other  symptoms  of  tabes,  and 
their  nature  is  difficult  to  determine.  If  they  are  the  sequel  of 
syphilis,  or  associated  with  loss  of  action  in  the  iris,  they  are  probably 
the  evidence  of  a  partial  tabetic  degeneration — a  tabetic  neuralgia. 
The  distinction  of  sciatic  neuralgia  from  neuritis  must  be  made  by  the 
indications  already  given  (see  also  "  Sciatica,"  vol.  i,  p.  106).  Of  still 
greater  practical  importance  is  the  distinction  of  crural  and  sciatic 
neuralgia  from  the  pains  due  to  pressure  on  the  lumbar  and  sacral 
plexus  by  tumours  in  the  pelvis  and  abdomen.  Such  pains  are  felt 
along  the'  course  of  the  nerves,  and  are  almost  invariably  thought  at 
first  to  be  neuralgic.  Pains  in  the  front  of  the  thigh  are  rare  except 
as  the  result  of  extension  of  neuritis  from  the  sciatic  nerve  to  the 
lumbar  plexus,  or  as  the  result  of  pressure.  In  each  case  there  is 
generally  muscular  wasting,  which  shows  organic  damage.  The  dia- 
gnosis between  neuralgia  in  the  front  of  the  thigh  and  pain  due  to  a 
lesion  of  the  nerves,  is  also  aided  by  the  state  of  the  knee-jerk,  which 
is  generally  early  lost  in  organic  disease,  but  remains  intact  in  neu- 
ralgia. In  every  case  of  neuralgic  pain  in  this  situation,  the  abdomen 
should  be  carefully  examined,  and  whenever  pain  in  the  sciatic  is  of  a 
progressive  character,  and  apparently  due  to  mischief  above  the 
accessible  part  of  the  nerve,  a  rectal  examination  should  be  made,  by 
which  the  source  of  pressure,  if  there  be  any,  will  often  be  felt.  It 
must  also  be  remembered  that  pain  felt  in  the  knee  may  be  a  reflex 
effect  of  the  irritation  of  the  branches  of  the  obturator  nerve  in  hip- 
joint  disease,  and  that  obscure  pains  in  the  groin  and  thighs  are 
sometimes  the  result  of  disease  of  the  femur.* 

The  diagnosis  of  the  special  forms  of  neuralgia  is  less  difficult.  In 
the  reflex  or  sympathetic  variety  the  cause  of  the  pain  will  usually  be 
discovered  if  it  is  remembered  that  it  may  be  outside  the  area  in 
which  pain  is  felt.  It  is  rarely  far  distant ;  often  in  another  branch 
of  the  same  nerve.  Pain  in  any  part  of  the  fifth  nerve,  for  instance, 
may  be  due  to  the  irritation  of  a  carious  tooth. 

It  is  possible  to  confound  epileptiform  neuralgia  with  the  form  of 

*  In  one  case  of  intense  stabbing  pains  in  the  groin,  closely  resembling  neuralgia, 
the  cause  was  ultimately  found  to  be  necrosis  of  the  great  trochanter. 


TREATMENT.  823 

true  epilepsy  in  which  the  aura  is  a  sudden  pain.  I  have  known,  for 
example,  slight  attacks  of  minor  epilepsy  to  be  preceded  by  a  most 
severe  momentary  pain  in  one  fifth  nerve.  The  occurrence  of  distinct 
loss  of  consciousness,  and  still  more  of  convulsion,  sufficiently  indicates 
the  epileptic  nature  of  the  case.  A  painful  epileptic  aura  in  a  limb, 
followed  by  local  convulsion,  could  only  be  mistaken  for  neuralgia 
with  reflex  spasm  in  a  patient  who  had  never  had  a  severe  fit.  But 
the  course  of  such  an  aura  is  usually  centripetal  and  deliberate,  and 
the  spasm  has  also  a  deliberate  march. 

Prognosis. — The  prognosis  in  neuralgia  is  influenced  by  the  age 
of  the  patient,  by  the  duration  of  the  affection,  its  situation,  severity, 
and  cause.  It  is  far  better  when  the  disease  is  due  to  any  consti- 
tutional condition  than  when  no  general  cause  can  be  discovered, 
since,  as  a  rule,  the  constitutional  states  that  cause  neuralgia  are 
amenable  to  treatment,  at  any  rate  in  such  a  degree  as  to  influence 
the  pain.  In  hysteria,  however,  some  neuralgias  are  readily  removed  ; 
others,  especially  when  there  is  no  anaemia,  are  most  obstinate.  The 
prognosis  is  better  when  there  is  no  hereditary  tendency  than  when 
this  is  marked.  "We  do  not  yet  know  whether  the  prognosis  is  influ- 
enced by  the  fact  that  the  heredity  is  general  or  special.  The  more 
severe  the  pain,  and  the  longer  the  disease  has  lasted,  the  more  diffi- 
cult is  its  treatment.  When  a  patient  has  suffered  from  neuralgia  in 
various  regions,  for  many  years,  the  ultimate  prognosis  is  less  favor- 
able. It  is  generally  believed  that  neuralgias  of  the  fifth  nerve  are 
more  intractable  than  others.  During  the  decline  of  life,  most 
varieties,  especially  those  of  the  degenerative  form,  are  peculiarly 
obstinate,  and  in  old  age  they  sometimes  cannot  be  relieved  by  any 
treatment  whatever.  However  severe  the  pain  may  be,  neuralgia 
involves  little  danger  to  life ;  as  Buzzard  has  well  said,  "  the  disease 
does  not  seem,  of  itself,  to  shorten  the  duration  of  the  life  which  it 
fills  with  suffering."  Epileptiform  neuralgia  is,  of  all  kinds,  the 
most  obstinate  ;  Trousseau,  in  his  large  experience,  never  knew  a  case 
to  be  cured.  When  neuralgia  has  once  ceased  it  is  extremely  prone 
to  recur ;  and  this  fact,  which  is  true  of  all  varieties,  must  be  remem- 
bered in  giving  an  opinion  regarding  the  future. 

Treatment. — The  treatment  of  neuralgia  consists,  first,  in  the 
relief  of  the  symptom,  pain  ;  and  secondly,  in  the  removal  of  its  cause, 
i.  e.  in  the  restoration  of  normal  conditions  of  function  in  the  sensory 
apparatus.  The  means  by  which  these  ends  are  to  be  secured  are 
threefold, — by  hygiene,  by  drugs,  given  internally  and  applied 
externally,  and  by  certain  surgical  operations  on  the  nerves.  It  is 
evident  that  the  treatment  to  be  adopted  must  be  influenced,  to  some 
extent,  by  the  nature  of  the  case.  When  there  is  distinct  evidence  of 
neuritis,  the  treatment  for  this,  already  described,  must  be  adopted. 


82A  JS^URALGIa. 

Tliat  which  has  now  to  Le  considered  is  the  treatment  of  the  "idio- 
pathic" form,  but  the  means  for  the  alleviation  of  all  varieties  is 
nearly  the  same. 

Although  the  relief  of  paiu  has  usually  to  be  the  first  actual  step  iu 
treatment,  the  first  in  importance  is  the  removal  of  the  causes  of  the 
disease.  Any  discoverable  condition  on  which  the  neuralgia  may 
depend  must  be  treated.  The  detailed  measures  that  are  necessary 
need  not  here  be  indicated,  since  they  are  sufficiently  suggested  by  the 
enumeration  of  the  causes  and  causal  varieties  already  given. 
Especially  should  any  source  of  nerve  irritation  be  removed,  whether 
in  the  region  of  the  painful  nerve  or  outside  it.  It  must  be  remem- 
bered, however,  that  it  is  not  certain  that  the  neuralgia  will  disappear 
on  the  removal  of  such  a  source  of  irritation.  This  is  often  true 
of  neuralgias  of  the  fifth  nerve  and  decayed  teeth.  The  almost 
universal  association  of  neuralgia  with  conditions  of  debility,  so 
strongly  insisted  on  by  the  late  Dr.  Anstie,  indicates  the  importance 
of  hygienic  measures  calculated  to  improve  the  general  health  ;  fresh 
air,  adequate  rest,  and  nutritious  food  in  full  quantity,  with  a  small 
quantity  of  alcohol  at  meals,  are  usually  directly  beneficial.  The  im- 
portance of  a  good  supply  of  animal  food  is  of  great  importance  for 
all  but  gouty  subjects.  I  have  known  severe  neuralgia  to  occur  first 
on  the  patient  commencing  a  purely  vegetable  diet,  to  disappear  when 
meat  was  taken,  and  recur  with  severity  at  each  of  four  successive 
attempts  to  return  to  vegetarianism.  Cod-liver  oil,  or  other  easily 
digested  fat,  may  often  be  added  with  advantage.  Iron,  when  there 
is  anaemia,  will  sometimes  alone  cure  the  disease,  and  even  when  there 
is  not  anaemia  it  seems  occasionally  to  be  beneficial.  Of  nervine 
tonics,  quiuine  is  of  most  value  in  true  malarial  forms,  given  in  a  full 
dose  shortly  before  a  periodical  attack  is  due ;  but,  as  we  have  seen, 
it  is  not  always  successful.  In  smaller  doses  it  is  occasionally  useful 
in  other  forms,  although  not  so  frequently  as  might  be  expected  from 
its  marked  influence  on  the  nervous  system.  In  stupefying  doses  it 
may  lessen  the  pain  for  a  time,  but  does  not  often  produce  a  lasting 
effect.  It  has  been  thought  to  be  most  useful  in  neuralgias  of  the 
first  division  of  the  fifth  nerve.  Nux  vomica  or  strychnine  often  does 
more  good  than  quinine.  In  general  it  may  be  said  that  whenever 
the  nervous  system  is  feeble,  as  it  so  frequently  is  in  neuralgia,  nux 
vomica  may  with  advantage  be  added  to  other  remedies  that  are  given. 
Zinc  (including  the  phosphide)  is  of  little  value.  Arsenic  is 
occasionally  useful,  especially  in  the  neuralgias  that  have  been  set  up 
by  malarial  poisoning,  and  in  the  degenerative  variety.  Tree  phos- 
phorus (-^g-  or  -Jg-  grain)  has  been  strongly  recommended,  but  my 
experience  coincides  with  that  of  most  recent  writers  in  assigning  it 
a  very  low  position  in  the  list  of  remedies, — low  so  far  as  numerical 
success  is  concerned,  although  in  rare  cases  its  influence  is  very 
striking.  For  instance,  a  woman  aged  forty-three,  with  neuralgia  of 
the  fifth  nerve  of  thirteen  years'  duration,  at  one  time  associated  with 


TKtATMEJUT.  825 

"brachial,  and  afterwards  with  crural,  neuralgia,  lost  the  pain  entirely 
during  three  months'  treatment  with  phosphorus,  although  when  the 
treatment  was  commenced  about  twelve  severe  paroxysms  occurred 
every  day.  Ammonio-sulphate  of  copper  has  been  recommended  in 
cases  of  neuralgia  of  the  fifth  nerve.  It  may  be  given  in  doses  of  11g 
or  -i-  of  a  grain  after  food.  In  syjmilitic  forms,  dependent  on  actual 
nerve-lesions,  iodide  of  potassium  and  mercury  should  of  course  be 
given.  Iodide  of  potassium  is  now  and  then  useful  in  cases  of 
neuralgia  that  are  not  due  to  syphilis. 

Of  remedies  that  have  a  sedative  action  on  the  nervous  system, 
although  they  are  not  anodynes,  bromide  of  potassium  has  been 
most  used.  It  is  occasionally  of  service  in  cases  of  idiopathic  neu- 
ralgia, paroxysmal  in  occurrence,  although  it  appears  to  have  less 
influence  on  sensory  than  on  motor  nerve-cells.  Its  value  is  greatest 
in  irritable,  anxious  subjects.  Chloride  of  ammonium  has  been 
recommended  in  intercostal  neuralgia.  In  the  rheumatic  forms 
salicylate  of  soda  has  been  occasionally  found  useful,  especially  in 
facial  neuralgia  and  sciatica,  but  in  the  cases  of  sciatica  which  depend 
on  neuritis  it  has  little  influence.  In  some  cases,  marked  relief  is 
afforded  by  antipyrine,  acetanilide  (antifebrin),  exalgin,  and  phena- 
cetin  ;  they  are  somewhat  uncertain  in  their  influence,  which  is  some- 
times great  at  first  and  afterwards  slight. 

Nervine  stimulants,  given  at  the  beginning  of  an  attack,  occasionally 
cut  it  short,  especially  in  neuralgias  of  the  fifth  nerve.  Sulphuric 
ether,  valerian,  and  alcohol  have  been  employed  for  this  purpose. 
The  use  of  alcohol  is,  however,  fraught  with  great  danger  to  the 
habits  of  the  patient,  and  should  be  avoided  as  far  as  possible. 
Another  nervine  stimulant,  turpentine,  is  an  old  remedy  for  sciatica, 
and  has  been  occasionally  of  service  in  cases  of  ordinary  neuralgia. 
Nitroglycerine  sometimes  gives  relief  to  the  pain,  and,  as  a  rule, 
it  succeeds  whenever  alcohol  is  effective.  It  is  also  extremely  service- 
able in  many  cases,  given  regularly  three  times  a  day,  in  doses  from 
Too  to  -=V  of  a  grain,  especially  in  combination  with  nervine  tonics  ; 
the  dilatation  of  the  arteries  seems  to  favour  the  access  of  the  tonic 
to  the  nerve-tissues. 

Anodynes  are  necessarily  very  important  agents  in  the  treatment 
of  the  disease.  It  is  the  pain  for  which  the  patient  seeks  help ;  the 
cause  of  the  pain  can  only  be  slowly  influenced,  and  in  the  mean- 
time the  pain  itself  has  to  be  relieved.  In  some  cases  relief  is  all 
that  can  be  afforded ;  treatment  fails  to  prevent  the  recurrence  of 
pain,  and  all  that  can  be  done  is  to  lessen  its  intensity.  But  in  a 
large  number  of  cases  of  neuralgia,  anodynes  do  more  than  merely 
palliate;  the  repeated  removal  of  the  pain  tends  to  prevent  its  recur- 
rence. This  makes  it  probable  that  the  relief  afforded  is  not  merely 
by  an  action  of  the  drug  on  the  general  sensorium,  but  that  it  has 
an  influence  on  the  specific  disturbance  which  gives  rise  to  the  sensa- 
tion of  pain.     The  same  conclusion  is  suggested  by  the  fact  that  the 


826  NEUEALGIA. 

most  acute  pain  may  be  sometimes  relieved  by  an  anodyne  which  has 
no  apparent  influence  on  the  general  sensory  functions  of  the  brain. 

No  drug  gives  relief  so  quickly  and  so  surely  as  opium  or  morphia. 
In  epileptiform  neuralgia  Trousseau  found  no  remedy  comparable  to 
opium,  which  he  gave  in  doses  rapidly  increased  up  to  300  grains  of 
opium  or  60  grains  of  sulphate  of  morphia  a  day.  Morphia  beneath 
the  skin  relieves  for  the  time  all  forms  of  neuralgia.  It  is  probable 
that,  in  most  cases,  it  is  better  to  inject  it  into  the  seat  of  pain,  because 
it  can  then  exert  some  influence  on  the  terminal  nerve-endings,  and, 
moreover,  the  injection  has  a  slight  counter-irritant  influence.  But  its 
chief  action  is  on  the  nerve-centres,  and  this  is  exerted  equally  wherever 
the  injection  is  made ;  therefore,  if  for  some  reason,  local  injection 
is  undesirable,  any  convenient  region  will  answer.  The  dose  should 
not  at  first  be  large,  -J^,  •§•,  or  a  of  a  grain,  according  to  the 
severity  of  the  pain.  It  is  unsafe  to  commence  with  a  larger  quantity  \ 
death  has,  in  more  than  one  instance,  resulted  from  an  injection  of 
a  gr.  It  is  remarkable,  however,  in  some  cases,  how  little  effect, 
beyond  the  relief  of  the  pain,  morphia  produces.  The  addition  of 
atropine  (in  the  proportion  of  one-twentieth  of  the  morphia  used) 
will  often  prevent  nausea.  Caution  should  be  used  to  prevent 
the  dangerous  "  morphinism,"  most  cases  of  which  have  been  set  up 
by  the  use  of  this  drug  for  the  relief  of  neuralgia.  The  hypodermic 
svringe  should  never  be  placed  in  the  hands  of  the  patient.  In 
cocaine,  moreover,  we  have  an  agent  that  can  often  replace  morphia. 
A  local  injection  of  from  half  a  grain  to  a  grain  often  gives  great 
relief  to  the  pain,  apparently  by  arresting  impressions  from  the  peri- 
phery, but  the  first  injection  may  wisely  be  smaller,  -^  gr.,  on 
account  of  individual  intolerance.  Repeated  injections  often  promote 
recovery,  especially  when  the  pain  is  superficial  and  is  accompanied 
by  tenderness. 

Belladonna  may  be  given  by  the  mouth  (-|- — a  gr.  of  the  extract) 
or  atropine  by  the  skin  (T^-u — Jg.  gr.).  Occasionally  these  give 
marked  relief  to  the  pain,  and  when  this  is  the  case  they  are  said  to 
produce  a  more  permanent  effect  than  morphia  (Hunter,  Anstie, 
Yanlair).  The  unpleasant  dryness  of  the  throat  cannot  be  avoided. 
It  is  often  well  to  alternate  injections  of  atropine  with  those  of 
morphia  in  cases  in  which  there  is  danger  of  the  establishment  of 
the  morphia  habit,  and  cocaine  is  insufficient. 

Aconite  and  gelsemium  are  said  to  have  a  special  action  on  the 
fifth  nerve,  and  are  frequently  useful  in  trigeminal  neuralgias. 
Aconite  is  the  more  powerful  of  the  two,  but  often  causes  nausea  and 
unpleasant  symptoms.  In  slight  cases,  especially  those  which  depend 
on  dental  caries,  gelsemium  is  sometimes  useful ;  fifteen  minims  of 
the  tincture  may  be  frequently  repeated.  Aconitia  may  also  be  given 
in  doses  of  -^o  *°  Too  °f  a  grain,  but  it  is  a  somewhat  dangerous 
remedy  to  employ  hypodermically.  The  alkaloid  of  gelsemium  (gel- 
semia)   is  convenient  for  subcutaneous  use;   the  dose  is  -^  to  -^ 


TREATMENT.  827 

of  a  grain.  Cimicifuga  is  often  very  useful  for  neuralgia  associated 
with,  rheumatism,  given  either  alone  or  combined  with  Indian  hemp. 
In  gouty  subjects,  lithia  may  be  combined  with  the  cimicifuga. 

Indian  hemp  is  of  value  in  certain  forms  of  neuralgia,  especially 
those  in  which  the  pains  are  sudden,  brief,  and  sharp,  without  the 
violence  which  marks  true  epileptiform  neuralgia.  It  may  be  admin- 
istered continuously  between  the  intervals  ;  a  quarter  to  half  or  even 
one  grain  three  times  a  day.  Piscidia  erythrina  has  been  recommended 
when  pain  is  not  severe ;  in  moderate  doses  (5ss  of  the  liquid  extract) 
it  leaves  no  unpleasant  after-effects.  Chloral  has  little  influence  over 
pain,  but  croton-chloral  (butyl-chloral)  is  sometimes  useful,  especially 
in  neuralgias  of  the  fifth.  It  is  usually  given  in  doses  of  five  grains, 
but,  as  Kinger  and  others  have  shown,  the  dose  may  often  be  increased 
(up  to  twenty  grains)  with  advantage.  Combinations  of  nerve-tonics 
and  sedatives  are  generally  necessary,  but  as  the  sedative  has  to  be 
continuously  given,  its  dose  must,  of  course,  be  moderate.  I  have 
found,  for  instance,  in  neuralgia  of  the  fifth,  the  combination  of  arsenic, 
quinine,  and  Indian  hemp  of  great  service. 

Neuralgic  pain  is  often  relieved  by  local  treatment,  which  is,  for  the 
most  part,  either  irritant  or  sedative  ;  and  some  remedies  combine  the 
two  effects.  Counter-irritation  seems  often  to  exert  an  inhibitory 
influence,  and  to  change  the  action  of  the  nerve-centre ;  just  as 
a  blister  around  the  limb  will  stop  the  aura  of  epilepsy.  Either 
blisters,  or  sinapisms,  or  the  actual  cautery  may  be  employed.  Flying 
blisters  may  be  applied  over  the  tender  spots,  or  by  the  side  of  the 
spine.  Chloroform  has  been  injected  beneath  the  skin,  fifteen  or  thirty 
minims,  but,  although  it  may  give  some  relief,  it  may  also  cause  a 
troublesome  slough.  The  actual  cautery,  in  mild  form,  is  most 
effective  in  spinal  neuralgias.  The  local  injection  of  carbolic  acid 
or  of  osmic  acid  has  been  recommended  ;  they  have  been  employed 
chiefly  in  trigeminal  neuralgia  and  in  sciatica.*  One  or  two  drops  of 
a  1  per  cent,  solution  of  osmic  acid  (in  water  and  glycerine)  have  been 
injected  at  a  time.  It  is  said  to  give  immediate  relief  to  the  pain ; 
some  cases  are  reported  as  being  cured  after  about  a  dozen  injec- 
tions. It  does  no  appear  to  be  entirely  free  from  danger;  Jacoby 
observed  palsy  of  the  radial  nerve  to  follow  an  injection  into  the  arm, 
as  it  occasionally  follows  an  injection  of  ether. 

Acupuncture,  the  introduction  of  needles  into  the  painful  part,  is  a 
method  employed  in  China  and  Japan,  the  value  of  which  is  not  great. 
If,  as  in  the  East,  the  needles  are  left  in  for  some  hours  or  a  day,  they 
cause  much  pain.  Aquapuncture  has  also  been  employed  ;  it  consists 
in  the  injection  of  pure  water  into  or  beneath  the  skin.  Originally  it 
was  introduced  into  the  skin,  or  between  the  true  skin  and  the  epi- 
dermis, under  considerable  pressure,  so  as  to  force  the  water  to  sepa- 
rate the  tissues  and  make  spaces  for  itself.     This  method  gives  much 

*  Merces,  '  Lancet,'  1885,  No.  2 ;  Jacoby,  '  Trans.  Am.  Neurolog.  Ass./  1885,. 
p.  11;  Schapiro,  '  Petersburg,  med.  Wochenschrift/  1885. 


828  '  NEURALGIA. 

pain  and  does  little  good,  but  tbe  injection  of  water  beneath  the  skin 
is  innocuous,  and  occasionally  relieves  a  slight  pain. 

Of  external  applications  tbat  are  at  once  irritant  and  sedative, 
■chloroform is  the  most  important,  pure,  or  as  the  Linimentum  Chloro- 
forini  (B.  P.),  or  a  dilution  of  one  part  of  chloroform  with  six  of  Lin. 
Saponis.  Next  in  value  are  the  ointments  of  veratria  and  aconitia. 
They  should  be  rubbed  in  until  tingling  is  produced,  followed  by  numb- 
ness. The  milder  tincture  of  aconite  may  also  be  painted  on  the  part 
two  or  three  times  a  day,  avoiding  any  sores.  Camphor-chloral 
(camphor  and  chloral  rubbed  up  together  in  equal  parts,  so  as  to 
liquefy)  may  also  be  applied  on  lint  covered  with  oil-silk.  Both  this 
and  chloral  will  blister  if  left  on  too  long.  Menthol  is  also  a  useful 
application  to  the  skin  in  the  slighter  forms  of  neuralgia.  It  causes 
a  singular  sen  ation  of  tingling  and  coldness,  and  for  the  time  lessens 
the  pain.  It  may  be  employed  pure  in  the  solid  form,  or  rubbed  up 
with  chloral,  or  with  spirit  or  glycerine.  Preparations  of  opium 
(usually  oleate  of  morphia)  are  of  very  little  value  as  external  appli- 
cations. A  strong  ointment  of  cocaine  and  lanoline  (10  or  15  per  cent.) 
-sometimes  does  good  by  numbing  the  skin,  but  it  should  not  be  used 
at  the  junction  of  a  mucous  membrane  and  the  skin,  or  when  the  skin 
is  irritated,  or  it  may  excite  a  troublesome  spreading  dermatitis. 
JBelladonna  is  of  service  if  employed  sufficiently  strong ;  the  extract, 
diluted  with  one,  two,  or  three  parts  of  glycerine  or  vaseline,  may  be 
smeared  over  the  skin  two  or  three  times  a  day.  The  oleate  of  atropia 
(5  per  cent,  solution  in  oil)  may  be  used  in  the  same  way. 

Among  external  applications,  that  of  simple  cold  or  warmth  should 
be  mentioned.  Each  occasionally  gives  temporary  relief  if  applied 
continuously  to  the  seat  of  pain.  In  most  cases  heat  is  the  safer 
•and  more  effectual.  Considerable  heat  is  often  little  felt  at  the  focus 
of  most  intense  pain.  If  there  is  the  least  suspicion  of  active  neuritis, 
heat  must  be  applied  to  the  distribution  of  the  nerve  with  extreme 
caution,  or  disastrous  consequences  may  ensue  (see  vol.  i,  p.  62).  A 
warm  douche  through  the  rfose  has  been  strongly  recommended  by 
Seeligmuller  in  cases  of  supra-orbital  pain,  supposed  to  be  produced 
in  the  frontal  sinuses,  even  when  of  malarial  origin.  Ether  spray 
to  the  spine  has  also  been  recommended  in  various  forms  of  neuralgia. 
Cold  to  the  painful  part  is  rarely  useful,  except  in  the  case  of  neuralgia 
of  the  testis,  where  refrigeration  can  be  more  completely  effected  than 
elsewhere. 

Electricity,  properly  employed,  is  an  agent  of  occasional  value  in 
the  treatment  of  neuralgia.  It  may  be  used  in  two  ways.  (1)  A  strong 
current,  causing,  for  the  time,  considerable  pain,  will  sometimes 
remove  the  neuralgia  at  once,  no  doubt  by  altering  the  form  of  central 
action,  just  as  does  a  counter-irritant.  The  effect  is  probably  only 
produced  in  cases  of  idiopathic  neuralgia  of  slight  degree.  In 
some  cases,  and  invariably  iu  active  neuritis,  a  strong  application 
renders  the  pain  worse,  and  the  risk  of  this  effect  must  be  borne  in 


TREATMENT.  8291 

mind.  The  forms  in  which  it  is  most  likely  to  he  successful  are  recent 
cases  of  hysterical  neuralgia,  especially  when  the  pain  is  seated  in  the 
joints.  To  produce  this  energetic  effect  either  faradism  or  voltaism 
may  be  used.  (2)  A  weak  current  may  be  used  for  its  sedative  action 
on  the  nerves.  Either  form  of  electricity  may  be  employed,  but 
the  action  of  the  two  is  essentially  different.  The  voltaic  current  is 
the  most  frequently  useful.  Authorities  are  divided  on  the  best  method 
of  applying  it,  but  the  majority  are  of  opinion  (and  with  this 
my  own  experience  agrees)  tbat  it  is  best  to  neglect  the  direction 
of  the  current,  and  to  place  the  positive  pole  near  the  seat  of  the  pain, 
and  the  negative  in  some  indifferent  situation.  If  there  is  reason  to 
believe  that  the  neuralgia  is  central,  the  positive  pole  may  be  placed, 
during  part  of  the  application,  as  near  as  may  be  to  the  central  termi- 
nation of  the  nerve,  and,  for  another  part  of  the  time,  on  the  seat  of 
the  pain.  The  strength  should  be  from  two  to  five  milliamperes,  but 
if  the  battery  is  not  provided  with  a  galvanometer,  the  number  of  cells 
must  be  regulated  according  to  its  effect  on  the  sensory  nerves,  so  as  to 
cause  a  slight  tingling  or  burning  sensation,  not  actual  pain.  The 
number  of  cells  to  be  used  will  vary  in  different  parts,  chiefly  in  con- 
sequence of  the  varying  sensibility  and  resistance  of  the  skin.  The 
patient's  sensations  are,  indeed,  often  the  best  guide.  For  the  face, 
three,  and  elsewhere  five,  cells  may  be  employed  to  begin  with,  and  the 
current  gradually  increased  until  it  can  just  be  felt.  All  sudden  varia- 
tions in  strength  should  be  avoided.  A  well-wetted  sponge  should  be 
employed  as  the  electrode,  and  this  should  be  very  gently  and  gradu- 
ally applied,  and  very  gently  removed  when  the  strength  is  altered. 
If  the  faradic  current  is  employed  as  a  sedative,  it  must  be  extremely 
weak  (so  as  to  be  just  felt,  but  to  occasion  no  pain),  and  rapidly  inter- 
rupted. The  rapidly  recurring  slight  stimulation  of  the  nerves  pro- 
duces after  a  time  a  sedative  effect,  at  first  slightly  increasing,  but 
after  a  few  minutes  distinctly  relieving,  the  pain.  Its  action  is  analo- 
gous to,  and  quite  as  effectual  as,  the  mechanical  percussors  recently 
introduced. 

The  Surgical  Treatment  of  Neuralgia. — Cases  of  neuralgia  are 
occasionally  met  with,  especially  in  the  region  of  the  fifth  nerve, 
and  in  persons  who  have  passed  middle  life,  in  which  every 
attempt  to  afford  even  relief,  fails  entirely.  In  such  cases  the  only 
measure  which  is  likely  to  be  successful  in  curing  the  disease  is  one 
that  interrupts  the  passage  of  all  impulses  along  the  nerve,  from  the 
periphery  to  the  centre.  Such  impulses,  as  we  have  seen,  are  con- 
stantly traversing  the  nerve  ;  some  affect  consciousness  and  are  felt  as 
sensations  ;  of  others  we  are  usually  not  conscious,  but  can  perceive 
them  by  fixing  our  attention  on  the  part.  But  all  these  are  probably 
only  a  small  part  of  the  impulses  which  habitually  pass  up  to  the 
cells  in  which  the  fibres  end,  and  these  impulses  seem,  in  cases  of  cen- 
tral neuralgia — the  common  variety  in  the  class  now  under  considera- 
tion— to  maintain  the  morbid  action  of  the  cells  when  this  has  been 


830  NEURALGIA. 

once  set  up  and  fixed  in  them.  If  these  impulses  can  be  arrested, 
absolutely  and  permanently,  the  disturbed  centre  is  afforded  perfect 
rest  from  all  peripheral  influences,  and  in  a  large  number  of  cases, 
with  such  rest  the  morbid  process  subsides.  Indeed,  it  often  ceases  at 
once  ;  the  shock  to  the  cells,  involved  in  the  operation  necessary  for  the 
arrest  of  conduction  along  the  nerve,  seems  at  once  to  inhibit  the 
cells,  and  in  the  absence  of  the  previous  excitation  they  do  not  again 
resume  their  normal  activity. 

The  influence  of  nerve-stretching  is  seldom  permanent  enough  to 
produce  the  desired  result;  even  division  of  the  nerve  is  uncertain  in 
its  effects,  apparently  because  union  may  take  place  between  the 
divided  extremities  which  are  left  in  juxtaposition.  The  only  proceed- 
ing which  has  been  found  effectual  and  trustworthy  is  the  excision  of 
a  short  piece  of  the  trunk  of  the  nerve,  to  the  distribution  of  which 
the  pain  is  referred.  If  the  pain  is  referred  to  more  than  one  division 
of  the  nerve,  it  is  usually  sufficient  to  operate  upon  the  branch  first 
and  chiefly  affected.  But  a  recurrence  may  take  place,  and  the  nerve 
may  afterwards  have  to  be  resected  above  its  division.  It  was  at  one 
time  supposed  that  the  removal  of  Meckel's  ganglion  was  essential  in 
some  cases,*  but  this  has  not  been  confirmed  by  recent  experience. f 
The  various  procedures  devised  by  surgeons  to  attain  the  object  have 
been  similar  in  aim,  viz.  the  exposure  of  the  nerve  at  a  point  as  near 
the  centre  as  is  thought  necessary.  On  account  of  the  tendency  for  the 
pain  to  affect  other  branches  of  the  nerve,  after  that  primarily  affected 
has  been  interrupted,  the  main  divisions  of  the  nerve,  at  one  or  the  other 
side  of  theforamina  through  which  they  pass  from  the  skull,  may  have  to 
be  divided.  Rose  J  even  recommended  removal  of  the  Gasserian  ganglion 
and  has  carried  out  the  operation  in  several  cases  ;  while  Horsley,§  who 
asserts  that  removal  of  the  Gasserian  ganglion  as  a  whole  is  impossible 
on  account  of  its  close  connection  with  the  cavernous  sinus,  advocates 
division  of  the  nerve  between  the  pons  and  the  ganglion. 

Success  is  a  frequent  but  not  a  constant  result  of  the  operation  of 
neurectomy.  In  nineteen  cases  reported  by  Horsley,||  the  operation 
had  to  be  repeated  in  six  on  account  of  recurrence  of  pain  ;  one  patient 
died,  in  whom  he  had  separated  the  fifth  nerve  from  the  pons  ;  one 
became  demented  after  repeated  operations,  which  failed  to  give  more 
than  temporary  relief.  In  the  others,  there  was  relief  up  to  the  time 
at  which  the  paper  was   written,  this  interval  varying  from  a  few 

*  See  a  paper  by  Dr.  Chavasse,  of  Birmingham  (Royal  Medical  and  Chirurgical 
Society,  meeting  of  February  20th,  1884,  and  discussion  thereon). 

t  Neuralgia  will  sometimes  disappear  for  a  time  under  strong  mental  influence. 
Lefort,  for  instance,  mentions  that  a  most  obstinate  lingual  neuralgia  ceased  during 
the  siege  of  Paris,  and  returned  when  the  anxious  time  was  over. 

X  "  Lettsomian  Lectures,"  '  Brit.  Med.  Journ.,'  i,  1892. 

§  'Brit.  Med.  Journ.,'  ii,  1891. 

||  Loc.  cit.  In  these  papers  will  be  found  described  the  details  of  the  various 
operations. 


TREATMENT.  831 

months  to  some  years.  In  five  cases  in  which  Eose  operated  on  the 
G-asserian  ganglion,  complete  relief  persisted  up  till  the  time  of  the 
publication  of  the  result,  but  in  three  of  the  cases  that  time  was  less 
than  a  year.  The  same  is  true  of  a  case  in  which  Professor  Andrews, 
of  Chicago,  carried  out  the  same  operation. 

Although  operative  measures  in  the  treatment  of  trigeminal  neu- 
ralgia are  thus  uncertain  in  their  result,  even  when  carried  out  on  the 
main  trunk  and  still  more  upon  the  peripheral  branches,  the  measure 
has  resulted  in  complete  relief,  certainly  or  probably  permanent,  in  a 
considerable  number  of  cases  in  which  other  measures  have  failed. 
With  wider  experience,  a  selection  of  cases  may  be  possible,  that 
will  much  increase  the  practical  value  of  the  operation. 

Nerve-stretching  is  an  operation  which  produces  some  of  the 
effects  of  neurotomy,  arresting  for  a  time  the  conducting  function, 
and  effecting  what  may  be  called  an  alterative  stimulation  of  the 
nerve.  If  its  influence  is  less  lasting,  so  are  also  its  inconvenient 
effects,  and,  as  it  is  sometimes  successful,  it  may  often  wisely 
precede  division  of  the  nerve.  It  has  been  recommended  that  strong 
traction  should  be  made  on  the  central  end,  but  it  is  doubtful  whether 
this  has  much  influence,  and,  in  the  case  of  the  fifth  ijerve,  it  is 
somewhat  perilous.*  Recent  literature  abounds  with  records  of  cases 
of  apparent  cure  from  nerve-stretching,  even  when  the  neuralgia 
seemed  to  be  central.  For  instance,  a  severe  intercostal  neuralgia  of 
twenty  years'  duration  is  said  to  have  been  cured  by  stretching  the 
terminal  branches  of  two  or  three  of  the  nerves. f  Intensely  severe 
neuralgia  of  the  third  division  of  the  fifth — the  pain  being  in  the  ear, 
temple,  lower  jaw,  and  tongue, — of  five  years'  duration,  is  said  to  have 
been  cured  by  a  single  stretching  of  the  lingual  nerve  in  the  tongue.  J 
In  this  and  many  other  cases  the  pain  did  not  immediately  cease,  but 
gradually  subsided  in  the  course  of  one  or  two  weeks.  In  some  rare 
cases,  in  which  the  sheath  of  an  accessible  nerve  can  be  felt  to  be 
greatly  thickened,  the  nerve  has  been  exposed,  the  sheath  opened 
carefully,  and  the  nerve  for  some  distance  separated  from  it.  This 
operation  has  been  successful  in  arresting  the  pain,  especially  in 
traumatic  cases.  § 

Ligature  of  arteries  has  been  confined  to  that  of  the  carotid,  as  a 
last  resort  in  cases  of  neuralgia  of  the  fifth  nerve.  All  that  can  be 
said  to  justify  so  serious  an  operation  is  that  it  has  sometimes,  but 
very  rarely,  been  successful.     Compression  of  the  carotid  occasionally 

*  There  is  evidence  that  too  vigorous  stretching  of  the  second  division  of  the 
fifth  nerve  has  caused  destructive  inflammation  of  the  eyeball,  probably  by  the 
mechanism  of  inflammation  of  the  Gasserian  ganglion  (Nicaise  and  Tillaux,  Soc. 
Clin,  de  Paris,  March  9th,  1882). 

t  Nussbaum,  '  Aerzt.  Int.-bl.,'  1878,  No.  53. 

t  Le  Dentu,  '  L'Un.  med.,'  1881,  vol.  ii,  p.  766. 

§  An  instance  is  recorded  by  Le  Fort,  '  Soc.  de  Chir.,'  July  26th,  1882,  in  which 
the  median  was  surrounded  by  a  dense  sheath  of  connective  tissue,  due  to  inflamma- 
tion produced  by  a  gunshot  wound. 


832  NEURALGIA. 

cuts  short  au  attack  of  paiu,  and  the  repetition  of  this  treatment,, 
continued  for  a  loug  time,  has  even  produced  permanent  alleviation. 

An  attempt  to  estimate  the  true  position  of  the  surgical  treatment 
of  neuralgia  is  unfortunately  beset  with  almost  insurmountable  diffi- 
culties, due  to  the  fact  that  after  many  operations  the  pain  has  ceased, 
or  has  been  much  lessened,  for  a  time,  but  has  afterwards  returned, 
and  many  cases  have  been  published  before  sufficient  time  has  elapsed 
to  permit  an  opinion  to  be  formed  of  the  permanence  of  the  effect. 
Moreover,  the  numerous  cases  in  which  there  has  not  been  even  tem- 
porary relief  are  seldom  published.  In  some  instances,  operation  after 
operation  has  been  submitted  to  by  the  patient  under  the  urgent  com- 
pulsion of  continued  suffering,  and  the  records  of  many  cases  illustrate 
very  strikingly  the  need  for  caution  in  drawing  any  inference  from 
transient  relief  .* 

Yisceeal  Neuralgias. 

The  internal  viscera  of  the  thorax  and  abdomen  are  sometimes  the 
seat  of  neuralgic  pain.  Such  neuralgias  are  described  in  full  in  the 
works  that  deal  with  the  diseases  of  these  organs,  and  this  arrange- 
ment is  convenient,  since  the  principles  of  diagnosis  involve  a  dif- 
ferential discussion  of  the  symptoms  of  organic  disease  of  these 
organs  which  would  be  out  of  place  in  the  present  work.  A  brief 
outline  of  the  general  facts  may,  however,  be  given  here. 

Most  of  the  organs  in  which  these  neuralgias  are  felt,  receive  their 
chief  nervous  supply  from  the  sympathetic  system.     Little  sensation 

*  The  following  cases  are  illustrations  of  this.  In  one  instance,  a  man,  at  the 
age  of  forty-five,  had  his  first  attack  of  neuralgia  in  the  third  division  of  the 
fifth  nerve.  Fonr  teeth  were  extracted  from  the  lower  jaw  and  then  one  from  the 
upper,  and,  as  the  pain  ceased  for  three  weeks,  the  case  was  published  as  cured.  The 
pain  returning,  resection  of  the  alveolar  process  was  performed;  the  pain  ceased  for 
five  months,  and  the  case  was  again  published  as  cured.  After  a  relapse,  the  inferior 
alveolar  nerve  was  excised,  and  freedom  for  some  time  was  followed  by  a  return,  for 
which  the  carotid  artery  was  tied,  but  the  effect  of  even  this  was  not  permanent 
(J.  C.  Hutchinson, '  Am.  Med.  Xews,'  1885,  p.  395).  The  same  author  relates  a  case 
of  neuralgia  of  the  fifth,  in  which  the  following  operations  were  performed  without 
success : — an  incision  through  the  skin  above  the  ear,  division  of  the  supra-orbital 
and  infra-orbital  nerves,  excision  of  half  an  inch  of  the  supra-orbital,  ligature  of  the 
carotid,  destruction  of  the  nerve  in  the  infra- orbital  canal.  In  a  case,  recorded  by 
Schupper,  of  neuralgia  of  the  fifth  with  reflex  spasm  in  the  face,  the  first  procedure 
was  scarification  of  the  outer  and  inner  surfaces  of  the  upper  jaw  ;  this  failing,  the 
surgeon  excised  the  infra-orbital  nerve  ;  this  likewise  failing,  he  excised  the  superior 
maxillary  nerve  in  the  spheno-maxillary  fossa ;  there  being  no  relief,  he  removed  the 
peripheral  segment  of  the  same  nerve  from  the  base  of  the  orbit.  The  pain  then 
migrated  to  the  third  division  of  the  fifth :  the  inferior  maxillary  nerve  was  there- 
fore excised.  An  interval  of  freedom  was  followed  by  a  return  of  the  pain,  and  the 
common  carotid  was  tied.  The  pain  continuing,  the  facial  nerve  was  divided,  and 
on  account  of  severe  haemorrhage,  the  external  carotid  and  temporal  arteries  were 
tied,  and  the  patient  is  said  at  last  to  have  been  "  cured." 


VISCERAL    FORMS.  833 

attends  their  normal  function.  Although  it  cannot  be  doubted  that 
afferent  impressions  are  constantly  passing  to  the  cerebro-spinal 
ceutres,  these  fail  to  affect  consciousness  under  normal  circumstances. 
But  repeated  attention  may  vastly  increase  the  sensitiveness  of  the 
percejvtive  centres  to  such  impressions,  and  from  such  increase  arises 
a  large  amount  of  the  discomfort  of  those  patients  who  are  termed 
"  hypochondriacs  " — correctly,  in  so  far  as  the  organs  which  lie  below 
the  rib-cartilages  disturb  their  conscious  life.  But  the  sensation  from 
the  viscera  may  also  amount  to  actual  pain,  in  consecpuence  of  the 
afferent  impressions  being  abnormal,  owing  to  organic  disease  and 
varied  functional  distui'bance.  Pain  may  also  be  felt  apart  from  either 
of  these  causes,  and  such  pain  is  called  "  visceral  neuralgia."  Often 
we  cannot  tell  to  what  extent  it  is  the  result  of  a  local  abnormal  con- 
dition of  the  nerves  of  the  organs,  and  how  far  it  is  central.  It  is 
probably  local  in  causation  to  a  larger  extent  than  in  the  case  of  the 
cerebro-spinal  forms  of  neuralgia,  but  the  same  general  pathological 
laws  doubtless  underlie  the  two.  The  difficulty  of  investigation  de- 
pends not  only  on  the  fact  that  the  organs  are  concealed  from  direct 
examination,  but  also  on  the  circumstance  that  they  receive  their  inner- 
vation from  two  sources,  from  the  sympathetic,  and  from  the  cerebro- 
spinal centre  by  the  pneumogastric  and  spinal  branches  ;  and  we  do  not 
know  what  share  these  sets  of  nerves  respectively  take  in  the  produc- 
tion of  visceral  pain.  There  is,  moreover,  reason  to  believe  that  not 
only  the  nerves  in  the  viscera  but  also  the  nervous  plexuses  outside 
them  may  be  the  seat  of  neuralgia.  The  difficulties  of  investigation 
are  greatly  increased  by  the  fact  that  pain  may  be  the  only  symptom 
of  organic  and  of  functional  disease,  and  it  is  certain  that  many 
examples  of  the  former  have  been  included  among  the  visceral  neu- 
ralgias by  some  writers  on  the  subject. 

Most  forms  of  visceral  neuralgia  are  more  frequent  in  females  than 
in  males,  and  may  be  disposed  to  by  the  same  inherited  tendency  that 
produces  the  cerebro-spinal  forms.  The  general  causes  of  the  two  are 
also,  for  the  most  part,  similar.  In  women,  anemia  and  hysteria  are 
especially  prominent.  They  may  also  result  from  causes  that  have  a 
local  action,  and  this  fact  adds  not  a  little  to  the  obscurity  of  their 
diagnosis.  The  essential  symptom  is  pain,  which  varies  greatly  in 
character,  sometimes  dull  and  diffuse,  sometimes  sharp,  circumscribed, 
lancinating  or  burning.  It  usually  presents  paroxysmal  exacerbations, 
and  is  sometimes  actually  intermitting.  I  have  known  paroxysms  of 
gastric  pain  to  alternate  with  headache.  The  exacerbations  may  be 
apparently  spontaneous,  or  may  be  produced  by  various  stimuli,  espe- 
cially by  those  concerned  in  the  functional  activity  of  the  organ.  We 
ought  not,  however,  to  include  among  the  neuralgias  (as  some  have 
done)  cases  in  which  pain  is  confined  to  periods  of  functional  activity. 
It  is  doubtful  whether,  in  such  cases,  the  affection  is  ever  a  pure 
neuralgia. 

The  diagnosis  of  visceral  neuralgias  is  difficult,  not  only  in  the 
vol.  ii.  53 


834  NEURALGIA. 

recognition  of  the  actual  cause  of  the  pain,  but  also  in  that  of  the 
organ  or  structure  from  which  it  proceeds.  The  first  aud  chief  element, 
however,  is  the  exclusion  of  organic  disease,  by  every  method  of  investi- 
gation that  can  be  made  available.  If  functional  disturbance  exists, 
the  affection  can  only  be  regarded  as  neuralgic  when  the  pain  is  not 
related  to  the  disturbance  of  function  either  in  time  or  in  degree. 

The  treatment  of  visceral  neuralgias  must  be  based  on  the  same 
general  principles  as  that  of  the  cerebro-spinal  forms.  It  consists  in 
the  removal  of  causes,  general  tonic  treatment,  abundant  rest,  and 
the  use  of  sedatives.  The  mode  of  employment  of  the  latter  differs  in 
each  case,  and  in  each,  also,  special  measures  are  necessary,  related  to 
the  function  of  the  organ  concerned. 

Special  Forms. — Of  the  intra-thoracic  organs,  the  lungs  do  not 
appear  to  be  the  seat  of  neuralgia,  although  the  pain  of  "  pleurodynia," 
already  described,  is  probably  due  to  an  affection  of  the  pleural  nerves. 
The  only  important  cardiac  affection  of  this  class  is  the  disease  known 
as  "  angina  pectoris."  Severe  nerve-pain  is  a  prominent  symptom  of 
the  disorder,  but  its  peculiar  and  special  characters  and  associations 
prevent  its  inclusion  among  the  forms  of  pure  neuralgia. 

The  most  impoi*tant  visceral  neuralgias  are  those  of  the  abdominal 
organs.  They  are  usually  local  and  well  defined,  but  occasionally 
abdominal  neuralgic  pain  varies  in  its  seat,  and  is  felt  now  on  one 
side,  now  on  another.  That  of  the  stomach  (gastralgia,  gastrodynia) 
is  one  of  the  best-marked  forms.  It  is  frequent  in  anaemia  and 
hysteria,  and  a  special  form  constitutes  the  gastric  crises  of  ataxy. 
The  pain  is  felt  at  the  epigastric  region,  and,  like  most  gastric  pains, 
passes  through  to  the  back.  Pressure  does  not  usually  increase  it; 
often,  indeed,  it  relieves  the  more  intense  suffering.  There  is  generally 
a  constant  dull  pain,  with  more  acute  exacerbations.  It  may  be  most 
intense  when  the  stomach  is  empty,  and  may  be  relieved  by  food ; 
it  is  then  possibly  due  to  the  morbid  action  of  the  nerves  or  centres 
from  which,  in  health,  the  sensation  of  hunger  arises.  Or  the  pain 
may  be  increased  by  food,  and  in  such  cases  food  is  often  vomited  as 
soon  as  it  is  taken.  Appetite  may  be  absent,  lessened,  increased,  or 
perverted.  The  relation  of  the  condition  of  appetite  to  the  effect  of 
food  in  relieving  or  increasing  the  pain  deserves  further  study. 

The  stomach  is  readily  influenced  by  sedatives,  and  their  adminis- 
tration by  the  mouth  forms  an  important  part  of  the  treatment.  Other 
agents  are  sometimes  useful.  In  the  form  that  is  relieved  by  food, 
oxide  of  silver  is  often  of  great  service.  When  there  is  anaemia,  the 
combination  of  subcarbonate  of  bismuth  and  saccharated  carbonate  of 
iron,  given  before  food,  is  frequently  effective.  No  sedative,  however, 
is  on  the  whole  so  useful  as  cocaine,  of  which  half  a  grain  may  be 
given  when  the  pain  comes  on.  By  repeatedly  relieving  the  pain  in 
this  manner,  the  disease  is  often  cured,  apparently  by  the  rest  thus 
given  to  the  nerves  of  the  mucous  membrane. 


VISCERAL    FORMS.  835 

The  frequency  of  intestinal  neuralgia  {enteralgia)  has  probably  been 
exaggerated.  We  are  not  justified  in  regarding  as  enteralgia  either 
vague  abdominal  pains,  which  are  not  incz'eased  by  peristaltic  action, 
or  pain  that  occurs  only  when  the  intestines  ai'e  in  energetic  action, 
or  in  which  there  is  conspicuous  disturbance  of  the  mucous  membrane. 
If  these  are  excluded,  the  cases  of  enteralgia  become  extremely  rare, 
and  the  history  of  the  affection  has  yet  to  be  worked  out.  There 
is,  however,  one  part  of  the  intestine  which  is  undoubtedly  the 
seat  of  neuralgic  pain, — the  lower  part  of  the  rectum.  This  form 
occurs  in  both  sexes  as  a  deeply  seated  pain  above  the  anus  and 
coccyx,  more  or  less  constant,  but  with  severe  exacerbations,  appa- 
rently due  to  spasm.  It  is  usually  effectually  relieved  by  supposi- 
tories. In  some  cases,  indeed,  it  is  probably  a  primary  spasm,  and  I 
have  known  it  to  be  produced  in  a  child  by  the  use  of  senna  as  an 
aperient. 

Of  neuralgia  of  the  liver,  Jiepatalgia,  much  the  same  may  be  said  as 
of  enteralgia.  Deep-seated  pain  is  occasionally  felt  in  the  position  of 
the  organ,  sometimes  diffuse  and  dull,  sometimes  sharp  and  lanci- 
nating, but  the  cases  in  which  we  can  be  sure  that  it  is  truly  neuralgic 
are  extremely  few.  In  some  cases,  such  pain  may  be  due  to  disturbed 
function  of  the  organ.  Disturbance  of  function  has  been  regarded  by 
some  writers  as  a  consequence  of  neuralgia.  It  cannot  be  denied  that 
severe  nerve-pain  may  cause  such  reflex  derangement  of  function,  just 
as  it  causes  vaso-motor  disturbance  in  other  situations.  But  the 
frequency  with  which  pain  is  the  first  evidence  of  disease  outside  the 
nervous  system,  which  afterwards  causes  other  symptoms,  renders  it 
necessary  to  exercise  great  caution  in  regarding  such  cases  as  primarily 
neuralgic. 

The  existence  of  neuralgia  of  the  spleen  is  not  well  established,  but 
occasionally,  especially  in  cases  of  hysteria,  there  is  deeply  seated  pain 
and  tenderness  in  the  position  of  the  organ,  apparently  situated  in  it  or 
in  the  nerve-plexuses  in  its  vicinity. 

The  kidney,  and  apparently  the  ureter,  may  be,  in  rare  cases,  the  seat 
of  the  neuralgic  crises  of  tabes,  analogous  to  the  more  frequent  gastric 
crises ;  but  the  occurrence  of  primary  nephralgia  is  a  still  more  rare 
event,  and  can  hardly  be  regarded  as  proved.  Many  cases  of  sup- 
posed renal  neuralgia  have  certainly  been  due  to  the  passage  of  a 
calculus.  I  have,  however,  met  with  one  case  in  which  paroxysms  of 
pain  in  the  renal  region  had  occurred  at  times  during  forty  years 
without  any  indication  of  a  calculus,  and  it  seemed  on  the  whole 
probable  that  the  pain  was  of  nervous  origin. 

Neuralgic  pain  which  cannot  be  referred  to  any  organ  is  sometimes 
felt  within  the  abdomen.  Such  pain  is  diffuse,  varies  in  intensity,  is 
not  increased  by  pressure,  and  is  not  related  in  time  to  the  functional 
activity  of  the  organs,  or  in  degree  to  their  disturbance.  It  is 
generally  central  in  position,  but  may  be  felt  above  or  below  the 
umbilicus,  apparently  seated  in  the  sympathetic  nerves,  although 


836  MIGRAINE. 

without  such  a  relation  to  their  plexuses  as  to  permit  definite 
localisation. 

The  female  generative  organs  are  frequent  seats  of  pain  and  tender- 
ness. Tenderness  in  the  region  of  the  ovaries  is  extremely  common  in 
hysteria  and  conditions  of  nervous  weakness;  sometimes  there  is 
much  spontaneous  pain  in  this  situation,  deeply  seated,  and  aching  or 
burning  in  character.  This  pain  may  exist  when  no  evidence  of 
organic  change  in  the  ovary  can  he  detected,  and  appears  then  to  he 
a  pure  neuralgia;  but  in  most  cases  the  tenderness  is  extensive, 
and  exists  in  the  vicinity  of  the  ovary  as  well  as  in  the  organ  itself,  so 
that  it  is  probably  due,  at  least  in  part,  to  the  abundant  nerve-plexuses 
with  which  the  ovary  is  surrounded.  The  uterus  is  also  the  seat  of 
spontaneous  pain  and  of  tenderness,  apai't  from  organic  disease  or  of 
displacement.  These  symptoms  may  occur  in  the  young  and  also  in 
later  life,  even  when  the  involution  of  the  organ  is  complete.  They 
are  often  associated  with  neuralgic  pains  elsewhere — in  the  ovaries, 
and  especially  in  the  spine,  including  the  sacrum.  By  some  writers  the 
pains  of  menstruation,  when  no  organic  cause  for  them  can  be  discovered, 
are  regarded  as  neuralgic. 

Of  the  male  organs  of  generation,  that  which  is  most  frequently  the 
seat  of  neuralgic  pain  is  the  testicle,  but  even  here  such  pain  is  com- 
paratively rare.  It  is  important  to  remember,  however,  that  inflam- 
mations of  the  urinary  passages  are  not  uncommon  causes  of  neuralgia 
seated  in  the  adjacent  spinal  nerves. 


MIGRAINE:     PAROXYSMAL  HEADACHE. 

Migraine  is  an  affection  characterised  by  paroxysmal  nervous  dis- 
turbance, of  which  headache  is  the  most  constant  element.  The  pain 
is  seldom  absent  and  may  exist  alone,  but  it  is  commonly  accompanied 
by  nausea  and  vomiting,  and  it  is  often  preceded  by  some  sensory 
disturbance,  especially  by  some  disorder  of  the  sense  of  sight.  The 
symptoms  are  frequently  one-sided,  and  from  this  character  of  the 
headache  the  name  is  derived,  the  Latin  "  hemicrania  "  (still  often 
employed)  furnishing  the  Erench  migraine,  the  G-erman  migran,  and 
the  English  megrim.*  The  Erench  word  is  that  most  frequently 
employed,  and  is,  on  the  whole,  the  most  convenient.  On  account  of 
the  associations  of  the  pain,  it  has  received  the  popular  names  of 
"  blind  headache,"  "  sick  headache,"  and  "  bilious  headache,"  the 
latter  being  derived  partly  from  the  fact  that  bile  is  often  vomited, 

*  The  English  word  has  been  developed  by  the  following  steps,  going  backwards : 
megrim,  megrene,  emigranea ;  Low  Latin,  hemigranea ;  Latin,  hemicranea,  herni- 
cranium ;  Greek,  Tjfuicpaviov  (Skeat). 


ETIOLOGY.  837 

partly  from  the  old  humeral  pathology  which  regarded  the  bile  as  one 
of  the  chief  morbific  fluids  of  the  body.  The  disease  is  often  associated 
with  high  intellectual  ability,  and  many  distinguished  scientific  men 
have  suffered  from  it,  and  have  supplied  more  careful  observations  of 
the  subjective  symptoms  than  we  possess  of  any  other  malady. 
Amongst  the  sufferers  may  be  mentioned  the  celebrated  Dr.  Fothergill, 
Marmontel,  Haller,  Wollaston,  Du  Bois  Eeymond,  Sir  Charles 
"Wheatstone,  Sir  John  Herschell,  Sir  G-eorge  Airy,  and  his  son,  Dr. 
Hubert  Airy.* 

Etiology. — Females  suffer  from  migraine  more  frequently  than 
males,  but  their  preponderance  is  not  great,  and  has  been  much 
exaggerated  by  some  writers.  The  affection  usually  commences  in 
the  first  half  of  life.  One  third  of  the  cases  begin  in  later  childhood 
between  five  and  ten  ;  about  two  fifths  between  ten  and  twenty,  and 
most  of  the  others  between  twenty  and  thirty.  The  maximum  periods 
are  late  childhood,  puberty,  and  early  adult  life.  Now  and  then 
the  disease  commences  after  thirty  ;  I  have  met  with  one  well-marked 
•case  which  began  at  sixty.  In  the  ratio  between  the  sexes,  and  the 
large  number  of  cases  which  commence  at  the  time  of  puberty,  the 
disease  resembles  another  paroxysmal  neurosis,  epilepsy,  and  we  shall 
see  that  there  are  other  points  of  resemblance  between  the  two  diseases. 
Migraine  is  strongly  hereditary ;  in  more  than  half  the  cases  inherit- 
-ance  can  be  traced,  and  it  is  usually  direct,  i.  e.  other  members  of  the 
family  (very  often  a  parent)  suffer  from  paroxysmal  headache.  Now 
and  then  the  inheritance  is  indirect ;  relatives  suffer,  not  from 
migraine,  but  from  some  other  neuroses,  especially  pure  neuralgia  and 
epilepsy.  For  instance,  a  woman  aged  forty- six  had  suffered  for 
many  years  from  migraine  (paroxysmal  headaches  with  dimness  of 
sight  and  vomiting).  One  of  her  children  was  epileptic,  and  her 
mother  had  been  epileptic  and  insane.  I  once  had  under  treatment 
a  brother  for  migraine,  and  his  sister  for  epilepsy.  One  patient's 
brother  suffered  from  paroxysmal  headache,  her  father  from  severe 
neuralgia,  and  her  father's  brother  was  insane.  Occasionally,  mi- 
graine seems  due  to  the  inheritance  of  the  gouty  diathesis  :  a  father 
may  suffer  from  gout,  and  his  son  from  migraine.  A  similar  trans- 
formation may  occur  in  the  course  of  the  disease ;  migraine,  com- 
mencing in  early  life,  may  cease  when  distinct  gout  is  developed. 
Trousseau  has  emphasised  (but  also  exaggerated)  this  relation  by 
saying  that  "  migraine  and  gout  are  sisters." 

When  migraine  begins  early,  no  immediate  cause  can  usually  be 
traced  ;  but  when  the  disease  begins  later,  its  occurrence,  or  in  cases 
that  begin  earlier  its  exacerbation,  is  related  to  influences  that  depress 
and  weaken  the  nervous  system,  either  directly  or  through  the  general 

*  Dr.  H.  Airy  has  given  a  very  interesting  account  of  his  ocular  symptoms  in  the 
'  Philosophical  Transactions  '  for  1870.     The  best  systematic  account  of  the  dise*   i 
is  that  of  Dr.  Edward  Liveing  ('Megrim,  Sick  Headache,  and  some  allied  Disorder 
London,  1873). 


838  MTGRAINK. 

health.  Such  causes  are  excessive  brain-work  (especially  combined 
•with  anxiety  and  loss  of  rest),  over-fatigue  of  all  kinds,  work  in  hot 
and  crowded  rooms,  ana?uiia,  over-lactation,  and  the  like.  I  have  seen 
one  case  that  appeared  to  date  from  attacks  of  ague,  which  the  patient 
had  had  in  early  life. 

Symptoms. — The  essential  feature  of  migraine  is  paroxysmal  head- 
ache, but  a  large  number  of  the  patients  present  also  other  sensory 
symptoms  in  association  with  the.  headache,  and,  in  rare  cases,  these 
sensorv  symptoms  occur  alone,  without  headache.  These  associated 
symp^ms  are  so  peculiar  and  sti-iking,  that  undue  importance  has 
been  given  to  them  as  the  characteristics  of  the  disease.  They 
are  often  inconstant;  even  the  same  patient  may  have  some  head- 
aches with,  and  others  without,  these  accompaniments,  or  may  have 
simple  headaches  at  one  period  of  his  life  and  the  more  complex  series 
of  symptoms  at  another  period.  The  simple  headaches  have  the  same 
characters,  and  occur  under  the  same  causal  conditions  of  heredity, 
&c,  as  those  in  which  there  are  in  addition  other  sensory  symptoms. 

The  characteristic  feature  of  the  symptoms  is  their  paroxysmal 
character.  During  the  intervals  most  patients  are  free  from  any 
symptoms  of  nerve  derangement,  although  a  few  suffer  from  slighter 
headaches  of  a  different  character,  occasional  or  continuous.  The 
precise  elements  that  make  up  the  paroxysmal  seizure  vary  in 
different  cases,  and  often  even  in  the  same  individual.  Headache, 
as  already  stated,  is  the  most  constant,  and  is  very  seldom  absent ; 
next  in  frequency  are  nausea  and  vomiting,  then  some  disturbance  of 
vision,  affection  of  speech,  disturbed  sensation  in  the  limbs,  and  vaso- 
motor derangement,  while  the  least  common  are  motor  symptoms  in 
the  limbs.  The  frequency  of  vaso-motor  derangement  will  be 
variously  estimated,  however,  according  to  the  phenomena  included  in 
the  term,  and  if  a  simple  change  in  frequency  or  tension  of  the  pulse, 
or  in  the  colour  of  the  face,  is  included,  this  disturbance  becomes  one 
of  the  most  frequent  features  of  the  attacks. 

But  the  above  order  of  frequency  is  not  that  in  which  the  symptoms 
occur  during  an  attack.  The  various  sensory  accompaniments  of  the 
headache  usually  occur  first,  then  comes  the  pain,  and  after  the  pain 
has  lasted  for  a  time,  nausea  occurs,  followed  by  vomiting,  and  this 
often  ends  the  attack.  Yaso-motor  disturbance  may  be  present  in  some 
form  throughout  an  attack,  or  may  come  on  only  towards  the  close. 
When  sensory  disturbance  is  absent,  the  pain  is  the  first  symptom. 

Various  infl  uences  will  induce  a  paroxysm.  Fatigue  and  excitement 
are  the  most  common.  Digestive  disturbance  is  a  potent  cause,  and 
sometimes  a  particular  article  of  diet  will  always  induce  an  attack, 
but  most  of  the  sufferers  who  are  thus  susceptible  learn  by  experience 
the  dietetic  errors  that  are  efficient,  and  carefully  avoid  them  ;  hence, 
as  an  actual  fact,  it  is  not  very  common  for  attacks  to  be  thus  induced. 
Frequently,  after  the  usual  interval  between  the  attacks  has  nearly 


SYMPTOMS.  839 

elapsed,  a  slight  error  in  diet  is  sufficient,  although,  soon  after  the 
patient  has  had  an  attack,  even  actual  indigestion  has  no  effect.  The 
influence  of  stomach  derangement  is  also  exaggerated  on  account 
of  a  misconception  of  the  significance  of  the  vomiting  that  so  often 
occurs.  The  bile  that  comes  up  is  thought  to  be  a  proof  of  "  bilious- 
ness," when  its  rejection  is  merely  the  result  of  the  repeated  vomiting. 
In  some  patients  exposure  to  cold  will  bring  on  a  paroxysm.  Another 
occasional  excitant  is  a  visual  impression,  such  as  watching  moving 
objects  or  seeing  some  peculiar  kind  of  motion.  Over-use  of  the 
eyes  may  also  bring  on  an  attack.  In  some  patients  a  bright 
light,  or  a  sudden  change  of  light,  has  the  same  effect,  and  so  has  a 
loud  noise  or  a  peculiar  odour.  Indeed,  it  seems  as  if  a  peculiar  habit 
may  become  established,  so  that  a  certain  sensory  impression  will 
always  induce  a  paroxysm. 

Premonitory  symptoms  are  present  in  some  cases,  but  are  less 
frequent  when  there  are  accessory  symptoms  than  in  the  attacks  that 
consist  of  pain  only.  The  day  before  an  attack  the  patient  may  com- 
plain of  heaviness  in  the  head,  or  of  slight  pain,  or  of  somnolence. 
When  attacks  consist  of  simple  headache,  the  patient  often  wakes  up 
with  it.  When  sensory  symptoms  occur  first,  these  often  begin  quite 
suddenly.  The  patient,  for  instance,  may  feel  perfectly  well,  when  he 
is  suddenly  conscious  of  some  disturbance  of  vision,  of  a  bright  spot, 
for  instance,  on  one  side  of  the  field  of  vision,  which  slowly  enlarges 
and  spreads,  becoming  darker  in  the  centre  as  it  extends,  and 
changing  its  round  outline  into  an  angular  form.  Or  he  may  sud- 
denly be  conscious  of  dimness  of  sight  towards  one  side,  which 
increases  in  extent  and  intensity  until  one  half  of  each  field  is  blind. 
Or  the  first  symptom  may  be  tingling  in  one  hand,  which  spreads 
up  the  arm.  Such  sensory  disturbance  lasts  for  ten,  twenty,  or  thirty 
minutes,  and  then  passes  away,  and  as  it  subsides,  headache  comes 
on ;  it  is  usually  of  great  intensity,  commences  at  one  spot,  and  slowly 
spreads.  After  a  few  hours  the  patient  feels  sick,  and  the  nausea 
slowly  increases  and  at  last  ends  in  vomiting;  then  the  sufferer 
goes  to  sleep  for  an  hour  or  two  or  for  the  night,  and  wakes  up  well. 
These  various  symptoms  are  generally  unilateral  in  distribution. 
The  pain  is  sometimes  bilateral,  but  it  is  then  greater  on  one  side 
than  on  the  other.     The  symptoms  may  now  be  considered  in  detail. 

Yisual  disturbance  occurs  in  at  least  half  the  cases,  and  is  the 
earliest  symptom  of  an  attack.  It  may  consist  in  partial  loss  of 
sight,  or  spectral  appearances,  or  both.  The  unilateral  character  of 
visual  symptoms  is  always  manifested  as  affection  of  the  correspond- 
ing halves  of  both  fields  of  vision. 

Loss  of  sight  is  always  imperfect.  There  may  be  sudden  general 
dimness  of  vision,  or  there  may  be  a  lateral  limitation  of  the  field, 
extending  from  one  side  and  not  reaching  the  centre,  or  commencing 
first  on  one  and  afterwards  on  the  other  side,  during  the  same  attack. 
The  resulting  hemianopia  may  be  complete.     In  other  cases,  the  first 


840  MIGRAINE. 

change  in  vision  is  a  spot  of  dimness  of  sight,  lateral  or  central  in 
position,  which  gradually  increases  in  size  and  extends  towards  the 
periphery ;  when  lateral  in  position  it  usually  does  not  pass  beyond 
the  middle  line,  so  that  from  this  also  hemianopia  results.  Yery 
rarely  the  spot  is  situated  in  tbe  upper  or  lower  parts  of  the  field,  and 
may  cause  a  form  of  transverse  hemianopia.  The  degree  of  loss 
varies  ;  it  is  often  described  as  a  "  cloud,"  but  the  darkness  may 
be  noticeable  only  when  a  bright  light  is  looked  at.  As  the  dark 
spot  increases  in  size  it  often  clears  in  the  centre.  When  spectral 
appearances  occur,  they  may  commence  as  a  bright  spot,  gradually 
expanding,  or  they  may  develop  out  of  this  area  of  dimness.  In 
the  latter  case,  as  the  dark  spot  increases  it  becomes  luminous  at 
the  periphery  and  expands,  so  as  at  first  to  form  a  circle ;  but,  if 
lateral,  it  may  break  at  the  middle  line  into,  a  ci*escent.  In  some 
cases  it  spreads  over  almost  the  whole  field  of  vision.  When  a 
luminous  spot  is  the  first  change  and  this  expands,  it  may  become 
dim  in  tbe  centre.  Very  commonly  the  outer  edge  assumes  a  zigzag 
shape  with  prominent  and  re-entrant  angles,  like  the  ground  plan  of 
a  fortification,  and  hence  called  "  fortification  spectrum."  At  one 
part  it  becomes  fainter  and  ceases,  so  that  there  is  a  break  in  the 
outline.  The  outer  boundary  is  the  most  brilliant,  and  is  often 
limited  by  colour;  inside,  the  luminosity  extends  for  a  little  dis- 
tance, gradually  becoming  fainter.  Very  frequently  within  tbe  bright 
outline,  however  it  arises,  there  seem  to  be  luminous  particles  in 
rapid  irregular  movement.  Tbe  spectrum  increases  with  the  blind 
area,  gradually  becomes  indistinct,  and  disappears  at  the  periphery 
of  the  field.  These  visual  phenomena  always  affect  the  field  of 
vision  of  both  eyes,  although  the  patient  often  imagines  that  the 
phenomena  observed  on  one  side  are  seen  with  one  eye  only.  They 
may  present  considerable  variation  in  tbe  same  case.  Thus  one 
patient  described  sometimes  hemianopia,  sometimes  coloured  lights, 
sometimes  merely  a  sensation  as  of  moving  water  before  the  eyes. 
Many  patients  experience  only  slight  and  vague  ocular  symptoms, 
such  as  sparks  or  mere  flashes  of  light.  Very  rarely  there  is  double 
vision. 

Disturbance  in  the  function  of  the  other  special  senses  is  exceed- 
ingly rare,  but  a  few  cases  are  on  record  in  which  phenomena  have 
been  observed  in  hearing  and  taste  similar  to  those  in  vision.  Thus 
there  has  been  one-sided  deafness  followed  by  a  noise  in  the  ear,  or 
loss  of  taste  followed  by  a  subjective  sensation.  Transient  tinnitus 
is  occasionally  observed  in  the  subjects  of  migraine,  without  connection 
with  the  attacks. 

Other  sensory  symptoms  are  felt  in  the  limbs,  face,  throat,  tongue, 
and  adjacent  parts,  but  these  are  far  less  frequent  than  is  the  visual 
disturbance.  In  the  limbs,  the  sensation  is  felt  chiefly  in  the  arm,  very 
seldom  in  the  leg.  It  may  occur  alone  as  the  first  stage  of  the  attack, 
but  is  more  often  associated  with  the  visual  phenomena,  succeeding 


SYMPTOMS.  841 

the  latter  but  commencing  before  the  affection  of  sight  has  quite 
ceased.  In  character,  the  disturbance  of  cutaneous  sensibility  is  very 
similar  to  that  of  vision,  allowance  being  made  for  the  difference  in 
the  character  of  the  function.  There  is  the  same  combination  of 
sensory  irritation  and  sensory  loss.  Tingling  in  the  skin,  or  "  pins  and 
needles,"  is  felt  in  some  part  of  the  hand,  as  the  fingers,  or  in  the  wrist, 
and  as  it  spreads  it  is  succeeded  by  numbness  and  defect  of  sensibility, 
sometimes  amounting  to  actual  anesthesia.  In  other  cases  the 
numbness  occurs  first,  and  is  succeeded  by  tingling.  The  sensory 
disturbance  in  its  double  form  may  pass  up  the  limb  from  the 
extremity,  and  the  leg  may  be  affected  after  the  arm,  just  as  in  the 
sensoi-y  aura  of  epilepsy.  Sometimes,  instead  of  a  gradual  extension, 
the  tingling  passes  from  one  part  to  another  at  a  distance.  It  is 
generally  confined  to  one  side,  but  sometimes  is  felt  first  in  one  arm 
and  then  in  the  other.  A  sensation  in  the  lips  and  tongue  is  generally 
secondary  in  time  to  that  in  the  limbs ;  it  rarely  exists  alone.  It  may  be 
felt  in  the  cheek,  lips,  tongue,  or  fauces,  on  one  side  or  on  both  ;  the 
side  is  usually  the  same  as  that  of  the  limbs,  but  the  sensation  may  be 
bilateral  in  the  lips  and  throat,  and  unilateral  in  the  limbs.  The 
duration  of  these  sensations  is  generally  about  ten  or  fifteen  minutes. 
Occasionally  slight  motor  weakness  accompanies  the  tingling,  just  as  it 
may  do  in  the  sensory  discharge  of  epilepsy.  For  instance,  the  attack 
in  one  patient  commenced  by  dimness  of  sight,  and  this  was  followed  by 
tingling  in  the  fingers  of  the  left  hand ;  the  sensation  passed  up  the 
arm  to  the  shoulder,  and  was  followed  by  weakness  of  the  limb  for 
about  ten  minutes ;  then  headache  came  on  in  the  right  occipital 
region,  and  lasted  for  twelve  hours. 

Motor  symptoms  in  the  limbs,  with  or  after  the  sensory  disturbance, 
are  usually  confined  to  such  transient  weakness  as  occurred  in  the 
case  just  mentioned.  If  any  motor  spasm  is  present,  the  case  usually 
diverges  very  much  from  the  type,  and  sometimes  is  of  such  a  character 
as  to  render  it  doubtful  whether  it  should  be  classed  with  migraine  or 
not.  In  one  patient  each  attack  of  headache  was  preceded  by  sudden 
tingling  in  the  calf,  followed  by  painful  cramp  in  the  calf  muscles, 
lasting  a  few  minutes  only.  The  same  patient,  however,  had  at 
other  times  attacks  in  which  her  face  suddenly  became  crimson,  sharp 
pains  occurred  in  the  head,  and  seemed  to  pass  down  the  side  to  the 
leg,  which  was  then  "  drawn  up  "  in  spasm  for  a  few  minutes. 

Difficulty  in  speech,  transient  aphasia,  is  another  occasional  sym- 
ptom of  the  commencing  attack.  If  there  are  sensory  symptoms, 
these  are  almost  always  right-sided,  and  are  situated,  in  most  cases, 
in  the  right  arm.  If  there  is  visual  disturbance,  this  also  is  in 
the  right  half  of  the  field,  but  I  have  only  once  met  with  aphasia 
in  association  with  an  affection  of  sight  alone.  The  rule  of  the 
right-sided  association  probably  does  not  hold  good  of  left-handed 
persons,  and  it  is  not  quite  absolute  in  other  cases.  I  have  met  with 
one  case,  in  a  right-handed  man,  in  whom  the  attack  began  with  left- 


842  MIGEAINE. 

sided  hemianopia,  followed  by  tingling  in  the  left  foot,  which  passed 
up  the  leg  and  side  to  the  mouth  and  tongue,  and  then  the  speech 
was  deranged,  the  words  of  a  sentence  "  coming  out  in  wrong  order.'* 
The  common  character  of  the  defect  is  that  there  is  a  difficulty  in 
finding  the  right  word,  or  a  use  of  wrong  words  in  both  speaking  and 
writing,  or  very  rarely  a  total  inability  to  speak.  The  latter  sug- 
gests motor  aphasia  (see  p.  114),  but  the  more  common  form  has  the 
character  of  the  sensory  variety.  In  one  case  the  affection  of  speech 
was  clearly  of  this  character;  the  patient  was,  for  a  few  minutes, 
completely  "  word-deaf ;"  when  spoken  to,  she  heard  the  sound  per- 
fectly, but  could  not  tell  what  was  said.  A  few  similar  cases  are  on 
record.* 

Slight  mental  change  occurs  in  some  patients  during  the  attack. 
Emotional  depression,  restlessness,  or  confusion  of  ideas  are  the  most 
common  ;  sometimes  there  is  transient  loss  of  memory.  Brief  stupor, 
without  complete  unconsciousness,  sometimes  occurs  soon  after  the 
onset  of  an  attack,  without  interrupting  the  progress  of  the  sensory 
disturbance.  Among  other  peculiar  conditions  that  have  been 
described  is  a  sensation  of  "  double  consciousness  "  or  a  vivid  recollec- 
tion of  events  long  past.  The  mental  change  may  be  the  earliest 
symptom,  or  it  may  succeed  the  affection  of  sight,  or  occur  when  the 
sensation  in  the  limbs  ascends  to  the  head. 

G-iddiness  is  not  a  frequent  symptom  of  the  attacks  themselves. 
It  is  usually  a  vague  sense  of  defective  equilibrium,  rarely  amounting 
to  definite  vertigo.  It  varies  in  time,  being  occasionally  early,  but 
more  often  succeeding  the  sensory  disturbance,  and  it  often  accom- 
panies the  headache.  Any  one  of  this  series  of  symptoms  may 
precede  the  headache,  or  all  may  be  absent.  Even  when  many  of 
them  occur,  their  duration  is  short,  varying  from  fifteen  to  thirty 
minutes,  before  they  give  place  to  the  pain  in  the  head. 

The  headache  is  not  only  the  most  constant  symptom,  it  is  also 
the  most  distressing.  It  is  not,  however,  so  alarming  to  the  patient 
as  the  sensory  symptoms  are,  especially  in  those  who  are  unaccustomed 
to  them,  and  in  whom  they  occur  at  long  intervals,  or,  for  the  first 
time,  in  adult  life.  The  pain  has  generally  recurred  during  many 
years,  and  the  sufferer  knows  what  to  expect  and  how  best  to  endure 
it.  It  varies  much  in  degree,  but  is  very  seldom  trifling.  Often  it 
has  a  characteristic  course,  uniform  in  the  same  patient;  it  begins 
gradually,  slowly  inci'eases  to  a  considerable  degree  of  intensity,  and 
after  a  variable  time  it  subsides,  sometimes  slowly,  sometimes  rapidly. 
It  is  usually  an  acute  pain  at  the  onset,  and  may  remain  so  throughout, 
or  may  assume  a  duller  character  as  it  spreads.  Movement,  noise, 
and  light  usually  increase  its  intensity.  Sudden  stooping  also  makes 
it  worse,  but  the  patient  is,  nevertheless,  most  comfortable  in  the 

*  It  is  probable,  and  in  harmony  with  the  other  symptoms,  that  the  primary  dis- 
turbance of  speech  is  "  sensory  aphasia,"  and  that  when  there  is  "  motor  aphasia," 
this  is  analogous  to  the  weakness  of  the  arm  that  accompanies  the  sensory  discharge. 


SYMPTOMS.  843 

recumbent  posture,  and  suffers  more  when  he  attempts  to  sit  up  or  to 
stand.  In  most  eases  the  headache  begins  on  one  side,  and  in  many 
it  is  confined  to  one  side ;  in  others  it  becomes  general,  so  that  the 
name,  while  founded  on  a  common  characteristic,  has  no  universal 
significance.  When  the  pain  begins  at  one  spot  it  most  frequently 
is  in  the  temple,  and  is  confined  at  first  to  a  small  area  that  can  be 
covered  by  the  tip  of  the  finger.  In  other  cases  it  begins  in  a  small 
spot  on  the  forehead,  or  in  the  forehead  and  eyeball,  seldom  in  any 
limited  area  at  other  parts  of  the  head.  When  thus  limited  at  first, 
it  seems  generally  superficial,  but  often  has  a  boring  character,  as 
if  some  instrument  were  being  forced  into  the  skull.  After  a  time 
the  pain  may  spread  through  a  considerable  part  of  one  side  of 
the  head,  and  not  unfrequently  through  both  sides.  Sometimes 
it  begins  at  the  back  of  the  head,  in  the  occipital  region  on  one  side, 
and  may  then  extend  forward  to  the  temple.  It  occasionally  com- 
mences in  the  middle  of  the  head,  and  spreads  down  one  side.  From 
the  back  or  side  of  the  head,  the  pain  may  pass  down  the  side  of  the 
neck  and  even  into  the  arm.  Occasionally  it  spreads  from  one  side  to 
the  other,  and  may  then  cease  on  the  side  first  affected.  In  one  in- 
stance in  which  it  had  this  course,  it  ultimately  ceased  on  the  second 
side,  and  recommenced,  in  slight  degree,  on  the  side  first  affected 
before  finally  passing  away.  Even  when  the  pain  is  limited  in  area 
and  superficial  in  character,  there  is  seldom  any  local  tenderness,  but 
now  and  then  extensive  pain  over  the  head  may  be  accompanied  by 
some  general  tenderness  of  the  hairy  scalp,  which  continues  for  a  time 
after  the  headache  has  ceased.  When  the  pain  is  unilateral  and  felt 
over  a  considerable  area,  it  is  generally  on  the  side  opposite  to  the 
peripheral  symptoms.  It  usually  comes  on  as  the  sensory  disturbance 
is  declining,  and  always  lasts  for  several  hours,  often  for  the  rest  of 
the  day.  It  is  not  always  constant  either  in  character  or  seat,  but 
when  inconstant  in  seat  the  patient  has  certain  kinds  of  headache 
which  maintain  their  characters,  although  sometimes  one,  sometimes 
another  comes  on.  In  other  cases,  at  a  certain  period  of  life,  there  is  a 
change  in  the  seat  and  character  of  the  pain.  Thus  in  one  case  the 
pain  for  many  years  was  occipital,  but  afterwards  it  was  always 
limited  to  one  frontal  region. 

Nausea  accompanies  the  headache  in  a  large  number  of  cases,  but 
often  does  not  commence  until  the  pain  has  reached  its  height..  It  is 
attended  with  a  total  inability  to  take  food,  and  food  that  is  taken  is 
not  digested,  apparently  from  a  derangement  of  the  gastric  secretions. 
The  nausea  often  results  in  vomiting,  but  retching  is  still  more  fre- 
quent. Neither  occurs,  as  a  rule,  until  after  the  pain  in  the  head  h  as- 
reached  its  climax,  and  often  not  until  the  pain  is  subsiding,  and  then 
it  may  terminate  the  seizure,  even  when  nothing  is  ejected.  It 
is  common  for  the  headache  to  commence  in  the  morning,  for  nausea 
to  come  on  in  the  course  of  the  day,  and  vomiting  in  the  evening. 
Sometimes  the  vomiting  begins  earlier  ;  in  one  case,  in  which  the  visual 


S44  MIGEAINE. 

disturbance  was  unusually  prolonged,  lasting  two  hours,  the  vomiting 
commenced  before  it  had  ceased  and  before  the  headache.  If  it  occurs 
while  the  headache  is  severe,  the  vomiting  does  not  influence  the  pain. 
When  there  is  no  headache  there  is  no  vomiting.  The  condition  is 
acompanied  with  great  prostration,  and  the  patient  is  very  much  like 
one  suffering  from  sea-sickness. 

The  most  common  vaso-motor  symptom  is  pallor  of  the  face  at  the 
onset  of  an  attack,  and  often  throughout  its  course.  The  extremities 
also  are  usually  cold.  The  face  is  not  only  pale,  but  has  a  "  pinched  " 
or  "  drawn  "  expression.  The  accessible  arteries  may  be  sometimes 
felt  to  be  contracted.  In  some  cases  this  aspect  continues  throughout 
the  attack;  in  others  the  pallor  gives  place  to  flushing  as  the  pain 
in  the  head  develops,  and  there  may  even  be  general  perspiration. 
Earely  the  face  is  flushed  from  the  first.  Still  more  rarely  there  is  a 
conspicuous  difference  in  the  aspect  of  the  two  sides  of  the  face ;  there 
may  be  pallor  only  on  one  side,  and  in  addition  the  eye  may  be 
retracted,  the  conjunctiva  injected,  and  the  pupil  small;  as  the 
paroxysm  goes  off  this  condition  may  be  exchanged  for  one  of  hyper- 
emia, the  face  becoming  warm,  the  ear  red,  and  the  pupil  resuming 
its  normal  size  (Du  Bois  Eeymond,  Morselli).  The  latter  must  be 
referred  to  diminished  action  and  the  former  to  increased  action  of 
the  sympathetic  fibres,  although  in  over-action  the  retraction  of  the  eye 
&nd  redness  of  the  conjunctiva  are  exceptional.  Unilateral  sweating 
has  also  been  observed.  At  the  end  of  an  attack,  in  which  the 
final  dilatation  of  vessels  has  been  marked,  puffiness  of  the  scalp  has 
been  observed  in  rare  cases,  and  even  ecchymoses  at  the  seat  of  the 
most  intense  pain.  It  must,  however,  be  remembered  that  such 
unilateral  sympathetic  symptoms  are  not  only  exceptional,  but  ex- 
tremely rare.  In  a  woman,  aged  fifty,  liable  to  right- sided  migraine 
from  youth,  the  right  temporal  artery  was  harder  and  more  rigid 
than  the  left,  and  the  right  cornea  presented  an  arcus  senilis  twice  as 
broad  as  that  on  the  other  side  (De  Giovanni).  QSdema  of  the  optic 
disc  has  been  said  to  occur  during  the  paroxysm  (Mollendorff),  but 
•as  a  rule  both  during  the  attack  and  in  the  intervals  the  appearance 
of  the  discs  is  perfectly  normal.  Occasionally,  retardation  of  the 
pulse  occurs  during  the  paroxysms.  In  one  of  my  patients  the  pulse 
always  fell  to  about  56,  and  a  retardation  to  40  has  been  observed. 

The  termination  of  the  paroxysm  is  sometimes  attended  not  only 
by  vomiting,  but  also  by  some  secretion,  copious  diuresis  or  perspira- 
tion. The  pain  passes  away  gradually,  very  seldom  quickly.  The 
most  frequent  termination  is  by  sleep.  During  the  height  of  the 
attack,  the  patient  may  be  drowsy  and  doze,  but  this  brings  no  relief ; 
as  the  pain  is  subsiding,  however,  he  goes  to  sleep,  sometimes  for  a 
short  time  only,  and  wakes  up  free  from  pain.  The  duration  of  the 
headache  is  always  several  hours ;  often  it  commences  in  the  early 
morning  and  lasts  the  entire  day;  in  severe  cases  it  may  last  for 
several  days. 


VARIETIES.  845 

Varieties. — The  cases  in  which  the  collateral  disturbance  is  absent, 
and  the  attacks  consist  only  of  pain  and  sickness,  are  ver  j  common.  The 
pain  has  the  same  characters  as  in  the  cases  with  other  sensory  sym- 
ptoms, and  may  be  attended  by  the  same  vaso-motor  disturbance.  In 
one  patient,  for  instance,  the  pain  began  in  one  eye  and  the  supra-orbital 
region,  and  commenced  alternately  on  each  side  ;  from  the  place  of 
commencement  it  extended  over  the  whole  head,  and  into  the  throat. 
It  is  very  common  for  two  kinds  of  headache  to  occur,  and  for  one  only 
to  be  accompanied  by  other  sensory  symptoms.  Sometimes  one  is 
attended  with  vomiting,  and  the  other  is  not.  One  patient,  for 
instance,  sometimes  had  attacks  of  pain  in  the  forehead  and  temples, 
and  at  other  times  pain  at  the  top  and  back  of  the  head,  and  only  the 
latter  were  attended  by  sickness. 

Migraine  in  adults  is  not  commonly  attended  by  any  alteration  in 
the  temperature  of  the  body,  but  in  children  there  may  be  considerable 
pyrexia,  which  impresses  a  special  and  sometimes  misleading  character 
on  the  attack.  Thus,  a  child  at  the  age  of  two  became  liable  to 
attacks  which  lasted  only  a  few  hours,  and  recurred  at  intervals  of 
two  or  three  months.  In  each  there  was  severe  one-sided  pain  in  the 
head  ;  the  temperature  rose  to  102°  or  103° ;  sickness  came  on,  the 
child  went  to  sleep,  and  woke  up  well. 

The  sensory  symptoms  of  migraine,  as  we  have  seen,  sometimes 
occur  without  headache,  or,  more  frequently,  with  headache  that  is  so 
slight  as  to  cause  the  patient  no  distress,  and  to  lead  him  to  place  no 
weight  upon  it  in  his  description  of  the  symptoms.  These  cases  are  of 
great  importance,  because  their  nature  is  often  misunderstood.  In  one 
case,  with  characteristic  visual  disturbance  (an  expanding  luminous 
spot  and  hemianopia),  the  only  discomfort  was  that  a  cough  or  deep 
inspiration  caused  momentary  pain  over  the  eyebrows  during  two  or 
three  days  after  an  attack.  A  more  common  history  is  that  some 
attacks  are  complete,  consisting  of  sensory  disturbance  and  headache, 
while  in  others  the  former  occurs  alone.  In  rare  cases  the  sensory  dis- 
turbance or  aphasia  generally  occurs  by  itself,  headache  being  seldom 
or  never  associated.  Lastly,  some  sufferers  from  migraine  often  have 
slighter  and  variable  sensory  disturbance,  evidently  of  the  same  nature, 
although  not  of  the  same  form,  as  that  which  precedes  the  headaches. 
One  patient,  for  instance,  with  characteristic  headaches  preceded  by 
hemianopia,  complained  of  bright  stars  before  the  eyes  whenever  she 
had  looked  at  a  brilliant  light,  and  sometimes  one  of  these  stars, 
brighter  than  the  rest,  would  start  from  the  right  lower  corner  of  the 
field  of  vision,  and  pass  across  the  field,  generally  quickly,  in  a  second, 
sometimes  more  slowly,  and  when  it  reached  the  left  side  would 
break  up  and  leave  a  blue  light  in  which  luminous  points  were  moving. 
These  sensations  were  not  succeeded  by  headache,  although  the  pain 
always  followed  the  hemianopia.  Aphasia  does  not  often  occur  without 
headache ;  such  attacks  may  be  very  puzzling  unless  their  nature  is  sus- 
pected.  I  have  once  known  ocular  spectra  to  develop  after  the  headache 


846  MIGRAINE. 

had  commenced,  and  also  tingling  in  the  limbs  of  one  side,  from  the 
hand  to  the  elbow,  and  foot  to  the  knee,  to  follow  characteristic  attacks 
of  pain.     Very  rarely  vomiting  may  precede  the  headache. 

I  have  met  with  one  curious  case  in  which  visual  disturbance, 
exactly  such  as  precedes  attacks  of  migraine,  occurred  frequently 
during  many  years  as  an  isolated  symptom  ;  at  no  time  was  there  any 
pain.  The  patient  was  a  man  of  sixty,  the  subject  of  chronic  bron- 
chitis and  some  loss  of  memory,  but  with  no  other  indications  of  nerve 
disease.  The  visual  spectrum  was  generally  a  brightly  coloured 
zigzag ;  sometimes  it  had  the  shape  of  a  broken  oval,  but  more  often 
a  long  comet-like  form,  commencing  on  one  side  of  the  field  of  vision 
and  extending  downwards.  Rarely  there  was  a  luminous  disc,  which 
would  ascend,  break  into  a  four -leaved  object,  and  then  disappear. 
A  noteworthy  feature  of  the  illusion  was  that  the  angular  spectrum 
was  sometimes  related  to  the  image  of  some  seen  object.  Thus,  on 
one  occasion,  a  plate,  which  was  before  the  patient  as  he  sat  at  table, 
appeared  surrounded  by  the  coloured  angular  spectrum.*  A  similar 
relation  has  been  described  to  me  in  other  cases ;  a  zigzag  spectrum 
would  fix  itself  for  a  short  time  around  some  object  at  which  the 
person  was  looking.  A  more  general  phenomenon  of  the  same  class  is 
the  greater  brightness  of  the  subjective  sensation  when  the  eyes  are 
open  than  when  they  are  closed — the  morbid  activity  is  intensified  by 
the  impulses  from  the  optic  nerves. 

Sensory  disturbance  in  the  limbs  does  not  often  occur  without  head- 
ache, but  occasionally  the  headache  is  slight.  Sometimes  an  attack 
is  apparently  rendered  abortive  in  consequence  of  some  drug  that 
is  taken,  such  as  bromide, — as  in  the  following  case,  which  deserves 
description  on  account  of  the  illustration  it  affords  of  the  deliberate 
march  of  the  sensory  disturbance.  A  gentleman,  the  subject  of 
migraine,  was  working  with  the  microscope  one  afternoon,  when  his 
sight  became  dim  so  that  he  could  only  just  read  large  print,  and 
continued  so  in  spite  of  a  drachm  of  bromide.  After  two  hours, 
tingling  suddenly  commenced  in  the  left  thumb,  and  spread  to  the 
fingers,  and  then  was  felt  in  the  middle  of  both  lips,  in  the  tip  of 
the  nose,  and  beneath  the  tip  of  the  tongue.  Then  it  was  felt  in  the 
left  arm  near  the  axilla,  and  in  the  left  side  of  the  fauces  and  of  the 
face  over  the  lower  jaw.  A  few  minutes  later  it  involved  the  fauces 
on  both  sides  and  the  palate,  and  caused  an  unpleasant  sense  of  con- 
striction. It  then  ceased  and  headache  came  on.  Another  attack 
began  in  the  same  manner,  but  after  being  felt  in  the  fingers  and  lips 
and  tongue,  it  became  intense  at  the  wrist,  and  ceased  in  the  lips  ;  the 
sensation  passed  up  the  ulnar  side  of  the  forearm  and  then  ceased,  but 
afterwards  recurred  in  the  cheek  and  side  of  the  throat. 

The  variations  in  the  character  and  seat  of  the  pain  which  have  been 
already  mentioned  are  sometimes  such  as  to  make  the  case  deviate 

*  The  patient  was  a  mechanical  draughtsman,  and  he  had  a  small  book  full  of 
drawings  of  the  appearances  that  he  saw. 


COURSE.  847 

definitely  from  the  type.  This  is  especially  marked  in  cases  in  which 
the  pain  presents,  in  its  extreme  development,  an  approximation  to 
neuralgia.  It  may,  for  instance,  spread  from  the  head  down  the 
cervical  spine,  or  the  sides  of  the  neck  to  the  shoulders.  In  one 
patient,  in  whom  the  pain  (preceded  by  the  usual  visual  symptoms)  was 
chiefly  over  the  posterior  half  of  the  head  on  the  left  side,  one  severe 
attack  was  followed  by  an  eruption  of  herpes  over  the  left  half  of  the 
occipital  bone,  which  had  definite  neuralgia  for  its  sequel.  Both 
before  and  after  this,  the  commencing  subsidence  of  the  pain  in  each 
attack  was  commonly  attended  by  the  occurrence  of  small  slightly 
raised  "  lumps  "  in  the  skin  of  the  same  region,  about  the  size  of  a  pea. 
I  have  met  with  tenderness  of  the  scalp  after  the  pain,  in  other  cases, 
in  which  it  began  in  one  temporal  region,  after  hemianopia. 

Course. — The  interval  between  the  attacks  varies  in  different  cases ; 
it  is  usually  between  a  fortnight  and  two  months.  It  is  generally 
about  three  or  four  weeks,  but  the  periodicity  is  not  often  exact.  In 
a  case  mentioned  by  Trousseau,  however,  the  attacks  occurred  each 
fortnight  almost  to  an  hour.  In  women  they  often  occur  about  the 
menstrual  period,  generally  after  the  catamenia  have  ceased.  The 
intervals  are,  on  an  average,  shorter  in  the  cases  in  which  there  is  only 
pain  than  in  those  in  which  there  are  associated  sensory  symptoms ; 
and  when  these  symptoms  occur  alone,  without  headache,  the  intervals 
generally  amount  to  several  months.  The  intervals  are  doubtless 
rendered  more  irregular  than  they  otherwise  would  be  by  the  influence 
of  exciting  causes,  effective  when  the  usual  period  has  nearly  elapsed. 
In  the  intervals  there  are  often  no  symptoms,  or  there  may  be  slight 
headache  of  a  different  character,  or  definite  neuralgia,  or  some  other 
functional  disturbance. 

It  is  not  uncommon,  as  already  mentioned,  for  some  change  in  the 
character  of  the  disease  to  occur  at  a  certain  period.  Sensory 
disturbance  may  cease,  or,  if  previously  present,  may  come  on.  Thus 
one  patient  had  hemianopia  with  the  attacks  of  migraine  until  the  age 
of  fifty,  when  the  visual  disturbance  ceased,  and  the  headaches 
occurred  alone.  Occasionally,  some  morbid  influence,  chronic  ill- 
health,  acute  disease,  anxiety,  or  injury,  may  induce  an  increase  in  the 
intensity  of  the  affection  or  a  change  in  its  character.  Thus  one 
patient,  whose  mother  was  the  subject  of  migraine,  suffered  from 
simple  "  sick  headaches  "  since  childhood.  At  twenty-five  he  had  a 
slight  concussion  of  the  head,  falling  against  a  wall.  Hemianopia 
came  on  in  a  few  minutes,  followed  by  headache  more  severe  than  the 
patient  had  had  before,  and  from  that  time  each  attack  was  preceded 
by  the  same  visual  symptom. 

Migi*aine  does  not  itself  involve  any  danger  to  life.  We  have  seen, 
however,  that  the  vascular  disturbance  may  lead  in  time  to  local  vas- 
cular degeneration,  and  this  affords  an  explanation  of  the  observed 
fact  that  sufferers  from  migraine  occasionally  suffer  from  vascular 
lesions  of  the  brain  comparatively  early  in  the  degenerative  period  of 


848  "  MIGRAINE 

life ;  but  this  sequel  is  rare.  It  may,  however,  occur  in  the  part  of 
the  brain  that  has  been  the  seat  of  the  periodical  functional  derange- 
ment. Hemianopia  habitually  preceded  the  headaches  in  a  woman 
who,  after  reaching  the  degenerative  period,  found  one  day  that  the 
hemianopia  persisted  after  tbe  pain.  It  was  permanent,  and  due,  as 
was  subsequently  ascertained,  to  a  lesion  in  the  opposite  cuneus.* 
In  some  cases,  after  many  attacks  attended  by  intellectual  impairment, 
some  failure  of  mental  power  has  been  observed  in  the  intervals. 

Complications  and  Associations. — Yertigo  is  occasionally  met  with  in 
the  subjects  of  migraine,  not  only  as  part  of  an  attack,  but  also  as  an 
occasional  symptom  at  other  times.  Some  of  those  who  present  it 
are  in  the  second  half  of  life,  and  the  associated  symptoms  show  that 
the  vertigo  is  of  the  labyrinthine  variety.  Thus  one  patient,  forty- 
seven  years  of  age  and  gouty,  who  had  been  liable  for  many  years  to 
migraine,  had  an  attack  of  vertigo  with  brief  tinnitus  and  sickness ; 
the  watch  was  almost  inaudible  through  the  bone  on  each  side,  and 
no  note  of  Galton's  whistle  could  be  heard  through  the  air.  In  him 
tinnitus  was  inconstant,  but  heard  occasionally  on  each  side.  It  is 
probable  that,  in  such  cases,  the  central  tendency  to  functional 
derangement  renders  the  patient  peculiarly  susceptible  to  the  influ- 
ence of  labyrinthine  changes.  I  have  several  other  examples  of  the 
same  combination.  In  other  cases,  again,  sudden  attacks  of  vertigo 
occur  without  any  indication  of  aural  changes,  and  sometimes  seem 
to  be  the  result  simply  of  the  central  instability.  Thus  one  patient 
was  liable,  in  the  intervals  between  the  attacks  of  migraine,  to  sudden 
sensations  of  unsteadiness,  vaguely  referred  to  the  legs,  without  any 
aural  symptoms.  Another  patient  had  sudden  attacks,  in  which  there 
was  a  tendency  to  fall  backwards,  accompanied  by  sickness.  At  other 
times  she  had  paroxysmal  headaches  without  sickness. 

The  relationship  of  migraine  to  other  diseases  is  of  great  import- 
ance. That  to  gout  has  been  already  mentioned  in  the  account  of  the 
causal  relations  of  the  disease.  An  alternation  is  often  observed 
with  some  other  form  of  neurosis,  or  at  least  a  transition  from, 
one  to  the  other.  Migraine  occasionally  ceases,  and  is  replaced  by 
simple  neuralgia.  Many  other  instances  of  such  transition  have  been 
collected  by  Liveing,  as,  for  instance,  to  gastralgia,  laryngeal  spasm, 
anginal  seizures,  and  paroxysmal  insanity.  In  one  case  acute  mania 
came  on. 

The  most  important,  and  one  of  the  most  frequent,  of  these  associa- 
tions is  the  relation  of  migraine  to  epilepsy.  The  connection  of  the 
diseases  is  of  special  interest  because  the  sensory  disturbance  of  the 
two  has  so  many  common  features.  I  have  met  with  many  cases  in 
which  these  maladies  occurred  in  the  same  individual,  a  few  of  which 
have  been  mentioned  in  the  chapter  on  "  Epilepsy."  In  some  instances 
migraine  had  existed  for  many  years,  and  the  patient  afterwards 
became  epileptic,  the  migraine  usually  ceasing  or  becoming  much 
*  Noyes,  '  Journ.  Nerv.  Ment.  Dis./  1889. 


PATHOLOGY.  849 

slighter  when  the  epilepsy  developed ;  but  one  epileptic  began  to 
suffer  from  migraine  when  his  fits  ceased.  A  recurrence  of  previous 
migraine  on  the  cessation  of  epilepsy  occurred  in  some  cases.  In  a 
few  cases  both  maladies  co-existed  in  considerable  intensity.  In 
almost  all  the  individuals  who  had  suffered  from  the  two  diseases,  the 
attacks  of  migraine  were  attended  by  well-marked  sensory  disturbance 
in  addition  to  the  headache  and  vomiting,  and  in  one  or  two,  abortive 
attacks  of  sensory  disturbance  occasionally  occurred.  In  several  cases, 
moreover,  the  epileptic  attacks  began  by  a  local  aura  in  the  limbs,  a 
rare  feature  in  idiopathic  epilepsy.  In  one  instance  of  this,  the  first 
convulsive  attack  occurred  after  a  fright.  I  have  met  with  cases,  in 
which  epilepsy  succeeded  migraine  and  the  epileptic  fits  seemed,  as  it 
were,  to  grow  out  of  the  attacks  of  migraine,  being  preceded  by  such 
sensory  symptoms  as  had  occurred  before  the  attacks  of  headache. 
Thus  a  young  man,  whose  sister  was  epileptic,  began  to  suffer  from 
attacks  in  which  he  saw  glimmering  lights  in  the  right  side  of  the 
field  of  vision,  lasting  about  twenty  minutes,  and  followed  by  head- 
ache, sometimes  for  half  an  hour,  sometimes  for  the  rest  of  the  day, 
accompanied  by  nausea  but  no  vomiting.  He  had  such  an  attack 
every  few  months ;  one  day  a  similar  light  appeared,  brighter  than 
usual,  and  after  it  had  lasted  for  twenty  minutes  he  lost  con- 
sciousness in  a  convulsive  attack,  which,  from  the  intensity  of  the 
subconjunctival  ecchymoses,  must  have  been  severe.  In  rare  cases  of 
epilepsy,  again,  a  visual  aura  may  consist  of  fortification-spectra  with 
colours,  and  even,  as  I  have  known,  with  hemianopia.  In  one  such  case 
the  visual  disturbance  lasted  ten  minutes,  occurring  sometimes  alone, 
sometimes  with  transient  loss  of  consciousness,  sometimes  with  a 
convulsive  attack.  Again,  a  woman  had  suffered  from  epileptic  fits 
for  two  years,  and  also,  since  youth,  from  attacks  of  severe  headache, 
lasting  all  day ;  in  the  course  of  the  headache  she  would  have  attacks 
which  began  with  a  sensation  at  the  epigastrium,  passing  up  to  the 
head ;  it  seemed  to  spread  over  the  head,  and  then  the  sight  became 
dim,  and  this  was  followed  by  complete  word-deafness  and  aphasia; 
after  about  ten  minutes  these  symptoms  suddenly  ceased.  Many  of 
her  epileptic  fits  were  preceded  by  the  same  sensation  starting  from 
the  epigastrium  and  going  to  the  head. 

Pathology. — No  anatomical  changes  are  known  to  underlie  the 
phenomena  of  migraine,  and  from  the  character  of  the  symptoms,  and 
the  analogies  of  the  disease,  it  is  unlikely  that  any  will  be  discovered. 
Hence  the  nature  of  the  malady  is  a  matter  of  inference,  and  hypo- 
theses are  sufficiently  abundant  and  precise. 

Two  chief  theories  have  been  held  regarding  the  origin  of  the 
attacks.  One  is  based  upon  the  alteration  in  the  state  of  the  vessels 
that  is  so  conspicuous  in  the  aspect  of  the  patient.  The  pallor  of  the 
surface  must  be  due  to  contraction  of  the  arteries,  the  flushing  of 
the  skin  to  their  dilatation,  and  it  is  assumed  that  a  corresponding 

vol.  ii.  54 


850  MIGRAINE. 

condition  of  the  vessels  of  the  brain  is  the  cause  of  the  derangement 
of  function.  The  suggestion  that  spasm  of  the  cerebral  arteries  is  the 
cause  of  the  symptoms  was  first  made  by  Whytt,  and  the  evidence  in 
favour  of  this  opinion,  afforded  by  the  state  of  the  accessible  vessels, 
was  pointed  out  by  Du  Bois  Eeymond.  Mollendorf  urged  that 
vascular  dilatation,  rather  than  spasm,  caused  the  symptoms,  and  the 
fact  that  the  condition  varies  in  different  cases  has  led  to  the  theory, 
extensively  held  in  Germany  (by  Eulenburg  and  most  other  writers), 
that  there  are  the  two  varieties  of  the  disease  already  mentioned,  the 
"  sympathetico-tonic  "  and  the  "  sympathetico-paralytic "  form,  as 
they  are  sometimes  termed.  Dr.  Latham,  of  Cambridge,  who  arrived 
independently  at  the  conclusion  that  the  attacks  depend  on  vaso- 
motor derangement,  has  suggested  that  the  early  symptoms  of  the 
paroxysm  are  due  to  spasm,  and  the  headache  to  dilatation  of  the 
vessels.  According  to  these  theories,  the  malady  is  essentially  one  of 
the  sympathetic  nerves. 

According  to  the  other,  and  alternative  explanation  of  the  disease, 
the  primary  derangement  is  of  the  nerve-cells  of  the  brain.  Their 
function  from  time  to  time  is  disturbed  in  a  peculiar  manner,  and  the 
visible  vaso-motor  disturbance  is  of  secondary  origin.  The  periodical 
derangement  of  function  has  been  called,  by  a  somewhat  inapt 
metaphor,  a  "nerve-storm."  This  theory  has  been  put  forward  and 
ably  advocated  by  Liveing. 

The  sensory  symptoms  must  depend  on  deranged  action  of  the 
sensory  centres  in  some  part  of  the  brain.  They  indicate  a  combina- 
tion of  arrest  of  action  and  of  over-action  in  the  nerve-cells  concerned. 
In  the  language  of  modern  pathology,  there  is  a  combination  of 
inhibition  and  discharge ;  the  loss  of  sight,  for  instance,  must  be  due 
to  inhibitory  arrest  of  action,  the  visual  spectrum  to  discharge.  We 
have  already  seen  (p.  739)  that  the  same  combination  occurs  in  some 
attacks  of  epilepsy.  The  peculiarities  in  the  disturbance  of  migraine 
are  its  special  and  often  uniform  features,  deliberate  course,  and  its 
limitation  to  sensory  structures.  To  explain  them  on  the  vaso-motor 
hypothesis,  we  must  assume,  first,  an  initial  spasm  of  the  arteries  in  a 
small  region  of  the  brain ;  secondly,  that  the  contraction  always 
begins  at  the  same  place ;  and  thirdly,  that  it  can  give  rise  to  a 
definite,  uniform,  and  very  peculiar  disturbance  of  function.  There 
is  no  evidence  of  the  truth  of  any  one  of  these  assumptions.  As  was 
pointed  out  in  the  discussion  of  the  pathology  of  epilepsy,  we  are 
not  justified  in  assuming  that  the  state  of  the  surface  vessels  and 
accesssible  arteries  is  an  indication  of  the  condition  of  those  of 
internal  organs.  If  it  were,  inasmuch  as  the  recognisable  vaso- 
motor spasm  is  bilateral  in  almost  all  cases,  even  when  the  sensory 
disturbance  is  unilateral,  we  must  assume  a  general  contraction  of 
the  vessels  of  the  brain.  A  general  contraction  could  only  cause  a 
local  disturbance  of  function  by  virtue  of  a  local  change  in  the  func- 
tional tendency   of   the   nerve-cells.      But   if  such  local  change  is 


PATHOLOGY.  851 

admitted,  the  need  for  the  vasomotor  mechanism  disappears.  Lastly, 
that  vaso-motor  spasm  can  cause  a  deliberate,  uniform,  and  peculiar 
"  discharge,"  is  not  only  unproved,  but  in  the  highest  degree  impro- 
bable. In  short,  the  difficulties  in  accepting  the  vaso-motor  explana- 
tion of  the  sensory  symptoms  are  so  great  that  it  could  only  be 
admitted  as  a  tenable  hypothesis  if  there  were  no  other  explanation 
of  the  coincidence  of  the  two  phenomena.  But  we  know  that  the 
vascular  system  is  in  a  special  way  under  the  influence  of  the  cerebral 
centres.  An  emotional  blush  and  the  pallor  of  fear  are  conspicuous 
examples  of  this  fact.  It  is  at  least  as  easy  to  conceive  that  the 
vascular  changes  are  the  result  of  the  disturbance  in  the  nerve- 
elements,  as  it  is  to  regard  them  as  its  cause.  The  vaso-motor 
nerves  are  peculiarly  sensitive  to  sensory  impressions  that  are 
felt  as  pain.  No  symptoms  at  all  resembling  those  of  migraine 
have  been  observed  when  the  sympathetic  is  distinctly  diseased  or 
deranged.  We  have  proof,  in  the  symptoms,  of  the  deranged  action 
of  sensory  cells ;  we  know  that  cells  are  susceptible  of  primary  dis- 
turbance of  function,  and  there  is  at  present  nothing  to  justify  us  in 
going  beyond  this  derangement  in  our  search  for  the  primary  morbid 
process.  The  peculiar  character  of  the  visual  impressions  affords 
strong  reason  for  regarding  it  as  the  result  of  a  tendency  to  func- 
tional derangement  in  the  cells  themselves.  This  opinion  is  supported 
by  the  fact  that  it  may  occur  as  an  isolated  symptom,  and  that  it  may 
be  related  to  an  actual  visual  impression,  as  is  shown  by  the  facts 
mentioned  on  p.  846.  Such  an  occurrence  can  have  been  due  only  to 
a  primary  functional  disturbance  of  the  cells  themselves,  and  that 
which  we  feel  sure  exists  in  one  case,  probably  exists  in  all. 

What  part  of  the  brain  is  concerned  in  the  production  of  the  initial 
symptoms  ?  Loss  of  speech  must  be  due  to  disturbed  function  of  the 
cortex.  The  sensory  symptom  in  the  limbs  is  like  that  which,  in 
far  more  rapid  evolution,  precedes  convulsions  from  cortical  disease, 
and  this  source  is  therefore  probable.  The  hemianopia  also  is  best 
explained  by  the  assumption  of  deranged  function  in  the  occipital  lobe, 
especially  since  right  hemianopia  may  correspond  to  almost  simul- 
taneous aphasia,  and  the  opinion  is  supported  by  the  fact  mentioned 
above,  that  hemianopia  was  fixed  by  a  lesion  in  the  cuneus. 

The  cause  of  the  headache  is  obscure.  We  know  very  little  of  the 
mechanism  of  this  symptom  in  any  condition.  But  when  the  pain  is 
opposite  in  side  to  the  sensory  symptoms,  we  are  obliged  to  assume 
that  its  seat  is  the  cerebral  hemisphere  that  is  deranged ;  and  the 
same  conclusion  is  suggested  when  the  pain  begins  on  the  side  of  the 
sensory  disturbance,  at  some  spot  which  has  no  definite  relation  to 
nerve  distribution,  as  the  very  common  initial  seat,  a  small  area  in  the 
temple.  This  is  best  understood  by  assuming  a  derangement  of  the 
sensory  centres  of  the  hemisphere  which  would  receive  impressions 
from  this  part.  It  is  difficult  to  separate  such  pain  from  the  sym- 
ptoms that  preceded  it ;  the  aspect  of  the  patient  is  unchanged  during 


852  MIGKAINK. 

its  development.  Flushing,  heat,  throbbing,  come  on  subsequently, 
often  as  the  pain  spreads  in  area.  How  far  its  increase  in  extent  and 
changes  in  character  are  due  to  a  vaso-rnotor  mechanism  permitting 
arterial  distension,  we  cannot  say.  Such  a  state  may  be  secondary  to 
over-action  of  the  sensory  centres,  and  may  induce  the  spread  of  the 
disturbance.  We  must  not  ascribe  too  much  significance  to  throbbing, 
or  to  the  increase  in  the  pain  by  the  causes  of  vascular  distension ;  these 
may  be  due  merely  to  the  over-sensitiveness  of  the  central  structures. 

There  is  evidence,  in  many  cases,  of  derauged  function  of  lower 
sensory  centres,  those  directly  connected  with  the  peripheral  fibres. 
These  are  apparently  the  common  seat  of  the  disturbance  in  neur- 
algia, and  we  have  seen  that  cases  of  migraine  which  begin  with 
distinct  cerebral  symptoms  may  be  followed  by  pain,  more  or  less 
definitely  neuralgic  in  character — even  tenderness  of  the  skin, 
vaso-motor  disturbance,  and  (although  exceptionally)  an  eruptive 
state,  or  actual  herpes  zoster.  But  it  is  possible  that  the  lower 
centres  may  be  affected  secondarily  to  the  higher.  We  must  not 
assume  that  influences  cannot  traverse  nerve-fibres  in  the  direction 
opposite  to  that  in  which  these  habitually  conduct,  for  we  have  an 
instance  of  this  in  the  propagation  of  trophic  influences  down  the 
peripheral  sensory  nerves.  But  only  when  such  symptoms  exist,  or 
pain  corresponds  in  area  to  nerve  distribution,  are  we  justified  in 
assuming  that  the  sensory  centres  in  the  pons  and  medulla  are  spe- 
cially disturbed.  Some  other  considerations  regarding  headache  are 
discussed  in  the  next  chapter.  When  all  has  been  said  that  can  be, 
mystery  still  envelops  the  mechanism  of  migraine. 

The  nausea  and  vomiting  throw  no  distinct  light  on  the  processes 
of  the  attack.  We  have  seen,  in  many  affections,  how  wide-spread  is 
the  central  representation  of  the  pneumogastric,  and  that  vomiting 
may  result  from  organic  disease  in  any  part  of  the  brain.  In  migraine 
it  seems  as  though  the  nervous  discharge  of  the  act  of  vomiting 
afforded  some  relief  to  a  morbid  state  of  the  nerve-cells,  but  only 
when  the  disturbance  has  nearly  run  its  course  and  is  ready  to  subside. 

The  hypothesis  that  the  derangement  is  primarily  one  of  nerve- 
cells  of  the  brain  enables  us  better  to  understand  the  relation  to 
other  neuroses,  and  especially  that  to  epilepsy,  which  is  occasionally 
so  distinct.  In  epilepsy,  as  we  have  seen,  we  must  assume  a  dis- 
turbance of  function,  in  some  cases  so  similar  in  character  that  we 
cannot  doubt  the  identity  of  its  seat  with  that  of  migraine.  But  the 
process  in  the  two  differs  in  its  course,  associations,  and  other  features, 
and  these  imply  an  essential  difference  in  its  minuter  characters. 
These  relations,  however,  make  it  intelligible  that  the  two  should 
occur  in  the  same  subject,  and  that  intermediate  forms  of  nerve  dis- 
turbance should  sometimes  be  met  with. 

Diagnosis. — From  other  forms  of  headache,  that  of  typical  migraine 
is  distinguished  by  its  sensory  accompaniments,  and,  if  these  are 


PROGNOSIS.  853 

absent,  by  its  paroxysmal  character,  severity,  definite  course,  and  in 
many  cases,  as  its  name  suggests,  the  unilateral  distribution  of  the 
pain.  But  it  is  important  to  remember  that  no  line  of  distinction  can 
be  drawn  between  simple  paroxysmal  headaches  and  migraine.  Every 
intermediate  form  is  met  with,  and  "sick  headache"  especially 
is  always  migraine.  In  malarial  headaches,  the  intermissions  are 
shorter  and  the  cause  is  generally  traceable.  The  j>ain  of  chronic  brain 
disease  is  more  or  less  constant ;  it  may  present  remissions  and  even 
intermissions,  but  not  the  longer  intervals  of  migraine.  The  sensory 
disturbance  in  the  limbs,  and  the  affection  of  speech,  may  excite  a 
suspicion  of  acute  brain  disease,  but  it  is  only  in  a  first  attack  of 
migraine  that  the  question  will  arise,  and  even  then  the  brief  duration 
of  the  symptoms,  and  the  peculiar  features  of  the  visual  disturbance, 
sufficiently  indicate  the  nature  of  the  attack.  When  these  occur  with- 
out headache,  a  mistake  is  common.  Such  patients  are  often  thought 
to  have  grave  organic  disease.  But  a  knowledge  of  the  occasional 
isolation  of  the  sensory  symptoms,  the  history  of  preceding  attacks, 
and  of  some  pain,  which  can  usually  be  obtained,  almost  always 
enables  a  correct  opinion  to  be  formed. 

Another  difficulty  is  presented  by  the  diagnosis  from  minor  epilepsy, 
in  which  the  visual  aura  may  closely  resemble  that  of  migraine.  In 
most  cases  of  epilepsy  with  a  visual  aura,  this  is  brief,  lasting  only  a 
few  seconds,  while  the  visual  disturbance  in  migraine  lasts  twenty 
minutes  to  half  an  hour.  The  fortification-spectrum  is  strongly  sug- 
gestive of  migraine  rather  than  epilepsy,  although  not  quite  conclu- 
sive. The  occurrence  of  a  convulsion,  of  course,  decides  the  question, 
but  where  the  patient's  account  is  all  we  have  to  guide  us,  we 
must  make  our  diagnosis  from  the  general  features  of  the  case,  not  for- 
getting that  the  one  disease  may  unquestionably  pass  into  the  other, 
and  that  some  attacks  seem  to  be  of  intermediate  nature. 

A  diagnostic  difficulty  of  another  kind  arises  in  cases  in  which  the 
subjects  of  migraine  become  affected  with  some  other  malady,  and  the 
symptoms  of  the  former  continue,  and  complicate  the  latter.  Thus 
one  patient  was  attacked  with  Bright's  disease  ;  he  had  retinal  changes 
and  optic  neuritis,  and  the  intensity  of  the  headache  led  to  a  diagnosis 
of  intra-cranial  tumour.  But  the  pain  was  purely  paroxysmal,  and  of 
the  same  character  as  that  to  which  he  had  been  long  liable.  The 
opinion  that  there  was  no  organic  cerebral  disease  was  confirmed  after 
death.  In  another  case,  a  subject  of  migraine  became  affected  with 
general  paralysis  of  the  insane,  and  the  sensory  disturbance  that  had 
preceded  the  attacks  of  headache  occurred  alone,  and  complicated  the 
paroxysmal  symptoms  of  the  cerebral  disease. 

Prognosis. — The  prospect  of  recovery  from  migraine,  that  is  of  the 
entire  cessation  of  the  attacks,  is  never  considerable,  but  in  most  cases 
a  diminution  in  the  frequency  and  severity  of  the  attacks,  often 
reducing  them  to  a  trivial  and  undisturbing  degree,  may  be  anticipated 


854  MIGRAINE 

from  persevering  treatment.  The  prognosis  is  best  when  the  malady  is 
of  short  duration,  and  there  is  some  removable  condition  in  the  general 
health  or  mode  of  life  which  has  distinctly  contributed  to  the  produc- 
tion of  the  malady.  The  longer  the  disease  has  lasted  the  less  is  the 
prospect  of  a  cure,  but  neither  this  nor  hereditary  tendency  has  an  un- 
favorable influence  on  the  prognosis  equal  to  that  of  conditions  which 
we  cannot  yet  discern,  and  which  may  render  one  of  two  apparently 
similar  cases  quite  intractable,  while  the  other  yields  at  once  and  per- 
manently. In  the  second  half  of  life  the  tendency  to  cessation  is 
greater,  provided  the  malady  has  not  recently  developed.  The  prog- 
nosis is  better  when  the  face  is  at  first  pale  and  pinched  than  when  it 
is  at  first  flushed.  It  is  better  when  there  is  a  family  history  of  gout 
than  when  other  neuroses  can  be  traced 

Treatment. — If  any  error  in  mode  of  life,  or  defect  in  general 
health  can  be  traced,  the  removal  of  these  is  the  first  and  most  essential 
step  in  treatment.  The  details  vary  in  every  case,  but  the  most  fre- 
quent conditions  that  need  attention  have  been  already  indicated  in 
the  account  of  the  causes  of  the  disease.  Of  especial  importance  are 
increased  rest,  regularity  in  meals,  attention  to  diet ;  whatever  is 
known  to  induce  a  paroxysm  should  be  carefully  avoided.  Hot, 
crowded  rooms  are  especially  injurious.  If  inherited  gout  is  probable, 
the  regimen  suitable  for  this  should  be  adopted. 

The  special  treatment  consists,  first,  in  the  continuous  administration 
of  drugs  during  the  intervals,  with  the  object  of  rendering  the  attacks 
less  frequent  and  less  severe ;  and  secondly,  the  amelioration  of  the 
attacks  themselves.  As  a  rule,  the  measures  that  do  good  when 
employed  during  the  intervals  have  no  influence  on  the  attacks. 

There  is  much  variation  in  the  effect  of  the  intermediate  treat- 
ment. As  already  mentioned,  the  measures  that  do  great  good  in 
one  case  will  fail  in  another,  apparently  quite  similar.  The  influence 
of  bromide  in  epilepsy  naturally  leads  us  to  turn  first  to  this  as 
likely  to  be  of  service  in  a  malady  that  has  so  many  features  in 
common  with  that  disease.  In  some  cases  it  is  of  service,  but 
less  often  than  might  be  expected.  It  is  most  likely  to  be  efficacious 
in  the  cases  in  which  there  is  no  change  in  the  colour  of  the  face,  or  in 
which  the  face  is  flushed  throughout  an  attack.  Ergot  may  often, 
then,  be  usefully  combined  with  it.  In  the  majority  of  cases,  how- 
ever, and  especially  in  those  in  which  there  is  conspicuous  pallor  in 
the  early  stage,  the  drug  that  has  most  influence  is  nitro-glycerine. 
Given  regularly  during  the  intervals,  just  as  bromide  is  given  for 
epilepsy,  it  has  a  striking  effect  in  many  patients,  rendering  attacks  far 
slighter  and  far  less  frequent,  and  often,  after  a  time,  stopping  them 
altogether.  It  should  be  given  twice  or  three  times  a  day,  after  food. 
If  taken  when  the  stomach  is  empty,  it  passes  rapidly  into  the  blood,  and 
may  cause  brief  cephalic  discomfort,  which  though  not  objectionable 
in  itself,  sometimes  deters  the  patient  from  continuing  the  medicine. 


TREATMENT.  855 

To  avoid  causing  alarm,  it  is  therefore  also  desirable  to  begin  with,  a 
small  dose,  t4-q,  t\^,  or  even  -^  of  a  grain.  The  most  convenient 
mode  of  administration  is  in  the  1  per  cent,  solution  in  alcohol,  now 
termed  Tinct.  Trinitrini  (B.  P.  Sup.)  ;  it  can  be  given  in  combina- 
tion with  tinctures  or  acids,  but  is  decomposed  by  alkalies.  A  very- 
useful  combination  is  with  tincture  of  nux  vomica,  tincture  of  gelse- 
raium,  and  dilute  phosphoric  acid,  or  with  citrate  of  lithia  and  the  acid 
syrup  of  lemons.  Sometimes  more  benefit  is  derived  from  the  combi- 
nation of  this  with  bromide,  when  a  little  hydrobromic  acid  should  be 
added  instead  of  the  phosphoric  acid.  If  there  is  much  dyspepsia, 
it  may  be  given  with  hydrochloric  acid,  and  some  liquid  preparation  of 
pepsine.  The  trisnitrate  of  bismuth  may  also  be  given  with  it.  I  have 
found  such  combinations  of  the  liquid  preparation  of  nitro-glycerine 
with  other  drugs  far  more  useful  than  the  administration  of  nitro- 
glycerine in  tablets.  It  is  not  well  to  continue  it  during  an  attack  ; 
at  the  very  onset  a  dose  may  be  taken,  but  if  this  is  not  effective 
the  medicine  should  be  omitted  till  the  attack  is  over;  it  seldom 
gives  relief  to  the  symptoms,  and  occasionally  makes  them  worse. 
It  is  possible  that  the  drug  acts  chiefly  by  periodically  flushing 
the  nerve-centres  with  arterial  blood,  and.  so  improving  the  nutri- 
tion and  the  function  of  the  nerve-cells.  A  purgative  at  the  onset 
will  occasionally  cut  an  attack  short  in  some  patients,  but  more  often 
it  fails. 

During  the  attack,  absolute  rest  is  essential,  and  is  indeed  impressed 
on  the  patient  by  the  distress  occasioned  by  activity.  The  recumbent 
posture  is  generally  that  in  which  the  sufferer  is  most  comfortable. 
All  strong  sensory  impressions  should  be  avoided.  Although  a  dose 
of  alcohol  or  of  nitro-glycerine  will  occasionally  cut  short  a  commencing 
attack,  when  the  headache  is  developed,  it  is  usually  increased  by  drugs 
that  dilate  the  vessels  or  excite  the  heart.  Relief  is  afforded  to  the 
pain  by  a  full  dose  (thirty,  forty,  or  sixty  grains)  of  bromide,  and  its 
effect  is  increased  by  the  addition  of  five  or  ten  minims  of  tincture  of 
Indian  hemp  ;  this  may  be  repeated  every  two  or  three  hours.  But 
more  often  relief  is  obtained  from  antipyrin,  acetanilide,  exalgin,  or 
phenacetin.  Unfortunately  their  influence  is  apt,  after  a  time,  to 
cease ;  a  change  from  one  to  another  sometimes  renews  the  benefit. 
Twenty  grains  of  chloral,  or  fifteen  of  butyl  hydrate  (croton-chloral) 
usually  makes  the  patient  drowsy  and  easier  for  a  time,  but  after  an 
hour  or  two  the  pain  returns  in  its  former  severity,  and  the  duration 
of  the  attack  does  not  seem  to  be  lessened.  The  same  is  true  of  most 
other  sedatives.  A  hypodermic  injection  of  morphia  often  acts  no 
better  than  other  sedatives,  but  occasionally  it  does  give  great  relief,  and 
may  terminate  an  attack  that  has  already  nearly  run  its  course.  When 
there  is  much  mental  depression  during  the  attack,  valerian  and  assa- 
fcetida  have  been  found  useful  by  Latham.  Drugs  that  cause  con- 
traction of  the  arteries  are  almost  powerless  ;  all  that  a  full  dose  of 
ergotin  does  is  to  lessen  the  throbbing  intensification  of    the   pain 


856  HEADACHE. 

complained  of  by  some  patients.  Strong  tea  and  coffee  are  popular 
remedies,  and  occasionally  give  some  distinct  relief,  which  may 
also  be  obtained  from  a  few  grains  of  caffeine.  Guarana  (the 
powdered  seeds  of  Paullinia  sorbilis)  has  been  often  used.  It  contains 
an  active  principle,  guarauine,  which  is  identical  with  caffeine.*  Three 
or  four  doses  of  guarana,  twenty  or  thirty  grains,  may  be  taken  at 
intervals  of  half  an  hour,  or  a  single  dose  of  sixty  grains,  or  guaranine 
may  be  given  in  doses  of  one  to  five  grains.  It  has  for  the  most  part 
disappointed  the  expectations  that  were  i-aised  by  the  praises  at  first 
bestowed  upon  it.  Some  relief  is  often  given  to  the  pain,  but  the 
relief  is  transient  only,  and  it  is  doubtful  whether  guarana  is  really 
more  effective  than  tea  and  coffee. 

Local  applications  sometimes  afford  relief — sedative  liniments  of 
belladonna,  aconite,  &c,  or  simple  counter-irritation  by  a  mustard 
plaster  to  the  nape  of  the  neck.  From  the  last,  some  patients  experi- 
ence relief  more  uniformly  than  from  any  other  measure.  Solid 
menthol  is  occasionally  useful,  rubbed  on  the  skin  for  a  few  minutes 
where  the  pain  is  greatest,  but  it  is  too  feeble  an  agent  to  have  much 
influence  on  any  severe  pain.  Sometimes  relief  is  afforded  by  a  hot 
bath  of  mustard  and  water  to  the  feet,  and  in  all  cases  it  is  well  to 
keep  the  extremities  warm. 

Electricity  is  of  little  service.  Faradisrn  usually  does  harm.  The 
voltaic  current  passed  through  the  head  occasionally  gives  transient, 
but  rarely  permanent  or  considerable  relief.  Repeated  galvanisation 
of  the  sym])athetic  has  been  recommended  as  a  remedial  measure,  one 
pole  pressed  deeply  in  front  of  the  sterno-mastoid,  the  other  held  in 
the  hand,  and  it  is  advised  that  when  the  symptoms  of  vaso-motor 
spasm  predominate,  the  positive  pole  should  be  placed  over  the  sym- 
pathetic, and  the  negative  when  there  is  evidence  of  vaso-motor  para- 
lysis (Berger,  Horst).  The  value  of  the  treatment  is,  to  say  the  least, 
seldom  perceptible. 


HEADACHE. 


Headache  is  a  symptom  of  almost  all  kinds  of  morbid  states  of  the 
system,  and  cannot  often  be  regarded  as,  in  itself,  an  independent 
disease.  Nevertheless  it  is  a  symptom  for  which  patients  seek  treat- 
ment more  often  than  for  any  other  of  equally  varied  causation.  Hence 
it  may  be  useful  to  indicate  the  chief  varieties  that  are  met  with,  and 
briefly  to  describe  the  symptom  in  its  apparently  primary  form.  As 
an  indication  of  organic  disease  it  has  been  already  described. 

*  Guarana  contains  twice  as  much  of  tlie  alkaloid  as  tea,  and  five  times  as  much 
as  coffee. 


HEADACHE.  857 

We  know  almost  nothing  of  the  structures  in  which  the  pain  of 
headache  is  felt  or  the  mechanism  of  its  production  (see  p.  97).  The 
subject  is  one  on  which  it  is  easy  to  theorise,  but  there  are  no  facts 
that  give  to  any  hypothesis  a  considerable  degree  of  probability. 
One  conclusion  is,  however,  suggested  by  the  symptoms, — that  the 
seat  of  the  pain  varies  in  different  cases.  Outside  the  skull  are 
nerves  that  frequently  give  rise  to  pain,  but  all  pain  that  corresponds 
to  the  course  or  distribution  of  nerve-trunks  must  be  regarded  as  neu- 
ralgic, and  not  as  headache.  Some  diffuse  headaches  seem  superficial 
in  character,  but  they  may  still  be  due  to  processes,  not  in  the  nerves, 
or  the  grey  matter  in  which  the  nerves  directly  end  (which  is 
supposed  to  be  deranged  in  neuralgia),  but  in  higher  centres  of  the 
cerebral  hemispheres  through  which  superficial  pain  is  perceived. 
This  is  especially  probable  when  the  pain  is  local,  but  does  not  corre- 
spond to  a  nerve  area,  resembling  in  this  some  forms  of  migraine. 
This  feature  is,  however,  more  frequent  in  occasional  exacerbations 
than  in  the  continuous  pain.  More  frequently  headache  seems  to  be 
•deeply  seated,  and  the  pain  is  referred  to  structures  within  the  cra- 
nium. Of  such  structures  the  membranes,  when  inflamed,  are  the 
seat  of  intense  pain,  which  is  probably  really  produced  in  them, 
because  other  organic  disease,  such  as  a  tumour,  which  is  seated  at 
the  surface  of  the  brain  and  involves  the  membranes,  may  also  cause 
intense  pain  corresponding  in  locality  to  the  disease.  "Whether  pain  is 
produced  directly  by  morbid  states  of  the  cerebral  tissue  we  cannot 
say.  We  are  certainly  not  justified,  however,  in  denying  the  possi- 
bility of  this  seat  of  pain  (see  p.  97) .  It  may  be  caused  by  organic  pro- 
cesses which  do  not  involve  the  surface.  After  necrotic  softening  in 
the  central  ganglia,  headache  is  common  on  the  side  opposite  to  the 
hemiplegia,  and  the  diffuse  pain  of  "  hemicrania"  may  be  on  the  side 
opposite  to  that  of  the  sensory  symptoms. 

When  pain  is  felt,  in  whatever  part  the  nerve-processes  occur 
that  cause  it,  the  consciousness  of  pain  is  related  to  the  activity  of 
certain  nerve-cells  of  the  cortex  of  the  brain.  In  pain  that  is  pro- 
duced in  the  limbs,  for  instance,  the  cortical  cells  concerned  are  those 
that  are  related  to,  and  receive  impressions  from,  the  fibres  by  which 
the  sensory  impulses  pass  from  the  periphery.  A  similar  relation 
must  exist  in  the  case  of  sensory  impressions  from  the  head  itself — 
from  the  structures  covering  the  head,  from  the  bone,  and  probably 
from  the  membranes.  The  pain  of  meningitis,  for  instance,  if  due  to 
the  irritation  of  the  meningeal  nerves,  must  be  perceived  by  means  of 
the  activity  of  those  cells  in  the  cortex  that  receive  the  impressions 
from  the  membranes.  Whether  there  is  a  similar  representation,  in 
the  cortical  cells,  of  the  tissue  of  the  brain  itself,  we  do  not  know. 
Sympathetic  nerve-fibres  accompany  the  arteries  in  the  cerebral  sub- 
stance ;  there  is  reason  to  believe  that  the  functional  state  of  the 
cortex  influences  the  state  of  its  arteries  (as  is  the  case  in  all  other 
organs),  and  this  must  mean  a  relation  of  the  cells  of  the  cortex  to 


858  HEADACHE. 

the  vasomotor  centre  ;  hence  it  is  quite  possible  that  there  may  be  a 
sensory  representation  of  the  substance  of  the  brain,  at  least  of  its 
interstitial  tissue,  in  the  cortex  of  the  brain  itself.  The  phenomena 
of  epilepsy  seem  to  show  that  the' central  representation  of  the  head, 
and  perhaps  of  the  brain,  is  connected  in  a  special  manner  with  the 
structures  related  to  the  mental  state  of  consciousness.  It  is  very 
common  for  an  aura,  felt  first  in  the  epigastrium  or  limbs,  to  seem  to 
ascend  to  the  head,  and  when  it  reaches  the  head,  consciousness  is 
almost  invariably  lost.  The  aura  is  the  result  of  the  spread  of  the 
discharge  in  the  brain,  and  the  phenomena  indicate  that  the  central 
sensory  representation  of  the  head  has  a  special  importance,  and  it 
may  be  that  it  has  a  special  susceptibility.  But  a  functional 
derangement  of  the  cortical  cells  in  which  the  membranes  are  repre- 
sented would,  by  itself,  explain  many  forms  of  headache. 

It  may  be  held,  indeed,  that  the  primary  derangement  in  headache 
is  not  of  the  highest  sensory  cells,  but  of  the  cells  of  lower  centres,  to 
which,  for  instance,  the  nerves  of  the  membranes  directly  pass,  but 
this  view  is  less  easy  to  reconcile  with  the  difference  between  head- 
aches and  the  true  cranial  neuralgias  (in  which  the  lower  cells  are 
probably  concerned),  and.  also  with  the  resemblance  often  observed 
between  the  headache  of  organic  and  of  functional  origin.  When 
pain  is  felt  in  the  side  of  the  head  on  which  the  hemisphere  is  deranged 
or  diseased,  its  origin  in  lower  centres  can  be  certainly  excluded ;  and 
the  same  inference  (of  cerebral  origin)  is  probable  when  severe  pain 
on  the  opposite  side  is  associated  with  other  symptoms,  and  is  felt 
only  in  a  part  of  a  nerve  area. 

Another  mysterious  factor  in  the  mechanism  of  headache  is  the 
influence  of  the  vessels.  It  is  probable  that  mere  vascular  dilatation, 
passive  or  active,  will  cause  pain  ;*  it  is  certain  that  pain  already 
existing  is  increased  by  even  trifling  mechanical  congestion.  "We  do 
not  know  how  the  vascular  dilatation  causes  pain.  There  are  no  facts 
to  show  that  the  nerves  of  the  vessels  ever  become  sensitive.  It  is 
certain,  however,  that  the  intra-cranial  pressure  must  be  increased  by 
the  dilatation,  since,  however  quickly  the  movement  of  the  cerebro- 
spinal fluid  may  compensate  for  vascular  repletion,  this  movement  is 
due  to  the  mechanical  pressure  from  the  vessels,  and  this  pressure  must 
act  on  the  whole  brain.  We  know  how  sensitive  nerve-fibres  are  to 
pressure ;  it  is  highly  probable  that  their  sensitiveness  is  vastly  ex- 
ceeded by  that  of  nerve-cells.  If  the  sensory  cells  of  the  cortex,  in 
which  the  cranial  and  intra-cranial  sensitive  structures  are  represented, 
are  the  most  readily  influenced  of  all  the  sensory  cells,  we  can  under- 
stand that  headache  should  result  from  vascular  repletion. 

The  frequency  with  which  pain  due  to  general  causes  is  referred  to 
the  frontal  region  is  very  peculiar,  and  does  not  seem  to  be  susceptible 

*  It  is  certain  that  pain  results  from  mechanical  congestion,  but  we  cannot 
separate  the  effects  of  the  state  of  the  vessels  and  the  increased  amount  of  venous 
blood  in  the  brain. 


VAEIETIES.  859 

of  any  satisfactory  explanation.  It  is  occasionally  a  feature  of  the 
pain  of  organic  disease,  such  as  a  tumour,  situated  away  from  the 
frontal  region.  Diffuse  pain  is  not  often  referred  to  this  region  alone 
in  primary  simple  headaches,  although  pain  in  other  parts  of  the  fifth 
nerve,  as  that  of  dental  irritation,  may  spread  up  to  this  region. 
In  simple  headache,  the  pain  may  seem  to  pass  through  the  bead  from 
the  back  to  the  front,  or  vice  versa,  or  may  be  referred  to  the  supra- 
orbital regions  or  the  temples. 

Varieties. — Toxsemic  headache  may  be  the  effect  of  either  acute  or 
chronic  blood-states.  Of  the  acute  form,  the  typical  example  is  that  of 
fever,  in  which  the  pain  is  generally  frontal,  rarely  occipital  or  general, 
and  scarcely  ever  vertical  or  one-sided.  In  slight  cases  it  may  have  a 
neuralgic  character  for  a  short  time,  and  may  be  felt  in  one  part  of 
the  head,  as  the  temple,  but  this  form  is  usually  transient.  The 
pain  is  commonly  dull  in  character,  but  often  very  severe,  and  is 
rendered  worse  by  stooping  or  by  whatever  causes  mechanical  conges- 
tion of  the  head.  The  deep-seated  character  of  the  pain  suggests 
that  it  is  referred  to  some  intra-cranial  structure.  There  is  no  evidence 
that  it  depends  on  any  vascular  state;  the  increase  by  mechanical 
congestion  is  a  common  feature  of  almost  all  severe  headaches. 

Many  poisonous  substances  cause  headache  as  one  of  their  toxic 
effects,  especially  when  the  dose  is  small,  or  as  an  after-effect  of  large 
doses.  Some  of  these  poisons,  such  as  nitrite  of  amyl  and  nitro- 
glycerine, dilate  the  vessels,  and  the  pain  may  be  in  part  or  altogether 
the  effect  of  the  active  congestion  produced ;  but  it  is  also  possible 
that  the  pain  is  sometimes  the  direct  effect  of  the  agent  on  the 
nerve-elements.  The  inhalation  of  a  small  quantity  of  ether,  as, 
for  instance,  when  the  air  of  a  room  is  charged  with  it  in  moderate 
degree,  generally  causes  headache,  which  seems  to  be  the  direct 
effect  of  the  ether,  since  it  is  not  attended  by  any  sign  of  vascular 
distension. 

Chronic  toxaemic  states  often  cause  very  severe  headache,  which 
may  be  quite  intractable  unless  its  cause  is  discovered.  In  the 
morbid  blood-state  that  is  caused  by  kidney  disease,  for  instance, 
there  is  often  intense  headache,  usually  frontal  and  continuous,  but 
with  occasional  exacerbations.  It  is  sometimes  increased  by  alcohol 
in  a  special  manner,  but  this  is  a  feature  also  of  some  other  forms. 
The  severity  of  the  pain  has  many  times  given  rise  to  an  erroneous 
diagnosis  of  cerebral  tumour  in  cases  in  which  there  is  albuminuric 
optic  neuritis.  Headache  also  results  from  diabetes,  from  chronic 
alcoholism,  lead  poisoning,  and  from  similar  toxaemic  states. 

Congestive  headache  is  often  produced  by  mechanical  hindrance  to 
the  return  of  blood  from  the. head.  It  is  generally  frontal,  but  some- 
times general.  A  tight  collar,  for  instance,  or  rest  with  the  neck  so 
bent  as  to  compress  the  veins,  frequently  causes  slight  headache  of 
this  character.     The  repeated   mechanical   congestion   produced  by 


860  HEADACHE. 

cough  is  another  frequent  cause,  and  may  even  occasion  the  patient 
more  distress  than  the  cough  itself.  Mechanical  congestion  not  only 
distends  the  veins,  but  causes  over-filling  of  the  capillaries,  and  increases 
the  amount  of  venous  blood  in  the  brain.  Thus  there  are  several 
factors  at  work  to  which  the  pain  may  be  due.  Active  congestion  of 
every  kind  also  gives  rise  to  pain  very  similar  to  that  produced  by 
passive  hypersemia,  but  more  distinctly  throbbing  in  character.  The 
action  of  poisons  that  dilate  the  vessels  has  been  already  mentioned. 

Gastric  disturbance  is  another  exceedingly  common  cause.  The 
pain  is  most  frequently  occipital  or  vertical ;  now  and  then  it  is  frontal. 
Sometimes  there  is  slight  pain  of  a  superficial  character  ;  the  severe 
neuralgic  headaches  associated  with  vomiting  cannot,  as  we  have  seen, 
be  ascribed  to  gastric  influences.  We  do  not  know  by  what  mechanism 
stomach  disorder  causes  headache — whether  it  is  by  some  influence  on 
the  cerebral  vessels,  or  whether  by  absorption  of  some  toxic  material 
from  the  stomach  or  bowel, — some  morbid  secretion,  or  product  of  the 
imperfect  digestion  of  food,  or  altered  bile.  A  purgative  often 
relieves  the  pain,  and  old  theories  regarded  the  bile  as  an  influential 
agent  in  the  production  of  this  and  other  symptoms  ;  but  when  there 
is  much  bile  circulating  in  the  blood,  as  in  jaundice,  headache  is 
usually  trifling  or  absent. 

The  term  "neuralgic  headache"  may  be  applied  to  the  forms  in 
which  the  pain  seems  to  be  superficial,  in  part  or  altogether,  and  is 
limited  in  area,  but  does  not  correspond  to  the  course  or  distribution 
of  the  superficial  nerve ;  such  pain  is  one  of  the  most  common 
varieties  of  headache.  The  subjects  of  neuralgia  often  suffer  from 
continuous  or  occasional  pain  in  the  head,  which  may  be  felt  in  any 
part,  sometimes  general,  but  more  often  local,  and  not  distinctly 
paroxysmal.  It  may  seem  to  arise  by  an  extension  of  the  pain  of  true 
nerve  origin  in  an  adjacent  region.  Such  local  headaches  are  common 
in  hysteria.  Many  forms,  such  as  the  sensation  of  a  nail  being 
driven  into  the  vertex,  are  intermediate  between  neuralgia  and  head- 
ache. A  common  cause  of  supra-orbital  pain  is  the  use  of  the  eyes 
when  there  is  hypermetropia.  The  strain  on  the  ciliary  muscle  seems 
to  be  the  immediate  excitant ;  the  pain  goes  off  when  the  use  of  the 
eyes  for  near  objects  is  discontinued. 

Ana3mic  headache  is  met  with  both  in  the  common  form  of  anemia, 
in  which  there  is  chiefly  a  deficiency  of  haemoglobin  (as  in  chlorosis), 
and  also  in  cases  in  which  much  blood  has  been  lost.  The  pain  is 
frontal  or  general ;  in  chlorosis  it  is  sometimes  peculiarly  intense  at 
the  back  of  the  eyes,  and  is  accompanied  by  a  sensation  as  if  the 
eyes  were  being  dragged  back  into  the  head.*     Neuralgic  headache 

*  The  fact  that  optic  neuritis  may  result  from  anaemia  is  of  great  interest  in  con- 
nection with  the  occurrence  of  headache,  since  it,  shows  that  the  disturbance  of  the 
nerve-elements  may  be  more  than  functional,  and  suggests  that  their  nutrition  may 
be  impaired  in  cases  of  apparently  Junctional  disturbance.  It  is  noteworthy  that  in 
Brio-ht's  disease,  when  optic  neuritis  preponderates  over  retinal  changes,  headache 
is  often  especially  severe. 


DIAGNOSIS.  861 

and  true  neuralgias  of  all  kinds  are  also  common  under  the  same 
conditions. 

Brain-work  and  brain  exhaustion  are  other  common  causes  :  some- 
times there  has  been  an  amount  of  brain-work  that  is  absolutely 
excessive;  in  other  cases  the  amount  has  not  been  large,  but  is- 
excessive  on  account  of  the  deficient  nerve-strength  of  the  individual. 
Pain  from  this  cause  is  often  general,  sometimes  local,  and  then 
generally  felt  in  the  forehead.  Occasionally  a  very  intense  form 
of  headache  results,  especially  where  there  has  been  an  acute  break- 
down from  overwork.  It  may  even  be  so  severe  as  to  cause  a 
suspicion  of  meningitis. 

In  various  conditions  of  nervous  weakness — "neurasthenia,"  as  it 
is  now  termed — headache  is  common,  and  may  have  almost  any  seat 
or  character.  Many  cases  in  young  girls  are  of  this  character,  and 
are  often  associated  with  symptoms  of  hysteria ;  the  headache  is 
then  called  hysterical,  but  it  is  doubtful  whether  there  is  any  closer 
association  with  that  disease  than  the  state  of  defective  nerve-strength 
which  underlies  both  conditions.  Indeed,  by  those  who  adopt  the 
prevalent  custom  of  using  the  term  "  neurasthenia  "  in  its  widest 
application,  almost  every  form  of  headache,  except  the  toxaemic,  may 
be  ascribed  to  this  cause.  Severe  continuous  headache  is  sometimes 
met  with  in  the  early  stage  of  constitutional  syphilis,  but  chiefly  in 
those  who  have  i*ecently  undergone  a  long  course  of  treatment  for  the 
disease.  This  also  has  been  regarded  as  a  manifestation  of  "  neuras- 
thenia syphilitica."  Many  of  the  slighter  continuous  headaches 
associated  with  nervous  weakness  are  largely  maintained  by  attention, 
as  is  the  case  in  even  greater  degree  with  the  cephalic  sensations  pre- 
sently to  be  described. 

Diagnosis. — The  diagnosis  of  the  form  and  nature  of  headache 
consists  first  in  the  search  for  any  general  condition  on  which  it  may 
depend.  It  is  important  to  note  the  time  at  which  the  pain  comes  on, 
its  relation  to  food,  to  mental  work,  and  to  other  influences  that  may 
possibly  be  concerned  in  its  causation.  The  general  state  of  the 
patient  must  also  be  carefully  investigated,  and  the  effect  of  various 
influences  in  augmenting  or  reducing  the  pain.  Anaemic  headaches,  for 
instance,  are  often  relieved  by  the  recumbent  posture ;  those  of  con- 
gestive or  toxsemic  origin  are  especially  increased  by  stooping  or  effort 
or  mechanical  congestion,  but  not  always* by  simple  recumbency,  which, 
perhaps  through  the  rest  it  involves,  often  lessens  the  pain,  and  does  so 
also  in  cases  of  neuralgic  nature.  The  seat  of  the  pain  is  often  sugges- 
tive, but  too  much  weight  must  not  be  placed  on  this  indication,  since 
many  variations  are  met  with.  Tift  pain  produced  by  acute  blood- 
states,  such  as  fever,  is  generally  frontal  and  deeply  seated,  and  is 
increased  by  cough  and  movement.  The  forehead  is  also  a  frequent 
seat  of  neuralgic  headaches  ;  these  are,  however,  generally  superficial 
in  character,  and  are  often  felt  just  over  the   eyebrows.     Pain  of 


862  HEADACHE. 

gastric  origin  is  also  sometimes  frontal.  Pain  in  one  or  both  temples 
is  generally  paroxysmal  and  allied  to  migraine;  so  are  all  one-sided 
headaches.  Occipital  pain,  deeply  seated,  felt  constantly  or  daily,  is 
more  often  due  to  disturbance  of  the  stomach  than  to  any  other  cause. 
Vertical  headache  is  seldom  due  to  blood-states ;  occasionally  it  also  is 
of  gastric  origin,  but  when  very  limited  it  is  usually  allied  to  neuralgia. 
General  headache  may  be  of  almost  any  nature  ;  it  is  often  due  to 
toxsemic  conditions,  anaemia,  and  conditions  of  nervous  weakness. 
It  must  be  remembered  that  blood-states  which,  on  account  of  their 
slight  degree  or  other  causes,  do  not  produce  considerable  headache, 
sometimes  cause  slight  local  pains. 

Treatment. — The  most  important  element  in  the  treatment  of 
headache  is  the  discovery  and  removal,  as  far  as  possible,  of  the 
state  of  the  blood  or  nervous  system  on  which  it  ultimately  or  imme- 
diately depends.  The  measures  necessary  for  this  object  must  vary 
with  each  variety  of  headache,  and  cannot  here  be  even  enumerated. 
Attempts  to  relieve  the  headache  by  direct  treatment  usually  fail 
unless  the  cause  is  discovered  and  removed.  Careful  inquiry  may 
be  needed  to  discover  its  real  origin.  Thus  a  patient  came  for  treat- 
ment for  headache,  in  whom  it  was  caused  solely  by  cough,  the  result 
of  phthisis.  It  is  important  that  in-  all  cases  except  those  in  which 
there  is  evidence  of  ansemia,  the  patient  should  sleep  with  the  head 
well  raised,  and  with  the  shoulders  raised  as  well  as  the  head,  so  that 
there  is  no  compression  of  the  cervical  veins  by  flexion  of  the  neck. 
Most  forms  of  headache,  except  those  due  to  anaemia  or  simple  weak- 
ness, are  relieved  by  aperients,  which  probably  act  partly  by  lessen- 
ing the  amount  of  blood  in  the  cephalic  vessels,  and  partly  by  im- 
proving the  state  of  the  blood.  Diuretics  are  useful  in  many  toxsemic 
headaches.  The  treatment  of  the  superficial  and  very  limited 
varieties  is  similar  to  that  of  migraine.  Indeed,  most  of  the  advice 
given  respecting  the  treatment  of  the  headache  of  migraine  is  appli- 
cable also  to  its  more  simple  form. 

Headache  of  every  kind  is  often  relieved,  although  seldom  removed, 
by  external  applications  that  sting  the  skin.  Chloroform,  or  any 
stimulating  liniment,  will  answer  the  purpose,  provided  evaporation  is 
prevented  by  an  impermeable  tissue.  Bisulphide  of  carbon  has  been 
recommended  for  the  purpose,  but  it  does  not  seem  to  have  any  special 
value.  Mustard  plasters  to  the  back  of  the  head  or  neck  are  useful 
when  the  pain  is  occipital,  and  often  induce  beneficial  sleep.  Slight 
pain  about  the  forehead  may  be  removed  by  the  application  of  menthol, 
which  is  especially  useful  when  such  pain  is  just  enough  to  prevent 
sleep.  ■ 

Sedatives  are  very  uncertain  in  their  influence.  Opium  and  morphia 
are  seldom  useful,  and  often  do  more  harm  than  good,  partly  in  con- 
sequence of  the  indirect  effect  of  the  constipation  that  is  produced. 
G-elsemium  and  Indian  hemp  frequently  lessen  the  pain ;  the  former 


CEPHALIC    SENSATIONS.  863 

chiefly  in  superficial  forms  about  the  front  of  the  head  connected  with 
neuralgia,  the  latter  not  only  in  neuralgic,  but  in  anaemic,  and  also 
other  ill-defined  forms  of  headache.  Bromide  of  potassium  may  be 
given  in  addition  to  the  Indian  hemp  if  there  is  restlessness,  irrita- 
bility, or  insomnia,  but  has  not  alone  much  influence  on  the  pain. 
Butyl-chloral  is  occasionally  serviceable.  Antipyrin,  acetanilide,  and 
phenacetin  often  give  great  relief,  especially  to  paroxysmal  exacerbations 
of  pain,  but  are  apt  soon  to  lose  their  power.  By  varying  them, 
however,  their  influence  may  often  be  maintained.  It  must  be 
remembered,  however,  that  these  palliative  measures  ought  to  be 
regarded  only  as  adjuncts  to  the  causal  treatment. 


Head  Pressure  and  other  Cephalic  Sensations. 

It  is  common  for  patients  to  suffer  from  various  more  or  less  dis- 
tressing sensations  in  the  head,  which  have  not  the  character  of  actual 
pain.  These  sensations  are  much  more  frequent  in  men  thau  in  women. 
They  occur  chiefly  during  the  first  half  of  adult  life,  between  twenty 
and  forty,  but  are  sometimes  complained  of  by  lads  of  sixteen  or 
eighteen,  and  occasionlly  by  persons  in  the  second  half  of  life,  at  fifty 
or  sixty.  In  late  life  they  are  relatively  more  common  in  females, 
coming  on  sometimes  after  the  cessation  of  the  menses,  at  the  "  climac- 
teric period."  They  are  sometimes  associated  with  a  gouty  state  of  the 
system.  Brain-workers  are  chiefly  liable  to  these  sensations ;  they 
are  seldom  met  with  among  those  who  earn  their  living  by  manual 
labour,  and  hence  are  rarely  complained  of  by  hospital  patients. 
Many  of  the  sufferers  are  the  subjects  of  pronounced  hypochondriasis, 
who  attend  to  their  sensations,  and  often  complain  of  other  kinds  of 
nerve  disturbance.  Excessive  brain- work  may  be  the  distinct  exciting 
cause  of  the  symptoms  ;  in  other  cases  they  succeed  a  definite  head- 
ache, of  short  or  long  duration,  severe  or  slight.  I  have  known  the 
sensation  to  follow  a  blow  on  the  top  of  the  head.  It  is  indeed 
probable  that,  in  a  large  number  of  cases,  they  are  set  up  by  some  real 
sensation,  sometimes  of  pain,  sometimes  of  other  character.  A  dis- 
tressing sense  of  constriction  over  the  whole  scalp  succeeded,  in  one 
case,  the  application  of  an  ice-cap  for  a  few  days,  on  account  of  deli- 
rium during  influenza. 

The  sensations  vary  in  different  cases,  but  by  far  the  most  frequent 
is  a  sense  of  pressure,  sometimes  trifling,  sometimes  as  if  a  heavy  weight 
were  on  the  head,  and  occasionally  as  if  the  top  of  the  skull  were  being 
driven  in.  Many  patients  describe  the  sensations  in  language  that  is 
clearly  exaggerated,  so  that  it  may  not  be  easy  to  ascertain  the  actual 
intensity  of  the  sensation,  but  it  is  certainly  often  very  distressing. 
It  may  be  called  "  headache  "  or  "  pain,"  but  however  intense  it  is, 
inquiry  shows  that  the  sensation  has  not  the  character  of  actual  pain, 


864,  CEPHALIC    SENSATIONS. 

either  acute  or  dull.  Its  common  seat  is  the  vertex  and  top  of  the  head, 
but  it  is  sometimes  felt  at  the  back  of  the  head,  less  commonly  in  the 
forehead.  One  patient  described  the  sensation  as  a  feeling  as  if  there 
were  an  iron  band  round  the  back  of  the  head.  Sometimes  it  is 
lateral,  in  the  parietal  region  or  the  temples,  "as  if  the  sides  of  the 
head  were  being  driven  in."  Much  less  common  is  the  opposite 
sensation,  a  feeling  of  expansion,  as  if  the  bone  of  the  skull  were 
being  pushed  out  or  up.  A  sensation  of  heat  or  burning,  not  amount- 
ing to  pain,  is  sometimes  described.  A  vague  sense  of  fulness  is  not 
uncommon,  and  it  is  sometimes  accompanied  by  a  sense  of  throbbing ;. 
in  other  cases,  again,  the  feeling  is  said  to  be  as  if  the  skull  were  empty. 
Various  other  sensations  are  occasionally  described,  which  the  patient, 
in  default  of  adequate  terms,  describes  by  some  simile  beyond  the 
range  of  ordinary  experience,  such  as  "  a  feeling  as  if  the  brains 
were  being  stirred  up  with  a  stick,"  or,"  as  if  red-hot  coals  had 
been  placed  on  the  brain,"  or  "as  if  the  head  were  being  alternately 
opened  and  shut."  Occasionally  a  superficial  sensation,  of  tingling, 
creeping,  &c,  is  complained  of  in  some  part  of  the  head,  on  one  side 
or  both. 

The  sensation  is  often  uniform  in  the  same  case,  and  may  continue 
unchanged  for  many  years.  Less  commonly  the  patient  has  first  one 
sensation  and  then  another.  The  sense  of  pressure  may  seem,  when 
most  intense,  to  give  rise  to  dull,  actual  pain.  The  discomfort  is 
commonly  increased  by  brain-work,  and  often  by  any  unpleasant 
emotion,  while  it  may  be  unnoticed  when  the  mind  is  occupied  by 
some  agreeable  subject.  It  is  often  only  observed  when  the  patient 
is  indoors,  being  unfelt  when  he  is  out  in  the  open  air. 

The  chief  agency  in  the  production  of  these  sensations  is  certainly 
the  mental  state  of  the  patient.  There  is  probably  at  the  outset  some 
actual  sensory  impression,  often  some  headache,  and  the  attention  is 
constantly  directed  to  the  part,  with  the  result  that  the  patient 
perceives  sensations  which,  under  normal  circumstances,  would  be 
unperceived.  Nerve-impulses,  in  health  unnoticed,  must  be  con- 
tinually passing  from  all  parts  to  the  centres,  and  they  may  be  readily 
perceived  if  attention  is  directed  to  them.  A  person  imagines  that  he 
is  unconscious  of  his  body  and  limbs,  but  let  him  direct  his  attention 
to  any  part,  and  in  a  few  moments  he  will  be  conscious  of  a  distinct 
sensation  in  it,  and  with  especial  readiness  of  sensations  in  the  head. 
If  the  reader  will  direct  his  attention  to  the  vertex,  he  will  probably 
soon  be  able  to  detect  a  distinct  sense  of  pressure  there,  especially  if 
he  is  fatigued  or  has  been  engaged  in  mental  work.  It  is  easy  to 
understand  that  such  a  sensation  may  be  increased  by  constant  atten- 
tion to  an  unpleasant  and  even  distressing  degree,  especially  if  some 
real  sensation  originally  "  drew  "  the  attention  to  the  part,  and  if  the 
individual  is  in  feeble  health,  or  of  a  nervous  temperament.  The 
physical  side  of  "  attention"  is  a  lowering  of  resistance  in  nerve-cells, 
so  that  they  are  more  rapidly  roused  to  activity,  and  their  activity  is 


CEPHALIC    SENSATIONS.  S65 

greater  than  normal.  Thus  the  ultimate  result  may  be  the  same  as  if 
the  afferent  nerve-impulses  were  increased  in  energy,  and  a  sensation 
is  produced  by  nerve-processes  that  should  be  unperceived.  The  con- 
dition may  be  described  as  a  "  receptive  dysesthesia." 

Rarely,  when  the  sensation  is  at  the  worst,  there  is  slight  tenderness 
of  the  scalp.  Although  the  sensations  are  usually  constant,  in  excep- 
tional cases  they  are  paroxysmal,  and  then  may  be  accompanied  by 
some  general  nervous  excitement  and  insomnia.  It  is  common  for  the 
patient  to  say  that  sleep  does  not  refresh  him.  There  is  occasionally 
also  a  little  mental  confusion.  An  inability  to  concenfrate  the  mind 
on  a  particular  subject,  with  a  little  consequent  failure  of  memory,  is 
often  described,  but  is  merely  the  result  of  the  engrossing  sensation 
which  obtrudes  itself  on  the  mind  and  prevents  attention.  The  sen- 
sations are  sometimes  distinctly  increased  by  stimulants.  Very  rarely 
there  is  slight  flushing  in  the  face  during  paroxysmal  sensations, 
but  this  is  not  common. 

Some  of  these  sufferers  complain  at  times  of  other  slight  functional 
nerve  disturbance.  An  actual  headache  may  alternate  with  the 
sense  of  pressure,  &c.  In  other  cases  there  are  occasional  sensations 
of  giddiness,  almost  always  vague  and  slight,  and  perhaps  sometimes 
scarcely  real,  since  the  patient  looks  out  lor  them.  Often  it  is  merely 
a  sensation  of  the  "  legs  giving  way." 

The  treatment  of  this  condition  is  a  matter  of  very  great  difficulty. 
Sedative  drugs  have  little  influence  upon  it,  unless  they  are  given  in 
large  doses,  and  then  their  effect  is  transient.  This  fact  is  in  harmony 
with  what  has  been  said  of  the  probable  pathology  of  the  affection. 
As  long  as  the  influence  of  attention  is  at  work,  the  patient's  distress 
continues,  and  the  mental  cause  is  beyond  the  influence  of  drugs. 
The  sufferer  cannot,  by  a  deliberate  effort  of  the  will,  ignore  the  sensa- 
tions that  distress  him.  The  only  method  of  treatment  that  is  effective 
is  to  make  the  patient  realise  the  unimportant  nature  of  the  sensa- 
tions, and  try  to  neglect  them  by  directing  his  attention  to  other  sub- 
jects. While  it  is  wise  for  him  to  avoid  whatever  greatly  increases 
the  sensations,  he  should  persistently  endeavour  to  "  snub "  them, 
rather  than  to  cultivate  them.  When  this  effort  is  made  and  main- 
tained, the  discomfort  slowly  ceases  to  trouble  the  patient,  and  at  last 
is  no  longer  noticed.  Unfortunately,  the  mental  constitution  of  some 
patients  makes  it  impossible  for  them  thus  to  ignore  their  suffering  ; 
they  continue  to  attend  to  the  sensations,  doubt  the  assurances  of 
physicians  who  assert  the  unimportant  nature  of  the  discomfort,  and 
seek  the  advice  of  others,  placing  most  trust  in  those  Avho  pander  to 
their  apprehensions  by  the  assurance  that  the  sensations  indicate 
some  grave  disease,  such  as  congestion  of  the  brain.  Many  a  patient 
of  this  class  may  be  truly  said  to  be  suffering  from  a  morbus  medicorum, 
and  his  best  chance  of  recovery  is  to  keep  away  from  doctors  altogether. 
Of  course  any  conspicuous  defect  in  general  health  should  be  put 
right ;  a  gouty  diathesis  should  be  treated  ;  distinct  nerve- weakness 
vol.  ii.  55 


866  FACIAL    HEMIATROPHY. 

may  require  tonics;    and  if   there  is  vertigo  or  insomnia,  bromide, 
with  small  doses  of  Indian  hemp,  gives  some  relief. 


FACIAL  HEMIATEOPHY. 


Facial  hemiatrophy,  as  its  name  implies,  is  a  wasting  of  one  side  of 
the  face,  in  which,  howevei*,  the  bones  and  subcutaneous  tissue  suffer 
more  than  the  muscles.  The  precise  relations  of  the  disease  are 
uncertain.  It  is  commonly  classed  with  exophthalmic  goitre  and 
migraine,  but  it  is  very  doubtful  whether  this  is  its  true  position. 
Many  facts  connect  it  with  organic  disease  of  the  fifth  nerve,  but  the 
relation  between  the  two  is  not  yet  ascertained  with  sufficient  uni- 
formity and  definiteness  to  justify  its  inclusion  among  the  effects  of 
disease  of  that  nerve.  In  many  cases  it  has  followed  a  blow  or  con- 
tusion of  the  face,  sufficiently  severe  to  have  acted  on  the  bone,  gener- 
ally in  either  early  or  later  childhood.  Sometimes  the  atrophy  has 
developed  in  the  course  of  a  year  or  two,  and  it  has  generally  affected 
chiefly  the  upper  and  lower  jaws.  Instances  are — a  blow  on  the 
angle  of  the  orbit ;  contusion  of  the  upper  and  lower  jaw  in  a  child 
of  three,  whose  head  was  jammed  and  twisted  between  iron  railings ; 
a  blow  and  exposure  to  cold  at  twelve,  the  atrophy  being  consider- 
able at  fourteen.  In  other  cases,  some  trifling  local  disorder  has  been 
the  apparent  cause,  as  the  forced  passage  of  a  sound  down  the  lac- 
rymal  duct  at  sixty-three,  an  "  abscess  in  the  ear,"  and  "  erysipelas 
of  the  face."*  An  instance  of  the  affection  was  first  recorded  by 
Parry  in  1825,  but  the  disease  only  received  attention  after  it  had 
been  described  by  Romberg  thirty  years  later.  It  is  very  rare,  and  is 
of  small  practical  importance ;  it  involves  no  danger  to  life  or  health, 
and  cannot  be  influenced  by  treatment. 

Causes. — The  disease  generally  begins  in  early  life,  sometimes  in 
childhood,  sometimes  in  the  second  decade.  It  has  commenced  as 
early  as  two  or  three  years  of  age.  It  occasionally  develops  in  adults, 
rarely  in  late  life.  A  disparity  in  size  between  the  two  sides  of  the 
face  is  sometimes  congenital,  but  such  cases  are  commonly  distin- 
guished from  those  that  commence  after  birth.  Females  seem  more 
liable  to  the  affection  than  males.  Most  of  the  cases  have  been 
isolated,  but  in  one  recorded  case  an  aunt  of  the  patient  had  suffered 
from  the  same  disease.  It  has  often  come  on  without  any  exciting 
cause,  but  in  some  cases,  the  affection  has  followed  a  morbid  process, 
local  or  general,  of  which  it  seemed  to  be  the  consequence.     Examples 

*  A  blow,  Wolff, «  Virchow's  Archiv,'  Bd.  xeiv;  Stewart,  « Montreal  Med.  Jouni.,' 
18S9;  contusion,  Skyrme,  *  Brit.  Med.  Journ.,'  March,  1892;  inflammation  of  the 
bone,  Rubemann;  passage  of  a  sound,  Borgherini,  'La  Psich,'  viii;  abscess  of  the 
car,  Preobashenski,  1890;  erysipelas  (at  nine),  Cohen. 


SYMPTOMS.  867 

of  local  influences  have  been  already  mentioned,  and,  in  addition,  the 
atrophy  has  supervened  on  some  disease  of  the  fifth  nerve,  such  as 
neuritis,  either  primary  (Mendel),  or  secondary  to  some  other  disease, 
a  tumour  beside  the  pons,  or  an  inflammation  of  the  upper  jaw  bone, 
spreading  to  the  nerve.  Among  the  cases  after  general  disease  is 
one  in  which  the  affection  commenced  on  the  right  side  of  the  face 
after  an  attack  of  scarlatina  with  diphtheria  at  six,  and  an  attack  of 
typhoid  many  years  afterwards  was  followed  by  distinct  atrophy  of  the 
left  side.  It  has  also  followed  "typhus"  (probably  in  most  cases 
typhoid),  at  five  and  at  eighteen.  Other  general  diseases  which  have 
preceded  it,  as  acute  rheumatism  and  influenza,  may  have  acted  by 
setting  up  changes  in  the  fifth  nerve  or  its  nucleus,  for  in  many 
instances  early  pain  in  the  corresponding  side  of  the  head  suggested 
such  a  process.* 

Symptoms. — A  gradual  diminution  in  the  bulk  of  one  side  of 
the  face  has  often  been  the  first  indication  of  the  disease.  In 
some,  however,  the  atrophy  has  begun  at  one  spot,  commonly  on 
the  cheek,  at  which  the  skin  has  been  observed  to  become  thin  and 
pale  from  loss  of  pigment,  and  depressed  from  the  loss  of  the  sub- 
cutaneous tissue.  The  hairs  drop  out  in  the  affected  parts  and  the 
sebaceous  follicles  waste.  The  condition  has  gradually  spread,  and 
has  involved  4he  bones.  In  the  cases  that  began  in  early  life,  the 
ultimate  difference  between  the  two  sides  of  the  face  has  been  greater 
than  in  those  that  developed  later,  a  hindrance  to  growth  increasing 
the  effect  of  the  wasting,  so  that  it  is  chiefly  in  these  cases  that  the 
disparity  in  the  size  of  the  bones  is  considerable.  In  these  cases  also 
the  usual  growth  of  hair  does  not  take  place  on  the  face,  although 
there  may  not  be  much  difference  in  the  anterior  part  of  the  scalp. 
The  ultimate  condition  in  well-marked  cases  is  very  striking.  The 
appearance  of  the  patient  is  as  if  the  face  were  made  up  of  two  halves 
from  different  individuals.  One  side  may  have  the  fulness  of  youth, 
and  the  other  the  furrows  of  age,  while  the  contrast  in  character  is 
intensified  by  the  difference  in  size.  On  the  affected  side  the  bone  of 
the  forehead  and  cheek  is  considerably  smaller  than  on  the  other  side  ; 
the  skin  covers  the  bone  closely,  and  so  presents  depressions  without 
counterparts  on  the  opposite  half,  while  a  vertical  furrow  usually  marks 
the  transition  from  the  affected  to  the  normal  side.  The  side  of  the 
lower  jaw  may  be  only  two  thirds  the  length  of  its  fellow,  and  is 
diminished  in  depth,  so  that  the  face  appears  much  shorter.  The 
cartilage  of  the  nose  shares  the  wasting,  and  in  the  cases  that  begin 
early,  it  may  be  so  small  on  the  affected  side  as  to  render  the  nose 
altogether  unsymmetrical,  the  tip  deviating  towards  the  smaller 
side  ;  the  external  ear  has  been  known  to  share  the  wasting  ;  the  teeth 
are  sometimes  small,  and  may  drop  out  or  decay  early.  In  spite  of 
the  wasting  of  other  tissues,  the  muscles  seldom  seem  to  be  altered, 
*  Typhus  or  typhoid,  Kona,  18S9;  Dreyer,  1890;  influenza,  Jolly,  1891. 


868 


FACIAL    HEMIATROPHY. 


either  in  .size,  in  voluntary  power,  or  electrical  excitability  ;  rarely 
they  have  been  wasted. 

Indications  of  implication  of  the  fifth  nerve  are  sometimes  distinct. 
Sensation  may  be  impaired  or  lost,  either  in  all  parts  or  in  the  second 
and  third  divisions,  and  taste  may  be  lost  on  the  front  of  the  tongue. 
Rarely  there  has  been  some  wasting  of  the  muscles  of  mastica- 
tion on  the  affected  side,  and  they  have  been  the  seat  of  spasm  in 
three  instances,*  tonic  (in  the  case  due  to  a  blow1,  and  paroxysmal 
tonic  and  clonic  contractions,  which  afterwards  spread  to  the  tougue, 
in  the  case  recorded  by  Sachs.  In  a 
few  instances  the  corresponding  halves  of 
the  tongue  and  of  the  palate  Lave  also  been 
wasted.  It  is  doubtful  whether  there  is 
any  alteration  in  the  size  of  the  arteries 
and  veins.  The  ultimate  wasting  of  the 
skin  may  be  very  great ;  it  is  said  that  a 
fold  of  the  skin  on  the  affected  side  may 
be  only  one  tenth  the  thickness  of  a  similar 
fold  on  the  other  side.  In  several  in- 
stances, the  wasting  was  preceded  by 
scleroderma. f  The  temperature  is  usually 
unchanged,  but  in  the  early  stage  it  has 
been  found  to  be  slightly  lessened.  The 
organs  of  special  sense  on  that  side  are 
not  changed,  but  the  eye  often  appears  re- 
tracted in  the  orbit  in  consequence  of  some 
wasting  of  the  orbital  tissue.  Neuro-paralytic  ophthalmia  has 
been  once  met  with  (Graff ).  The  secretion  of  saliva  and  of  tears 
is  not  affected.  As  a  rule  there  is  no  wasting  beyond  the  region 
of  the  fifth  nerve,  but  a  case  of  bilateral  atropby  has  been  already 
mentioned,  and  Yirchow  described  a  typical  hemiatrophy  of  the 
face,  associated  with  an  atrophy  of  the  skin  and  subcutaneous 
tissue  of  part  of  the  back  and  arm  on  the  same  side ;  in  the  arm, 
in  the  back,  it  extended  from  the  fourth  to  the  seventh  dorsal  spine, 
it  affected  chiefly  the  radial  side  of  the  forearm.  This  case  has 
become  important  on  account  of  its  pathological  investigation  by 
Mendel.  A  curious  case  of  local  wasting  of  all  the  subcutaneous 
tissues  in  small  areas  on  the  back  and  arm  has  been  mentioned  in 
vol.  i,  p.  481. 

The  affection,  beginning  commonly  in  childhood,  progresses  steadily 
for  some  years,  and  then  becomes  stationary  and  remains  so  for  the  rest 
of  life.  The  first  illustration  (Fig.  158)  is  the  case  of  a  man  named 
Schwann,  who  exhibited  himself  in  this  and  other  countries  a  few 
years  ago  ;  he  was  then  aged  forty  j  the  atrophy  began  in  childhood, 


FiG.   158. — Facial  hemi- 
atrophy (Schwann). 


*  Wolff,  Muratow,  Sachs, 
t  Gibney,  Rosenthal,  Muratow,  Nixon, 
existed  elsewhere. 


In  the  case  of  the  two  latter,  scleroderma 


PATHOLOGY. 


869 


■and  his  case  was  described  by  Eomberg  in  1851.  The  other  figure  is 
•of  a  child  of  seven  in  whom  the  affection  showed  itself  at  three  and 
half,  six  months  after  an  accident  in  which  the  face  was  jammed  and 
the  neck  twisted.     The  child  was  subject  to  attacks  of  migraine. 


Fig.  159. — Hemiatrophy  of  the  face  in  a. child  of  seven.* 

Facial  hemiatrophy  seldom  co-exists  with  other  maladies  except  the 
occasional  affection  of  the  fifth  nerve.  In  the  above  case  there  was 
also  a  liability  to  attacks  of  migraine,  in  another  there  were  symptoms 
of  tabes  (Jolly),  while  in  one  remarkable  case  the  condition  co-existed 
with  multiple  exostoses  of  the  bones  of  the  head  and  face.f 

Pathology. — The  great  variation  in  the  conditions  under  which,  and 
causes  from  which,  facial  hemiatrophy  seems  to  arise,  makes  it  difficult 
to  ascribe  all  cases  to  the  same  mechanism,  and  yet  other  features 
make  it  almost  equally  difficult  to  separate  the  immediate  causes. 

Especially  the  correspondence  of  the  hemiatrophy,  in  all  cases,  to 
part  or  the  whole  of  the  region  supplied  by  the  fifth  nerve,  is  a  fact 
of  clear,  although  limited  significance,  which  is  increased  by  the 
occasional  evidence  of  impaired  function  of  the  nerve  (corresponding 

*  I  am  indebted  for  this  illustration  to  Mr.  Skryine,  who  has  published  the  ease 
.('  Brit.  Med.  Journ.,'  1892,  p.  654). 
f  Karewski,  'Dieut.  med.  Zeit.,'  1891. 


870  FACIAL    HEMIATROPIA. 

to  the  atrophy  in  a  case  in  which  the  area  of  the  first  division  was 
unaffected),  aud  is  made  still  more  definite  by  certain  recent  patho- 
logical observations.  In  Virchow's  case,  Mendel  found,  seven  years 
later,  interstitial  neuritis  of  all  parts  of  the  nerve,  with  degeneration 
of  the  fibres,  and  atrophy  of  many  in  the  upper  root  and  of  the  cells 
of  the  locus  caeruleus.  (In  the  cord  slight  changes  were  found  in 
the  anterior  cornu  corresponding  to  the  wasting  in  the  back.)  Hence 
he  conjectures  that  the  upper  root  of  the  fifth  contains  trophic  fibres. 
The  tumour  beside  the  pons,  in  the  case  already  referred  to,  had 
compressed  the  fifth  nerve  and  the  pons  (as  well  as  the  nerves  of 
the  eyeball).  There  was  conspicuous  narrowing  of  the  fibres  of  both 
lower  and  upper  roots  of  the  fifth ;  the  cells  of  the  locus  caeruleus 
were  normal.  Moreover,  facial  hemiatrophy  has  been  produced  in 
dogs  by  dividing  the  fifth  nerve  within  the  skull  (Grirard).  It  thus 
seems  certain  that  disease  of  this  nerve  may  cause  the  affection,  but, 
on  the  other  hand,  the  effect  is  not  a  common  consequence  of  such 
disease,  even  when  complete  and  of  long  duration,  and  in  many  cases 
the  only  evidence  of  such  a  relation  is  correspondence  in  distribution 
or  some  early  pain  in  the  affected  parts.  Hence  it  has  been  thought 
to  be  due  also  to  other  causes.  Wasting  of  the  corresponding  side  of 
the  face  has  been  described  by  Seeligmiiller  in  a  case  of  injury  to  the 
cervical  sympathetic,  but  has  been  absent  in  most  cases  of  the  kind.* 
A  subsidiary  mechanism — compression  of  the  arteries  for  the  bone  by 
the  cutaneous  and  subcutaneous  changes — has  been  suggested,  but  is 
a  far-fetched  hypothesis. 

It  is  important  to  remember  the  fact  that  the  nutrition  of  all  parts, 
except  the  muscles,  seems  to  depend  on  the  posterior  root-fibres,  to 
which  the  fifth  nerve  chiefly  belongs,  and  that  the  influence  of  chronic 
lesions  is  to  cause  a  slow  wasting  distinct  from  the  acute  disturbance 
produced  by  irritation  (see  vol.  i,  p.  22).  The  atrophy  of  the  skin 
and  bone  in  the  finger  ends,  after  a  lesion  of  the  nerves  of  the  arm, 
may  proceed,  in  spite  of  normal  sensibility,  and  is  a  state  closely 
allied  to  facial  hemiatrophy. f  The  evidence  of  a  trophic  influence 
does  not,  however,  afford  any  proof  of  trophic  nerves.  The  rapid 
conduction  of  sensory  impulses  upwards  may  be  compatible  with  a 
slower  conveyance  of.  a  trophic  influence  downwards,  even  in  the  same 
fibres,  and  the  latter  may  be  lost  while  the  former  is  unchanged. 
There  is  not  sufficient  evidence  to  justify  the  assumption  that  the 
mechanism  is  a  damage  to  fibres  of  the  sympathetic  that  run  in  the 
fifth  nerve  ;  although  implication  of  these  fibres  may  have  co-existed 
in  the  rare  cases  with  evidence  of  disturbance  of  the  sympathetic. 

*  Much  weight  has  been  placed  on  a  case  described  by  Brunner,  in  which  the 
condition  was  associated  with  prominence  of  the  eyeball  and  pallor  of  the  skin, 
supposed  to  be  dependent  on  an  affection  of  the  sympathetic.  But  the  case  stands 
almost  alone. 

+  Even  thickening  of  the  skin  may  occur  in  neuritis,  as  sometimes  in  the  face, 
cf.  vol.  i,  p.  68. 


EXOPHATHLMIC    GOITRE.  871 

The  chief  indication  of  the  facts  is  that  there  is  a  loss  of  a  special 
influence  exerted  through  the  fibres  of  the  fifth  nerve,  independent  of 
its  conducting  functions,  although  sometimes  impaired,  together  with 
them  by  oi'ganic  disease.  It  is  an  influence  such  as  we  can  trace 
elsewhere,  not  only  in  the  conditions  mentioned,  but  in  the  trophic 
changes  in  tabes.  To  what  origin  of  the  fifth,  it  is  related,  we  can 
only  learn  definitely  by  further  investigations,  but  its  loss  may  not 
be  necessarily  associated  with  visible  alterations  in  the  nerve-elements 
on  which  it  depends. 

It  may  be  instructive,  in  this  connection,  to  remember  that  arthritic 
muscular  atrophy  may  be  set  up  by  merely  transient  joint  pain,  and 
that  it  is  not  attended  by  any  evidence  of  organic  changes  in  the 
motor  nerves,  through  which  it  is  certainly  produced.  Being  exten- 
sive, but  limited  in  range  and  often  persistent  in  some  degree,  it  is 
thus  a  process  bearing  some  analogy  to  facial  hemiatrophy,  especially 
to  such  cases  as  that  produced  by  the  forced  catheter isation  of  the 
lachrymal  duct  and  those  due  to  transient  injury.  Both  diseases  and 
the  trifling  nature  of  many  of  the  apparent  causes  of  facial  hemi- 
atrophy, show  how  little  ground  we  have  as  yet  on  which  to  erect 
theories  of  the  causation  of  this  malady. 

Diagnosis. — The  only  condition  with  which  the  affection  can  be 
confounded  is  that  in  which  there  is  a  congenital  difference  between 
the  two  sides  of  the  face.  In  this,  however,  the  inequality  is  slight, 
and  on  the  smaller  side  there  is  not  the  difference  in  the  gi-owth  of 
the  hair  or  the  colour  of  the  skin  seen  in  most  cases  of  hemiatrophy. 

Prognosis  and  Treatment. — There  is  no  prospect  of  improvement, 
except,  possibly,  in  some  of  the  rare  cases  that  come  on  in  adult  life 
after  injury,  or  are  accompanied  by  distinct  symptoms  of  disease  of 
the  fifth  nerve.  The  treatment  of  these  is  that  of  the  morbid  process 
in  the  nerve.  If  improvement  ever  occurs,  it  is  probably  consequent 
on  the  removal  of  the  cause. 


EXOPHTHALMIC  GOITKE. 


Exophthalmic  goitre  is  a  mysterious  malady,  usually  manifested  by 
three  sets  of  symptoms :  enlargement  of  the  thyroid,  prominence  of 
the  eyes,  and  a  peculiar  disturbance  of  the  vascular  system,  viz.  over- 
action  of  the  heart  and  increased  pulsation  of  the  arteries  of  the 
neck.  These  vary  in  relative  degree  in  different  cases,  and  any  one 
of  them  may  be  inconspicuous.  The  disease  was  first  fully  described 
by  Graves  in  1835,*  who  drew  especial  attention  to  the  coincidence  of 

*  Cases  had  been  published  earlier,  but  without  recognition  of  all  the  symptoms 
or  their  special  character;  in  1802  by  Flagani;  in  1816  in  the  'Medico-Chirurgical 


872  EXOPHTHALMIC    GOITRE. 

over-action  of  the  heart  and  enlargement  of  the  thyroid,  and  described 
the  co-existence,  with  these,  of  prominence  of  the  eyes,  in  a  case  com- 
municated to  him  by  Stokes.  He  thus  desci-ibed  all  the  symptoms, 
duly  recognising  the  predominance  of  the  cardiac  disturbance.  In 
Germany  the  first  full  account  of  the  affection  was  given,  in  1840, 
bv  Basedow.  Hence  the  affection  is  often  called  in  this  country  and 
in  France  "  Graves'  disease,"  but  in  Germany  "  Basedow's  disease."* 
Many  other  designations  have  been  proposed — "  struma  exoph- 
thalmica,"  "  cardio-thyroid  exophthalmos,"  &c,  no  one  of  which  has 
obtained  currency  or  can  claim  special  exactness. 

While  the  three  symptoms  named  above  are  usually  present,  and 
have  hence  been  termed  the  "  cardinal  symptoms "  of  the  disease, 
any  one  of  them  may  be  absent.  Moreover,  any  of  them  may  be  met 
with  in  association  with  the  less  common  symptoms,  or  complications 
of  the  disease.  Hence,  while  the  majority  of  the  cases  present 
definite  and  characteristic  features,  cases  occur,  more  or  less  closely 
allied  to  the  typical  form,  but  extremely  various  in  their  characters. 
It  is  not  practicable  (nor  would  it  be  useful)  to  do  more  than  indicate 
the  occurrence  of  these,  in  describing  the  leading  features  of  the 
malady. 

Causes. — Women  are  far  more  prone  to  suffer  than  men,  the  ratio 
being  uncertain,  but  probably  about  twenty  to  one.f  The  disease 
mav  occur  at  any  age,  from  two  to  sixty,  but  is  met  with  chiefly  in 
adult  life,  between  fifteen  and  fifty,  and  more  cases  begin  between 
twenty  and  thirty  than  in  auy  other  decade.  I  have  known  it  to 
commence  at  fifty-one  and  fifty-three,  and  also  at  seven  and  a  half  in 
an  epileptic  girl,  whose  mother  suffered  from  it  from  eighteen  to 
twenty-five.  Although  not  usually  inherited,  instances  such  as  that 
just  mentioned  are  occasionally  met  with.  In  several  recorded  in- 
stances two  sisters,  or  mother  and  daughter,  have  suffered ;  in  one  a 
mother  and  a  son  aged  eight,  in  another  an  aunt  and  three  nieces 
(Cheadle).  Eight  out  of  ten  children  suffered  in  various  degrees 
and  at  various  ages  in  a  family  observed  by  Oesterreicher.J  In  such 
instances,  some  of  the  cases  were  slight  or  imperfect,  so  that  they 

Journal/  anonymously  ;  in  1818  by  Demours  (thyroid  and  eyes  only)  ;  by  Parry  in 
1825  (posthumous  publication  of  a  case  observed  in  1785) ;  and  by  Adelmann  in 
1828.  See  "Wickham  Legg,  "  Note  on  tbe  History  of  Exophthalmic  Goitre,"  '  St. 
Barth.  Hosp.  Rep.,'  vol.  xviii,  p.  7  ;  and  JIaitland  Ramsay,  '  Glasgow  Thesis,'  1891, 
which  contains  tbe  best  account  of  the  history  of  the  disease. 

*  This  term  is  firmly  rooted  in  Germany,  but  if  the  disease  had  now  to  be  named, 
it  is  probable  that  the  Germans,  ever  ready  to  give  credit  where  it  is  due,  would 
term  the  malady  "  Graves'  disease."     It  has  been  also  called  "  Parry's  Disease." 

f  Recorded  series  have  presented  singular  discrepancies,  apart  from  those  that 
are  due  to  the  field  for  observation.  In  some  the  proportion  has  been  about  5  to  1, 
but  Russell  Reynolds  met  with  only  one  male  in  a  series  of  iorty-uiue  cases,  '  Lancet,' 
May  17th,  1890. 

t  '  YVieii.  mod.  Presse,'  1884. 


causes.  873 

would  probably  Lave  escaped  recognition  had  not  attention  been 
directed  to  them  by  the  other  cases.  Much  more  frequent  is  general 
neuropathic  inheritance,  indicated  by  insanity  or  epilepsy  in  rela- 
tions. Thus,  I  had  at  one  time  under  my  care  two  sisters,  one  for 
epilepsy,  the  other  for  severe  exophthalmic  goitre  ;  another  patient  had 
a  father  and  an  uncle  epileptic,  another  a  sister  and  an  aunt  epileptic. 
A  family  relation  to  diabetes  has  also  been  noted.*  The  causes  of 
ordinary  goitre  seem  to  have  little  influence  in  producing  the  exoph- 
thalmic fonn,f  and  recovery  has  actually  followed  removal  to  a  place 
"where  goitre  was  endemic  (Trousseau).  In  a  very  few  cases,  how- 
ever, the  special  symptoms  of  the  disease  have  supervened  on  goitre 
of  the  common  character  and  of  some  years'  duration. 

G-eneral  debility  and  anaemia  are  unquestionably  powerful  predis- 
ponents.  In  many  cases,  the  first  symptoms  have  shown  themselves 
after  a  period  of  constitutional  weakness  due  to  some  distinct  and 
adequate  cause,  such  as  pregnancy,  exhausting  discharges,  especially 
haemorrhage,  weakness  after  childbirth  or  abortion,  &c.  Amenorrhoea 
sometimes  precedes  the  onset.  But  the  disease  may  come  on  in  a 
person  who  otherwise  appears  to  be  in  perfect  health.  In  some 
instances,  organic  heart  disease  has  preceded  the  malady,  but  the 
association  of  the  two  is  not  frequent,  and  its  significance  is  uncer- 
tain. 

No  immediate  cause  is  so  frequent  as  emotion, — sudden  terror,  or 
prolonged  distress.  The  symptoms  have  been  known  to  follow  emotion 
with  great  rapidity,  and  to  become  distinct  after  a  few  days.  Many 
cases  were  seen  in  Alsace  and  Lorraine  after  the  Franco- G-er man  war. 
The  quick  action  of  the  heart,  due  to  alarm,  may  persist  as  that  of 
exophthalmic  goitre.  A  fright  at  nine  caused  tremor,  which  persisted, 
accompanied  by  stammering,  and  during  the  next  eight  years  the 
symptoms  of  exophthalmic  goitre  gradually  developed.^  Many  appa- 
rent causes  have  involved  alarm.  In  one  case  it  followed  the  removal 
-of  both  ovaries.  Violent  exertion  has  also,  in  some  instances,  appeared 
to  set  up  the  derangement — mountain  climbing,  severe  vomiting,  or 
violent  cough.  Among  other  rare  causes  are  stimulating  climatic  influ- 
ences, injuries  to  the  head,  cold,§  alcoholic  excess,  various  acute  diseases, 
scarlet  fever,  pneumonia,  rheumatism,  and  diarrhoea.  It  is  probable 
that  in  most  of  these  a  predisposition  existed,  for  in  many  other  cases, 
no  exciting  influences  can  be  traced. |] 

*  Manby,  '  Brit.  Med.  Journal,'  i,  1889  (three  instances). 

t  In  India  it  is  said  that,  although  endemic  goitre  is  common,  the  exophthalmic 
form  is  practically  never  seen  among  the  natives  (Brockman,  '  Trans.  Oph.  Soc./ 
1886,  p.  117). 

J  Lewin,  •  Inaug.  Diss.,'  Berlin,  1888. 

§  See,  for  instance,  a  case  recorded  by  Dr.  Bristowe, '  Trans.  Oph.  Soc.,'  1886,  p.  46. 

||  Russell  Reynolds  (loc.  cit.)  observed  an  unusual  number  of  cases  during  the 
■cold  sunless  weather  of  1888. 


874  EXOPHTHALMIC   GOITRE. 

Symptoms. — The  onset  of  the  disease  is  usually  slow  and  gradual. 
Tn  rare  cases  it  is  acute,  and  these  may  run  a  x-apid  course  and  end  in 
death,  or  the  acute  onset  subsides  into  a  chronic  stage.  Occasionally 
one  or  two  slight  attacks,  perhaps  recognised  only  afterwards  as  of 
similar  nature,  occur  and  pass  away,  months  or  years  before  the  onset 
of  graver  symptoms. 

The  three  sets  of  symptoms  in  eyes,  thyroid,  and  heart,  seldom 
commence  together.  As  a  rule  the  cardiac  disturbance  leads  the  way. 
Palpitation  troubles  the  patient  for  months  or  even  years  before  the 
other  symptoms  are  added.  The  enlargement  of  the  thyroid  and 
prominence  of  the  eyeballs  often  come  on  together ;  if  one  develops 
first  it  is  usually  the  former.  These  three  leading  symptoms  we  may 
first  consider  in  detail,  but  two  others,  a  hindrance  to  the  descent  of 
the  upper  lid  on  looking  down,  and  a  peculiar  tremor  of  the  limbs, 
are  so  frequent  (being  present  in  more  than  half  the  cases)  that  some 
observers  have  thought  that  they  should  be  classed  with  the  three 
leading  symptoms  just  mentioned. 

Heart. — The  characteristic  condition  of  the  heart  is  excited  action, 
shown  by  increased  frequency  and  increased  force  of  its  contractions. 
The  degree  of  excitement  varies  from  time  to  time,  and  is  readily 
increased  by  emotion  or  exertion.  At  first,  between  the  exacerbations, 
the  action  may  be  normal,  but  gradually  the  subsidence  becomes  less 
complete  and  the  over- action  persistent,  only  varied  by  attacks  of 
more  violent  "  palpitation."  The  increased  rate  of  action  is  some- 
times trifling,  and  the  pulse  does  not  exceed  90 — 100  per  minute. 
More  often  the  rate  is  higher,  120  or  140,  even  when  tranquil ;  some- 
times 150  or  160,  and  under  excitement  it  may  rise  to  180  or  200. 
It  is  usually  regular.  The  impulse  is  unduly  sharp,  and  felt  over  a 
larger  region  than  in  health.  The  action  of  the  heart  resembles  that 
of  a  person  under  considerable  nervous  excitement  or  after  exertion. 
The  area  of  cardiac  dulness  is  sometimes  normal  when  the  area  of 
impulse  is  increased,  but  usually,  after  a  time,  there  are  signs  of  enlarge- 
ment of  the  heart.  The  impulse  extends  far  outwards  and  becomes 
diffused,  while  the  cardiac  dulness  is  also  increased  to  the  left.  These 
signs  of  dilatation  usually  preponderate  over  any  indications  of 
hypertrophy.  The  dilatation  is  secondary  in  time,  and  doubtless  also 
in  origin,  to  the  excitation  of  the  heart.  The  sounds  are  usually 
increased  in  loudness ;  but  the  first  sound  is  often  short.*  Occa- 
sionally they  are  accompanied  only  by  the  murmurish  roughness 
that  is  common  in  excited  hearts  ;  more  often,  however,  there  is  a  dis- 
tinct systolic  murmur,  which  may  be  loud.  It  is  heard  over  the 
whole  heart,  loudest  near  the  sternum  or  at  the  base,  but  also  audible 
at  the  apex,  and  sometimes  outside  the  apex.  There  is  probably  then 
actual  mitral  regurgitation,  the  result  of  the  dilatation  which  the 
mitral  orifice  suffers  with  the  ventricle.     Slight  mitral  endocarditis 

*  Graves  mentioned  a  case  in  which  the  sounds  were  audible  four  feet  from  the- 
patient. 


SYMPTOMS. 


875 


has  been  occasionally  found  after  death,  and  is  perhaps  due  to  the 
mechanical  strain  on  the  valves.  The  impulse  of  the  heart  may  be 
attended  by  a  thrill.  As  the  disease  advances,  the  attacks  of  palpi- 
tation increase,  and  are  often  accompanied  by  considerable  dyspnoea, 
which  is,  indeed,  sometimes  an  early  symptom. 

The  arteries,  especially  those  of  the  neck  and  thyroid,  present 
increased  pulsation  and  are  dilated.  Sometimes  the  abdominal  aorta 
presents  a  similar  pulsation,  but  it  is  only  in  rare  cases  that  the 
arteries  of  the  limbs  share  the  derangement.  Indeed,  the  radial 
pulse,  though  of  course  unduly  frequent,  is  usually  smaller  than 
normal,  and  presents  a  marked  contrast  to  the  strong  pulsation 
of  the  carotids.  A  systolic  murmur,  often  loud,  may  almost  always 
be  heard  in  the  arteries  of  the  neck  and  thyroid,  continuous 
with  that  heard  at  the  base  of  the  heart  and  over  the  aorta. 
Sometimes  it  is  to  be  heard  in  other  arteries,  even  in  the  femorals. 
A  venous  pulse  has  occasionally  been  observed  in  the  neck,  and  even 
in  the  arm,  probably  due  to  the  influence 
of  the  pulsation  of  an  artery  on  the  flow 
through  an  adjacent  venous  trunk.  The 
vibrations  in  the  carotid  are  often  so  coarse 
as  to  be  felt  as  a  thrill. 

The  thyroid  usually  enlarges  after  the 
cardiac  symptoms  have  existed  for  some 
time.  This  "struma"  as  it  is  sometimes 
termed,  is  a  slow,  painless  enlargement,  at 
first  soft,  uniform,  but  sometimes  greater 
in  one  lobe  than  in  the  other,  and  occasion- 
ally confined  to  one  lobe  or  to  this  and  the 
isthmus.  When  one  lobe  is  the  larger,  it 
is  rather  more  often  the  right  than  the  left ; 
very  rarely  only  the  isthmus  has  been  en- 
larged. When  the  organ  is  increased  in 
size,  the  arteries  of  the  thyroid  always 
pulsate  strongly ;  sometimes  the  whole 
gland  seems  to  pulsate  ;  a  distinct  arterial  thrill  may  be  felt,  and  a  loud 
blowing  systolic  murmur  may  be  heard,  rarely  musical,  still  more 
rarely  double.  The  superficial  veins  over  it  may  be  enlarged.  The 
degree  of  enlargement  is  not  often  extreme ;  seldom  equal  to  that 
which  is  common  in  ordinary  bronchocele.  It  varies  somewhat  in 
size  from  time  to  time,  being  greater,  as  Graves  noted,  during  the 
attacks  of  palpitation.  Diminution  in  size  is  often  accompanied  by 
an  increase  in  firmness.  In  many  cases  the  enlargement  is  only 
trifling  in  degree,  and  it  is  occasionally  absent  altogether. 

Eyes. — The  prominence  of  the  eyes,  like  the  enlargement  of  the 
thyroid  (with  which  it  often  coincides),  commonly  succeeds  the  cardiac 
over-action.  In  rare  cases  it  has  been  the  first  symptom.  It  may  be 
equal  in  the  two  eyes,  or  occur  first  and  remain  greater  in  one  eye. 


Fig.  160.  —  Exophthalmic 
goitre;  early  stage.  Slight 
enlargement  of  the  thy- 
roid j  considerable  promi- 
nence of  the  eyes. 


876 


EXOPHTHALMIC    GOITRE. 


It  is  very  rarely  confined  to  one  side ;  then  the  thyroid  is  said  to  be 
most  enlarged  on  that  side,  but  exceptions  to  this  rule  are  common  ; 
I  have  twice  known  the  eye  and  thyroid  to  be  affected  on  opposite 
sides.*  In  degree  it  may  be  so  slight  as  to  easily  escape  notice, 
or  merely  to  cause  a  "  staring  "  appearance,  but  it  is  often  so  consider- 
able that  when  the  patient  looks  straight  forwards  the  white  sclerotic 
is  visible  above  and  below  the  cornea.  It  may  be  extreme  in  degree, 
so  that  the  insertions  of  the  recti  are  exposed,  the  movement  of  the 
eyes  limited,  and  so  that  the  lids  cannot  meet  over  it,  even  in  sleep.  It 
is  said  that  the  eyeball  may  even  be  dislocated  from  the  socket  and 
may  have  to  be  replaced  with  the  finger.  The  degree  of  prominence 
varies  from  time  to  time  with  the  over- action  of  the  heart.  When  it 
is  greatest,  pain  may  be  felt  in  the  eyeball.  There  is  also,  in  some 
cases,  an  actual  increase  in  the  size  of  the  globe,  especially  in  the 
antero- posterior  diameter,  which  has  been  found  to  be  one  tenth 
greater  than  normal  (Neumann).  Extreme  prominence  may  interfere 
with  movement,  apart  from  the  paralysis  to  be  described  later. 
Vision,  as  a  rule,  is  unaffected,  but  myopia  may  result  from  the 
enlargement  just  mentioned.      The  pupils  are  almost  always  normal ; 


Fig.  161.— Exophthalmic  goitre.     Defective  descent  of  the  upper  lid  on 
looking  down.     (After  Wilks.) 


*  A  remarkable  case  has  been  recorded  by  Burney  Yeo,  in  which  great  enlarge- 
ment of  the  right  half  of  the  thyroid  coincided  with  prominence  of  the  left  eye,  aud 
when  right  exophthalmos  came  on,  the  left  lobe  of  the  thyroid  enlarged  ('  Brit. 
Med.  Journ.,'  1887,  i,  320). 


SYMPTOMS.  877 

inequality  and  slight  irregularity  have  very  rarely  been  met  with. 
When  the  lids  fail  to  cover  the  eyes,  these  are  often  dry  in  the  morn- 
ing.    Corneal  inflammation  is  sometimes  met  with,  apparently  due 
to  the  imperfect  protection  of  the  globe  when  the  lids  fail  to  meet ; 
conjunctivitis  is  not  rare,  and  occasionally  there  has  been  opacity  of 
the  cornea,  and  even   sloughing,  generally  in  both  eyes,  but  in  one 
before  the  other.     (Edema  of  the  lids  is  occasionally  present ;  I  have 
seen  it  considerable  in  degree,  and  associated  with  oedema  of  the  con- 
j  unctiva,  in  a  case  in  which  the  prominence  was  slight.     The  ophthal- 
moscopic appearances  are  usually  quite  normal,  with  the  exception  of 
the  occasional  pulsation  of  the  retinal  arteries  and  veins.     The  latter 
is  due  to  the  effect  on  the  vein  of  the  pulse  in  the  adjacent  artery 
within  the  neiwe ;  when  the  latter  is  increased  the  vein  is  more  easily 
influenced,  and  the  venous  pulse  may  appear,  although  the  vessels  are 
not  quite  near  enough  for  a  normal  degree  of  pulsation  of  the  artery 
to  act  on  the  vein.     Hence  the  conditions  for  this  communicated 
pulsation  are  more  frequent  in  this  disease  than  in  health,  just  as 
they  also  are  in  aortic  regurgitation.*     (Edema  of  the  disc  is  occa- 
sionally met  with,  slight  in  degree ;  its  occurrence  is  not  related  to 
oedema  outside  the  eyeball.     Atrophy  of  the  optic  nerve  has   been 
observed  (Emmert),  and  is  probably  due  to  the  stretching  of  the  nerve. 
Another  frequent  ocular  symptom  has  been  already  mentioned — 
the  defect  in  the  descent  of  the  upper  lid  that  should  occur  when  the 
eyeball  is  rotated  downwards.     It  is  met  with  in  two  forms — (1)  there 
is  no  descent  or  only  a  very  trifling  movement ;  the  lid  is  held  up, 
sometimes  even  more  than  in  health,  by  a  "  retraction  "  of  the  lid 
(Eigs.  161  and  163)  ;  sometimes  it  exists  on  one  side  only  (Fig.  162). 
(2)  The  lid  does  descend,  but  is  retarded,  lags  behind  the  globe,  and 
descends   in   an  hesitating,  halting   manner,  now   suddenly  falling 
a  little,  then  stopping,  and  again  moving  down  suddenly  for  a  short 
distance,   the   movement   of    the   globe   meanwhile   being    uniform. 
It  may  at  last  descend  as  low  as  the  prominence  of  the  globe  permits 
(which  is  generally  a  little  above  the  level  of  the  canthus)   or  may 
stop  short  of  this  point.     In  the  latter  case  the  upward  movement,  of 
necessity,  does  not  quite  correspond  with  that  of  the  globe,  but  when 
the  lid  begins  to  rise  its  ascent  is  uniform.     It  is  important  not  to 
mistake  for  a  retarded   descent  the  mere  effect  of   the  prominence 
of  the  eyeball,  which  may  render  impossible  the  proper  approximation 
of  the  lids.     The  defect  in  descent  is  limited  to  the  movement  of  the 
lid  with  the  globe,  and  does  not  occur  when  the  lids  are  closed  by  a 
contraction  of  the  orbicularis,  as  in  going  to  sleep.     It  may  present 
every  variation  in  degree,  so  that  there  is  no  real  distinction  between 
retraction  and  hindered  descent.     The  latter  is  often  called  v.  Graefe's 
symptom,  the  former  Stell wag's,  but  v.  Graefe's  description  included 
retraction,  f    and   Stellwag   only  described   increased  width   of  the 
*  See  '  Medical  Ophthalmoscopy,5  3rd  ed.,  p.  20. 
t  '  Berlin  med.  Gesellsch.,'  1864,  and  '  Deutsche  Klinik,'  ib.,  p.  158.     He  stated 


:"",' 


878  EXOPHTHALMIC    GOITKE, 

palpebral  fissure  (an  obvious  consequence  of  the  defective  descent), 
and  added  nothing  to  our  knowledge  of  the  phenomenon.  It  may 
occur  early,  when  the  exophthalmos  is  trifling,  or  be  absent  when  this 
is  extreme.  Rarely  a  similar  defect  in  the 
ascent  of  the  lower  lid  has  been  noted. 
Its  possible  causation  will  be  considered 
presently. 

Retraction  of  the  lower  lid  has  been  verv 
rarely  observed.*      Occasionally    there    is 
some  weakness  of  the  ocular  muscles,  espe- 
cially  of  the  internal  recti,  lessening  the 
power  of  convergence^   and  more  exten- 
sive  ophthalmoplegia    has    been   observed 
(see  p.  882).     The  pupils  are  almost  always 
|P^  normal ;  very  rarely  there  has  been  undue 
v/.         ^  -'     contraction  or  dilatation. 
O;:  Of  the  three  chief  symptoms  of  the  dis- 

Fig.  162.  —  Exophthalmic  ease,  not  one  can  be  said  to  be  invariable, 
goitre,  early  stage.  Eetrac-  Prominence  of  the  eyes  is  absent  in  at  least 
tion  ot  the  left  upper  lid.  ,      ,.       „   .,  .,        . 

one  tenth  or  the  cases,  goitre  m  perhaps 

one  twelfth.  The  cardiac  disturbance  is  almost  constant.  It  is 
apparently  absent  in  rare  cases,  but,  on  the  other  hand,  is  often 
alone  obtrusive.  Occasionally  the  heart  is  not  enlarged,  although 
its  action  is  quick ;  there  may  also  be  severe  paroxysms  of  palpi- 
tation and  dyspnoea.  Increased  pulsation  of  the  arteries  of  the 
neck  is  very  seldom  absent,  and  a  careful  examination  often  detects 
a  slight  enlargement  of  the  thyroid  and  slight  prominence  of  the 
eyes,  when  these  are  not  obtrusive.  When  the  latter  does  not  ex- 
ceed the  degree  that  is  met  with  as  a  normal  condition,  the  friends 
of  the  patient  often  recognise  it  as  unnatural.  If  preponderant 
cardiac  disturbance  makes  rapid  progress,  the  patient  may  die  be- 
fore other  symptoms  attain  such  a  degree  as  to  attract  attention. 
When  the  enlargement  of  the  thyroid  and  exophthalmos  precede  the 

that  the  associated  descent  of  the  lid  on  movement  of  the  eye  was  "  almost  com- 
pletely arrested  or  reduced  to  a  minimum,"  sometimes  even  when  the  prominence 
was  slight.  Stellwag  v.  Car  ion  ('  Med.  Jahrb./  1869,  Heft  ii,  p.  25)  described  the 
increased  width  of  the  fissure,  the  lessened  frequency  of  involuntary  winking,  and 
the  defective  correspondence  in  movement  of  the  lid  and  globe.  V.  Graefe  only 
referred  to  the  descent  of  the  lid,  and  most  writers  have  followed  him,  limiting  the 
symptom  to  this  by  implication.  A  few  have  (it  would  seem  erroneously)  included 
impaired  correspondence  in  ascent  among  the  features  alluded  to  by  v.  Graefe.  The 
limitation  of  the  defect  to  descent,  which  most  writers  have  tacitly  implied,  has 
been  formally  emphasised  by  Bruns  ('  Neur.  Centralbl.,'  January,  1892).  "  Unnatural 
elevation  of  the  lid"  was  first  mentioned  by  White  Cooper  ('  Lancet,'  1849,  quoted 
by  Ramsay). 

*  By  Dr.  Hill  Griffith,  <  Trans.  Oph.  Soc.,'  1886,  p.  61. 

t  See  Mobius,  'Deutsch.  Zeitsch.  f.  Nervenh.,'  1891,  where  a  full  abstract  of 
recent  observations  will  also  be  found. 


COMPLICATIONS.  879 

deraugement  of  the  heart,  they  increase  very  rapidly  after  the  latter 
has  developed. 

The  general  health  of  these  patients  usually  suffers.  Anaemia  is 
frequent,  although  not  invariable.  Menstruation  is  irregular  and 
often  ceases.  Loss  of  flesh  occurs,  but  is  less  marked  in  the  face 
than  elsewhere.  Pyrexia  is  frequent  in  the  later  stages  of  the  disease, 
usually  moderate,  from  1°  to  3°  F.,  but  it  is  inconstant;  in  many  cases 
the  temperature  is  perfectly  normal  throughout,  while  in  others  it  is 
elevated  at  an  early  stage,  either  for  short  periods  or  persistently. 
The  pyrexia  has  occasionally  been  such  as  to  suggest  tuberculosis  or 
typhoid.  It  has  been  noted  that  the  urine  does  not  then  present 
the  characters  of  ordinary  febrile  urine.  There  may  be  a  subjective 
sense  of  heat,  without  actual  fever.  Profuse  perspiration,  sometimes 
of  a  penetrating  odour,  is  an  occasional  symptom,  and  is  especially 
common  in  acute  cases.  It  has  been  confined  to  the  side  on  which 
the  thyroid  and  eye  were  alone  enlarged  (Lewin).  The  "tache  cere- 
brale  "  is  often  to  be  obtained.  The  appetite  is  frequently  deficient, 
sometimes  capricious. 

Other  symptoms  on  the  part  of  the  nervous  system  may  be  present. 
A  sense  of  throbbing  in  the  head,  and  a  pulsating  noise  in  the 
ears,  are  occasionally  complained  of.  Headache  is  sometimes  trouble- 
some, and  maybe  one-sided.  There  is  often  insomnia,  and  sometimes 
transient  vertigo.  Mental  depression  or  irritability  is  very  frequent ; 
the  latter,  indeed,  is  almost  a  characteristic  feature. 

Another  very  common  symptom  is  muscular  tremor.  It  is  con- 
spicuous in  at  least  half  the  cases,  and  may  be  discerned,  in  slight 
degree,  in  most.  It  varies  in  character,  but  is  usually  a  rather 
coarse,  somewhat  jerlcy  tremor,  occurring  on  movement  only.  In 
some  cases  it  is  so  regular  as  to  resemble  that  of  paralysis  agitans ;  in 
others  it  is  so  irregular  as  to  remind  the  observer  of  chorea.  When 
regular,  it  is  a  little  more  frequent  in  time  than  that  of  paralysis 
agitans.*  It  may  be  general  or  partial,  and  has  been  known  to  be 
unilateral  when  the  goitre  and  exophthalmos  were  also  unilateral, 
and,  in  a  regular  form,  to  be  one  of  the  first  symptoms  of  the  disease. f 

Occasional  Symptoms  and  Complications. — Many  cases  have  been 
recorded  in  which  there  was  also  glycosuria.  The  change  in  the  urine 
has  followed  in  some  cases,  and  preceded  in  others,  the  special 
symptoms.  In  one  instance  of  this  complication  all  the  symptoms 
followed  a  blow  on  the  head  (Brunton).  In  another  it  succeeded  an 
eruption  of  urticaria,  but  previously  there  had  been  frequent  brief 
paroxysms  of  intense  sense  of  heat  of  skin  with  palpitation  (Budde). 
The  sugar  has  been  known  to  lessen  when  the  other  symptoms  im- 
proved. Intermittent  albuminuria  has  been  recorded  by  Begbie,  and 
since  observed  in  many  cases.     Increased  secretion  of  pale  urine  is 

*  According  to  Marie  8 — 9|  per  second;  paralysis  agitans  5 — 6  per  second;  but, 
as  we  have  seen,  that  of  paralysis  agitans  varies  much, 
t  Mobius,  18S3. 


880  EXOPHTHALMIC   GOITRE. 

common,  aud  lias  been  observed  to  precede  paroxysms  of  palpitation 
and  dyspnoea. 

Enlargement  of  the  lymphatic  glands  sometimes  occurs  in  the  course 
of  the  affection,  resembling  that  of  lymphadenoma,  but  moderate  in 
degree,  and  not  progressive.  It  may  develop  rapidly,  and  slowly  sub- 
side. I  have  seen  three  very  marked  instances  of  this  complication  ; 
one  was  a  severe  and  fatal  case  of  exophthalmic  goitre  in  a  girl  whose 
sister  suffered  from  lymphadenoma.  Enlargement  of  the  tracheal 
and  bronchial  glands  has  been  observed  by  G-.  de  Mussy. 

The  skin  presents  occasionally  other  morbid  states  besides  those 
mentioned.  Local  redness,  and  even  erythema,  have  been  observed. 
A  diminution  in  the  electrical  resistance  is  almost  constant  (Begbie, 
Vigoroux,  Eulenberg,  Wolfenden*).  Instead  of  being  equal  to  4000 
—6000  ohms,  it  is  reduced  to  1500,  1000,  900,  or  even  to  300  ohms, 
with  an  E.  M.  E.  of  15  volts.  It  is  ascribed  to  the  dilatation  of  the 
blood-vessels  and  the  moistening  of  the  skin  by  perspiration.  It  has 
little  practical  value,  for  its  determination  causes  considerable  pain, 
and  a  similar  reduction  is  met  with  in  other  diseases,  as  hemiplegia, 
epilepsy  and  chorea. f 

Abnormal  pigmentation  of  the  skin  is  not  uncommon  in  some 
degree,  as  vitiligo,  or  increased  pigmentation  in  the  same  positions  as 
in  Addison's  disease,  except  that  it  is  very  rarely  met  with  in  the 
mucous  membrane  of  the  mouth  £  It  is  sometimes  associated  with 
leucodermia.  The  pigmentation  generally  occurs  after  the  other 
symptoms  are  fully  developed,  but  has  been  known  to  precede  them. 
It  has  also  been  known  to  pass  away  with  the  over- action  of  the 
heart,  when  the  other  symptoms  became  stationary.  §  Loss  of  hair 
has  also  been  observed. || 

Slight  subcutaneous  anasarca  is  occasionally  met  with  in  anaemic 
subjects,  and  sometimes  there  has  been  more  considerable  oedema, 
peculiar  in  character  or  seat.  In  one  case  with  glycosuria,  terminal 
oedema  increased  from  the  feet  to  the  umbilical  level,  and  there 
stopped  (Mobius).  The  peculiar  subcutaneous  fulness  above  the 
clavicles,  common  in  neuralgia,  &c,  has  also  been  met  with  (Rendu). 
It  was  accompanied  by  some  pigmentation  of  the  skin  in  another  case 
(Sollier),  and  preceded  the  exophthalmos  and  cardiac  over-action,  the 
thyroid  being  small.  I  have  observed  myxcedematous  swelling  of  the 
eyelids  and  pigmentation  of  the  skin  to  follow  permanent  recovery 

*  See  also  Charcot,  '  Gaz.  des  Hop.,'  1885 ;  Eulenberg,  •  Berl.  kl.  Wochensch.,* 
1889 ;  Cardew, '  Lancet,'  1891. 

f  In  chorea  it  has  been  found  as  low  as  350  ohms.  (Wolfenden,  '  Practitioner/ 
1887). 

$  Where,  however,  it  was  found  by  Oppenheim,  « Berl.  Gesselsch.  f.  Psy.,  &c.,' 
Dec,  1887.  Several  instances  of  pigmentation  are  described  in  a  very  instructive 
lecture  by  Drummond,  '  Brit.  Med.  Journ.,'  1887.  See  also  Carrington,  •  Trans. 
Oph.  Soc.,'  1886. 

§  Davies,  '  Brit.  Med.  Journ./  1891.  ||   Barnes,  '  Brit.  Med.  Journ./  1889. 


.4 


r" 


COMPLICATIONS.  881 

from  exophthalmic  goitre.  Myxedematous  symptoms  have  hardly 
ever  been  observed  to  coincide  with  enlargement  of  the  thyroid  ; 
exceptions  are — a  case  observed  in  Thibet,*  and  one  in  an  epileptic 
woman  (Kowalevski).  Usually  the  thyroid  has  been  atrophied;  it 
was  so  in  a  case  in  which  transient  general  oedema  occurred  on  emotion 
and  at  the  menstrual  periods. f 

An  important  occasional  complication  is  mental  deraugemeut.  We 
have  seen  that  slight 
mental  change  (irrita- 
bility, restlessness,  de- 
pression), is  common ; 
the  derangement  now 
referred  to  amounts  to 
actual  insanity,  which 
often  commences  with 
hallucinations.  Its  form 
varies :  it  may  be  me- 
lancholia, or  simple 
mania  or  recurrent 
mania,  or  even  general  *^K 

paralvsis  of  the  insane  %  FlG"  163.— Exophthalmic  goitre.  Acute  mania  (fatal). 
Mania  is  the  most  com-  <From  a  Phot°g™Ph-) 

mon  condition,  and  may  be  the  cause  of  death.  Fig.  163  represents 
the  aspect  of  a  woman  suffering  from  acute  mania,  which  came  on  in  the 
course  of  exopthalmic  goitre  and  was  fatal  in  a  few  weeks.  Acute  mania, 
indeed,  generally  leads  to  speedy  death,  but  now  and  then  subsides  into 
chronic  insanity.  Hysterical  symptoms  are  also  common  in  this 
disease,  and  may  present  various  forms,  of  which  the  most  common  is 
some  variety  of  anaesthesia  or  paralysis.  But  symptoms  of  paralysis 
due  to  organic  disease  have  often  been  ascribed  to  hysteria,  in  this 
malady.  §  Restriction  of  the  fields  of  vision  has  been  observed,  and 
found  to  vary  with  the  action  of  the  heart. || 

The  tremor  already  mentioned  has  amounted  in  some  cases  to  a 
degree  of  clonic  spasm  or  choreoid  movement  that  must  be  regarded 
as  a  complication.  In  a  few  cases  in  childhood  or  youth,  true  chorea 
has  been  supposed  to  exist.  In  one  instance  this  was  probable,  since 
the  movements  increased  for  a  time,  and  then  subsided.  In  the  other 
cases,  however,  the  spasmodic  disturbance  persisted,  and  its  nature  is 
therefore  doubtful.  Tetanoid  spasm  and  painful  cramps  have  been 
described. 

Many  other  kinds  of  functional  derangement  of  the  nervous  system, 
besides  those  already  mentioned,  have  been  observed  to  coexist  with 
exophthalmic   goitre.      Epilepsy   occasionally   occurs,    generally    in 

*  '  Brit.  Med.  Journ.,'  1891,  p.  755.  f  Sollier,  «  Rev.  de  Med.,'  1891. 

X  See  Savage,  *  Guy's  Hosp.  Rep.,'  1882 ;  Drummond,  loc.  cit.  j  Reynolds,  loc.  cit.  j 
Schenk,  Inaug.  Diss.,  Berlin,  1890. 

§  E.g.  Ballet,  'Soc.  med.  des  Hop.,'  1888.  ||  Kast  aud  Willbmnd,  1891. 

vol.  ii.  56 


882  EXOPHTHALMIC    GOITRE. 

subjects  who  possess  an  inherited  tendency  to  it.  Neuralgia,  and 
migraine  in  typical  form,  have  also  been  met  with.  Paralysis  of  cranial 
nerves  sometimes  develops,  apparently  due  to  an  affection  of  their 
nuclei,  although  some  degree  of  weakness  of  the  ocular  muscles  may 
be  the  result  of  degeneration  of  their  fibres.  Besides  the  defect  of 
convergence  already  mentioned,  the  whole  of  one  third  nerve  has  been 
paralysed,  and  in  other  cases  the  fourth  or  the  sixth,  while  complete 
external  ophthalmoplegia  has  also  been  met  with.  In  one  case  this 
was  associated  with  complete  double  facial  palsy  (Ballet)  and  in  a  case 
recorded  by  Bristowe,  with  right  hemiansesthesia  (including  the  special 
senses),  epileptic  fits,  palsy  with  rigidity  of  the  right  side,  hemorrhages 
from  the  ears,  and  persistent  pyrexia — unexplained  by  the  post-mortem 
examination,  which  revealed  no  lesion  of  the  nervous  system.  The 
muscles  of  mastication,  the  palate,  and  the  tongue  have  also  been  para- 
lysed in  different  cases.*  Symptoms  of  disease  of  the  spinal  cord  have 
been  occasionally  observed.  Paraplegia,  with  flaccidity  or  rigidity  of 
the  legs,  may  come  on ;  in  the  latter  case  with  excessive  knee-jerk  and 
foot-clonus.  Charcot,  who  regards  it  as  a  special  form,  has  observed 
"  astasia-abasia  "  as  an  early  symptom.  The  sphincters  may  be  involved 
in  the  weakness.  Tabes  occasionally  coexists,  but  has  usually  pre- 
ceded the  symptoms  of  exophthalmic  goitre.  Chronic  muscular 
atrophy  has  been  observed. f  Subacute  ati'ophic  paralysis  in  the  arms 
was  preceded,  in  one  instance,  by  spasm,  tonic  and  clonic,  before  the 
special  symptoms  of  the  disease  came  on,J  and  in  a  case  described 
by  Drummond,  the  same  disease  was  followed  by  acute  myelitis. § 

Many  symptoms  occasionally  met  with  are  apparently  due  to  vaso- 
motor disturbance.  Sweating  has  been  already  mentioned  ;  in  a  case 
recorded  by  Money  a  copious  acid  sweat  broke  out  on  the  central  parts 
of  the  face  during  attacks  of  palpitation  and  extreme  frequency  of  the 
pulse  ||  Diarrhoea  is  sometimes  troublesome,  and  is  thought  to  be  a 
kind  of  intestinal  sweating.  Occurring  early,  it  has  been  mistaken  for 
sporadic  cholera.  Atony  and  distension  of  the  colon,  general  or  partial, 
may  often  be  detected  by  percussion. ^[  Occasionally  there  is  an 
abnormal  flow  of  tears.  Local  oedema  in  the  limbs,  local  congestion 
of  surface  vessels,  atrophy  of  the  mammae  and  other  parts,  some  skin 
diseases,  and  even  gangrene,  have  all  been  regarded  as  manifestations 
of  vaso-motor  disease  related  in  some  obscure  manner  to  the  primary 
disorder.** 

*  Fereol,  Mobius,  Jendrassik,  Potain,  &c.  f  Cazal,  '  Gaz.  hebd./  1885. 

X  Huber,  '  Deut.  med.  Wochensch.,'  1888.  §    Drummond,  loc.  cit. 

||  •  Trans.  Oph.  Soc.,'  1886,  p.  113.  It  is  noteworthy  that  this  patient  had  an 
epileptic  aura  consisting  of  "  an  awful  smell  that  seemed  to  ascend  from  the  leftside 
of  the  body  and  reach  the  mouth,"  but  it  was  not  followed  by  any  actual  fit  or 
1  jss  of  consciousness. 

%  Federn„ '  Berlin  klin.  Wochenscbr.,'  1888. 

**  In  the  curious  case  recorded  by  Burney  Yeo  (p.  876,  note),  the  occurrence  of 
exophthalmos,  first  on  one  side  and  then  on  the  other,  was  accompanied  by  loss  of 
the  hairs  of  the  eyebrow  and  eyelid. 


COURSE    AND   VARIETIES.  883 

Course  and  Varieties. — The  onset  is  usually  gradual,  and  that  of 
the  cardiac  over-action  often  cannot  be  fixed.  The  duration  of  the 
disease  is  generally  prolonged  through  several  years.  But  the  differ- 
ences in  course  are  extreme.  Occasionally  the  onset  is  acute ; 
marked  symptoms  may  develop  in  a  few  days,  commonly  after  some 
psychical  disturbance,  and  especially  when  there  is  an  hereditary 
tendency  to  the  disease.  They  may  pass  away  in  a  week  or  two.  Thus  a 
boy,  aged  eight,  the  son  of  a  woman  who  suffered  from  the  disease, 
after  a  disappointment  at  school,  was  seized  with  palpitation  and  pro- 
fuse sweating;  the  next  day  the  thyroid  was  large,  the  eyes  were 
prominent,  and  the  pulse  was  180.  After  two  days  more,  the  sym- 
ptoms gradually  disappeared,  and  in  ten  days  he  was  well  (Sobrig). 
Such  acute  cases  may,  however,  run  a  rapidly  progressive  course,  and 
end  in  death  at  the  end  of  six  weeks  (Bamberger),  but  cases  so  rapid 
are  extremely  rare.  Death  at  the  end  of  six  months  is  uncommon, 
and,  on  the  other  hand,  in  many  cases  the  disease  lasts  for  five  or 
even  ten  years.  An  acute  onset  may  subside  into  a  chronic  stage, 
similar  to  that  of  the  cases  that  commence  gradually. 

Considerable  and  prolonged  remissions  are  frequent,  and  sometimes 
actual  intermissions  occur,  of  such  duration  and  completeness  that 
the  patient,  in  effect,  suffers  from  several  distinct  attacks.  I  have 
known  a  patient  to  have  three  such  attacks  at  intervals  of  several 
years.  Pregnancy  is  sometimes  accompanied  by  improvement.  Per- 
manent recovery  may  also  occur.  It  is  most  frequent  in  the  cases 
that  develop  rapidly,  and  in  which  the  cardiac  symptoms  preponderate 
over  those  in  the  neck  and  eyes.  What  proportion  of  cases  recover  is 
uncertain.  It  has  been  estimated  at  a  quarter,  and  this  is  probably 
not  an  over-statement,  if  the  cases  are  included  in  which  the  cardiac 
symptoms  are  the  chief.  But  a  considerable  degree  of  severity  seems 
to  preclude  recovery.  I  have  seen  one  patient  in  whom  well-marked 
symptoms,  great  prominence  of  eyeballs  and  enlargement  of  thyroiJ, 
coming  on  in  early  womanhood,  passed  away  entirely,  and  twenty  years 
later  there  had  been  no  recurrence.*  Even  when  there  is  not  complete 
recovery,  however,  the  symptoms  may  subside  from  a  most  distressing 
degree  to  comparative  insignificance.  Just  as  the  cardiac  symptoms 
commence  before  the  others,  so  they  may  persist  long  after  the 
enlargement  of  the  thyroid  and  prominence  of  the  eyes  have  disap- 
peared. The  malady  is  said  to  run,  on  the  whole,  a  more  rapid  course 
in  men  than  in  women. 

In  most  fatal  cases,  death  seems  to  be  the  result  of  the  cardiac 
affection,  and  of  increasing  general  weakness.  Attacks  of  palpitation 
and  dyspnoea  become  more  frequent  and  troublesome;  oedema  of  the 
legs  comes  on  ;  exhausting  diarrhoea  may  also  cause  extreme  prostra- 
tion, which  ends  in  death.     Sometimes  the  loss  of  flesh  increases  to 

*  In  another  case,  characteristic  symptoms  for  six  months  gradually  passed  away, 
and  eight  years  later  there  was  only  trifling  prominence  of  the  right  eyeball,  and 
slight  firm  enlargement  of  the  left  lobe  of  the  thyroid. 


884  EXOPHTHALMIC    GOITKE. 

extreme  emaciation,  and  the  patient  sinks  slowly  or  rapidly.  These- 
events  may  occur  when  the  special  symptoms  are  moderate  in  degree. 
Other  occasional  causes  of  death  have  been  tuberculosis,  cerebral 
haemorrhage,  rarely  haemorrhage  elsewhere,  cerebral  softening,  and 
pachymeningitis.  Sometimes  sudden  death  occurs,  the  exact  cause  of 
■which  cannot  be  ascertained.* 

Pathological  Anatomy. — In  the  heart,  signs  of  dilatation  and 
hypertrophy  are  commonly  found  after  death,  but  are  far  less  than 
might  be  expected  from  the  symptoms  present  during  life.  Slight. 
endocarditis  is  occasionally  met  with,  and  graver  lesions  of  the  valves 
are  more  frequently  found  than  might  be  anticipated  ;  no  doubt 
because  such  cases  more  frequently  die.  The  arteries  are  found 
dilated,  and  may  appear  to  be  distinctly  hypertrophied  (Vogt).  The 
veins  also  may  be  enlarged.  In  the  old  it  is  doubtful  what  signi- 
ficance is  to  be  attached  to  the  state  of  the  arteries. f  Aneurismal 
dilatations  have  been  seen  on  the  arteries  of  the  thyroid,  in  which 
all  the  vessels  are  often  conspicuously  enlarged.  The  proper  tissue 
of  the  gland  is  increased  in  quantity,  without  being  materially 
altered  either  in  naked-eye  or  microscopical  appearance.  Occasion- 
ally, however,  there  is  a  greater  change,  either  cystic  or  "colloid" 
degeneration. 

In  the  orbit  the  most  frequent  change  is  an  increase  in  the  quantity 
of  fat,  sometimes  considerable,  but  never  extreme;  in  many  cases  the 
amount  of  fat  has  been  perfectly  normal.  Dilatation  of  the  orbital 
veins,  atheroma  of  the  ophthalmic  artery,  and  fatty  degeneration  of 
the  ocular  muscles,  have  been  met  with  in  rare  instances.  In  one 
case  in  which  the  fatty  degeneration  of  the  straight  and  oblique 
muscles  was  very  marked,  the  levatores  palpebrarum  presented  a 
marked  contrast  to  their  normal  condition.  J  In  this,  as  An  many 
other  cases,  no  trace  of  the  tissue  of  Midler's  muscle  could  be 
discovered.  The  optic  nerve  has  been  found  elongated  in  consequence 
of  the  exophthalmos. 

The  cervical  sympathetic  has  been  carefully  examined  in  many 
cases  by  competent  observers,  and  has  been,  as  a  rule,  free  from  any 
indication  of  disease. §  In  other  cases  slight  changes  have  been  found  ; 
the  most  frequent  has  been  an  increise  of  connective  tissue  in  and 
about  the  lower  cervical  ganglion,  and  with  this  change  the  ganglion 
has  been  described  as  enlarged,  or  reduced  below  the  average  size, 
as  normal  in  consistence,  or  distinctly  indurated.  An  atrophv 
of  the  nerve-cells  has   been  described  in  a  few  cases.     The  cardiac 

*  Two  instances  of  this  are  recorded  by  Hale  White,  'Brit.  Med.  Journal, 
July,  24th,  18S6. 

t  As,  for  instance,  a  case  recorded  by  Wahner,  in  which  thickening  of  the  arteries- 
of  the  spinal  cord  was  found  in  a  woman  of  sixty-two. 

J  Silcock,  '  Tr.ms.  Oph.  Soc.,'  1886,  p.  104. 

§  E.gr  in  thirteen  cases  reported  by  Lewin  (loc.  cit.)  it  -was  normal  in  all. 


PATHOLOGY.  885 

•ganglia  have  been  found  normal  when  they  Lave  been  examined.  In 
one  case  the  splanchnic  nerves  were  described  as  degenerated  (Siemer- 
ling). 

No  significant  changes  have  been  discovered  in  the  central  nervous 
system.  The  medulla  oblongata  has  generally  been  quite  noi'mal ; 
in  some  cases  there  have  been  signs  of  congestion,  and  even  recent 
heemorrhages  in  or  near  the  sixth,  the  vagus,  and  hypoglossal 
nuclei,  and  in  the  restiform  bodies.*  With  the  exception  of  polio- 
myelitis observed  by  Drummond,  the  spinal  cord  has  been  found  normal, 
observations  not  having  been  made  in  the  cases  in  which  there  were 
indications  of  its  disease.  This  is  also  true  of  the  cases  with  paralysis 
of  the  cranial  nerves.  The  other  organs  of  the  body  are  also  as  a 
rule  normal.  Disease  of  the  kidneys  has  been  found  in  some  cases, 
hut  in  most  of  these  there  had  been  organic  heart  disease.  The 
thymus  and  other  closed  glands  undergo  no  change,  f 

Pathology. — Two  questions  are  involved  in  the  pathology  of  ex- 
ophthalmic goitre,  as  in  that  of  most  other  diseases, — the  mechanism 
of  the  symptoms,  and  the  nature  of  the  malady, — questions  that  are 
in  part  the  same,  in  part  distinct. 

The  dilatation  of  the  vessels  and  over-action  of  the  heart  have 
directed  attention  to  the  sympathetic  system  of  nerves  as  capable,  by 
its  derangement,  of  giving  rise  to  the  symptoms.  The  cervical  sym- 
pathetic contains  fibres  which,  when  they  are  irritated,  increase  the 
irequency  of  the  heart's  action.  But  the  arterial  dilatation  must  be 
•either  passive,  due  to  paralysis  of  the  vaso-constrictor  sympathetic 
fibres,  or  active,  due  to  persistent  over-action  of  the  vaso-dilator 
fibres  (G-authier).  For  this  we  must  assume  a  partial  affection  of  the 
sympathetic,  or  on  tbe  other  hypothesis,  an  opposite  disturbance  of  its 
different  elements.  Either  seems  incompatible  with  the  assumption 
of  any  general  morbid  process  in  the  nerve,  such,  for  instance,  as  an 
irritation  or  inflammation  beginning  outside  the  nerve- elements. 
This  consideration  has  led  most  recent  pathologists  to  look  beyond 
the  sympathetic,  to  the  central  nervous  system,  for  the  seat  of  the 
primary  morbid  process  that  deranges  the  vessels  and  the  heart. 
This  view  is  supported  by  the  fact  that  the  association  of  arterial 
dilatation  and  frequency  of  the  heart's  action  is  in  harmony  with  the 
physiological  law,  discovered  by  Marey,  that  there  is  an  inverse  ratio 
between  frequency  of  pulse  and  general  blood-pressure,  so  that 
lowered  arterial  tone,  and  a  frequently  acting  heart  coincide,  in  con- 
sequence  of  their  relation  to  a  central  mechanism.  These  considera- 
tions certainly  suggest  that  these  two  symptoms  depend  on  the  derange- 

*  Cheadle ;  Hale  White,  '  Brit.  Med.  Journ.,5  1889  ;  Siemerling,  '  Berlin  Ges.  f. , 
Psych.,'  &c„  January,  1892.  Mendel  (ibid.)  found  a  simple  diminution  in  size  of  one 
restiform  body  and  the  opposite  "  solitary  bundle,"  probably  without  significance, 
■unless  it  entailed  a  disposition  to  functional  derangement. 

f  See  Hale  White,  loc.  cit. 


886  EXOPHTHALMIC    GOITfiE. 

merit  of  such  a  mechanism,  rather  than  on  a  random  process  in  any 
system  of  nerves.  On  the  whole,  the  results  of  pathological  anatomy 
favour  this  opinion.  The  frequency  with  which  no  morbid  appearance 
has  been  found  in  the  sympathetic,  and  the  equivocal  character  of  the 
changes  that  have  been  described  in  a  few  cases,  seem  to  prove  that 
these,  when  present,  are  of  secondary  origin,  or  else  are  accidentally 
associated.  The  point  chiefly  in  recent  dispute  has  been  whether  a 
general  state  of  weakness  of  the  nervous  system  does  not  underlie  the 
special  disturbance,  on  account  of  the  frequency  with  which  general 
nerve  symptoms  are  met  with. 

Leaving,  for  the  present,  these  general  questions,  we  may  con- 
sider the  probable  origin  of  tbe  special  symptoms.  The  dilation 
of  the  heart  may  reasonably  be  ascribed  to  its  quick  action.  The 
systole  is  too  short  to  be  complete ;  residual  blood  gradually  entails 
over-distension  and  dilatation.*  A  systolic  murmur,  such  as  is 
common  in  this  disease,  is  frequently  heard  in  simple  dilatation, 
apart  from  any  mitral  regurgitation,  which  may,  however,  result  if  ex- 
treme dilatation  stretches  the  auriculo- ventricular  orifice  beyond  the 
capacity  of  the  valves,  and  may  cease  when  the  dilatation  becomes  less. 

The  enlargement  of  the  thyroid  was  ascribed  by  Graves  to  the 
dilatation  of  its  vessels,  and  its  variation  in  size  with  the  action  of 
the  heart  seems  to  confirm  the  opinion.  It  is,  moreover,  certain  that 
some  enlargement  of  the  thyroid  will  result  from  vascular  distension, 
such,  for  instance,  as  follows  ligature  of  the  thyroid  veins  (Boddaert). 
According  to  this  view  the  increase  in  the  proper  tissue  of  the  organ, 
may  possibly  be  a  result  of  the  increased  blood-supply.  Yet  two 
considerations  suggest  that  the  relation  of  this  symptom  to  the 
primary  derangement,  whatever  this  is,  may  involve  more  than  mere 
vascular  dilatation.  (1)  The  thyroid  may  be  scarcely  enlarged  when 
the  cardiac  and  vascular  symptoms  are  very  marked ;  conversely, 
although  rarely,  the  thyroid  may  enlarge  considerably  when  the  heart 
is  but  little  excited ;  and  lastly,  its  enlargement  has  been  known  to 
precede  the  disturbance  of  the  heart.  (2)  The  mental  weakness,  &c, 
that  sometimes  results  from  extirpation  of  the  thyroid,  seem  to  show 
that  the  organ  has  a  mysterious  influence  on  the  central  nervous 
system,  and  an  opposite  influence  is  at  least  conceivable,  if  equally 
mysterious.  We  must  beware  of  the  assumption  that  the  process 
we  can  trace  is  the  only  one  in  operation. 

The  prominence  of  the  eyeballs  is  difficult  to  explain,  and  is  pro- 
bably due  to  the  co-operation  of  several  mechanisms.  (1)  The  increase 
in  the  orbital  fat,  when  present,  may  have  a  trifling  influence.  (2) 
The  distension  of  the  vessels  of  the  orbit  is  probably  a  more  powerful 
iactor;  its  existence  is  suggested  by  the  pulsation  of  the  retinal 
arteries,  and  its  influence,  by  the  variation  in  the  prominence  with  the 
over-action  of  the  heart.  (3)  The  unstriated  muscular  fibres  of 
Muller,  which  are  innervated  by  the  sympathetic,  and  run  from  the 

*  See  "Dilatation  of  the  Heart,"  Kewiolds'  'System  of  Mcdiciue,'  vol.  iv,  p.  738. 


PATHOLOGY.  887 

eyelid  to  the  membranous  lining  of  the  orbit,  are  generally  believed  to 
be  capable,  by  their  contraction,  of  causing  prominence  of  the  eyeball. 
The  eye  recedes  a  little  when  the  sympathetic  is  divided,  and  becomes 
slightly  prominent  when  it  is  stimulated.  Although  it  has  been 
questioned  whether  in  man  these  fibres  are  sufficiently  developed  to 
exert  an  appreciable  effect,  it  is  possible  that  they  may  become  hyper  - 
trophied  under  permanent  excitation.  Our  present  knowledge  per- 
mits us  to  invoke  no  other  than  these  three  mechanisms,  but  it  is  not 
easy  to  conceive  how  even  their  combined  influence  can  produce  the 
extreme  prominence  sometimes  seen. 

The  loss  of  descent  of  the  upper  eyelid  was  ascribed  by  von  Graefe 
to  spasm  of  some  of  the  unstriated  fibres  of  Miiller,  which  pass  from 
the  tendon  of  the  levator  to  the  posterior  edge  of  the  lid,  paralysis  of 
which  is  supposed  to  cause  the  slight  ptosis  that  follows  division  of  the 
sympathetic.  It  must  be  due  either  to  this  cause  or  to  a  deficiency 
in  the  relaxation  of  the  levator  which  normally  occurs  as  soon  as 
the  commencing  movement  of  the  globe  places  a  tension  on  the 
muscle.*  The  fact  that  it  does  not  interfere  with  closure  of  the  eyes 
— in  which  movement  the  orbicularis  at  once  overcomes  the  spasm — 
is  more  consistent  with  spasm  of  the  levator  from  a  central  mechanism, 
and  it  is  difficult  to  refer  the  retraction  of  the  lid  to  any  influence 
except  that  of  the  levator  itself,  f 

It  is  a  curious  fact  that  cocain  applied  to  the  conjunctiva  causes  a 
slight  retraction  of  the  lids  and  a  defective  descent  similar  to  that 
seen  in  exophthalmic  goitre.^  It  is  assumed  that  tbe  cocain  acts 
upon  the  sympathetic  nerve-endings,  since  Jessop  has  found  that  the 
effect  cannot  be  obtained  a  few  days  after  division  of  the  sympathetic 
in  the  neck.  This  does  not,  however,  throw  any  light  on  the  muscular 
mechanism  by  which  the  symptoms  are  produced,  but  it  supports  the 
view  that  they  are  due  to  over-action  of  the  sympathetic  nerves. 

Thus  the  symptoms  seem  to  be  due,  partly  to  the  direct  effect  of 
deranged  action  of  the  sympathetic,  and  partly  to  the  indirect  effect 
of  this  derangement  on  the  vascular  system. §  It  is  probable  that 
the  cause  of  the  derangement  is  to  be  sought  beyond  the  sympathetic 

*  This  is  apparently  an  example  of  the  relaxation  or  tension  by  which  the 
muscles  are  kept  adapted  to  passive  movement.  See  "  The  Movements  of  the 
Eyelids,"  '  Med.-Chir.  Trans.,5  1879,  and  '  Lancet,'  May,  1S90.  An  explanation  that 
has  been  suggested,  that  the  phenomenon  is  due  to  weakness  of  the  orbicularis,  is 
untenable,  because  the  symptom  occurs  in  the  movement  in  which  the  orbicularis 
takes  no  part,  and  is  absent  when  the  orbicularis  contracts,  as  to  close  the  eyes  lor 
sleep. 

f  See  note  on  the  effects  of  emotion,  p.  88S. 

J  This  fact  was  pointed  out  by  Roller  in  his  original  account  of  the  action  of 
cocain,  and  the  phenomena  have  been  carefully  studied  by  Jessop,  '  Trans.  Oph.  Soc./ 
vol.  v,  p.  240,  and  vi,  12i'>. 

§  A  difficulty  has  been  felt  by  some  in  conceiving  a  continuous  over-action  of  the 
sympathetic,  but  this  difficulty  can  hardly  persist  after  a  consideration  of  the 
vascular  tone. 


888  EXOPHTHALMIC    GOlTItE. 

in  the  central  nervous  system.  All  the  sympathetic  functions  ai*e 
under  central  control,  and  the  character  of  the  symptoms,  as  we  have 
seen,  is  in  harmony  with  the  physiological  relation  between  the 
degree  of  blood-pressure  and  the  frequency  of  the  heart's  action. 
The  chief  controlling  centres,  and  especially  those  that  determine  this 
relation,  are  in  the  region  of  the  medulla  oblongata,  and  it  is  to  this 
part  that  we  are  thus  directed  in  our  search  for  the  seat  of  the  disease. 
The  negative  results  of  pathological  investigation,  and  the  character 
of  the  disturbance  itself,  make  it  probable  that  the  morbid  state  is 
one  of  function,  and  of  that  finer  nutrition  that  baffles,  and  will  baffle, 
our  means  of  investigation.  Whatever  its  nature,  it  is  evidently  a 
condition  that  can  pass  away  even  after  the  lapse  of  years. 

Attempts  have  been  made  to  discover  whether  experiment  cau  supply 
the  evidence  that  pathological  anatomy  fails  to  afford.  Filehne,  in 
particular,  has  tried  to  demonstrate  the  dependence  of  the  disease  on 
the  medulla  oblongata.  He  divided  the  anterior  fourth  of  the  resti- 
form  bodies,  and  succeeded  in  producing  exophthalmos,  even  after 
division  of  the  sympathetic.  In  a  few  experiments  he  caused  also  some 
enlargement  of  the  thyroid,  and  in  one  case  all  three  symptoms  of 
exophthalmic  goitre  were  produced.  Filehne's  experiments  have  been 
repeated  by  others  with  very  similar  results.* 

These  results  certainly  confirm  the  view  which  refers  the  disease  to 
the  medulla  oblongata.  The  haemorrhages  found  in  some  cases  are 
doubtless  merely  indications  of  functional  (and,  therefore,  of  vascular) 
disturbance.  It  is  possible  that  some  of  the  cardiac  disturbance  is 
produced  through  the  agency,  not  of  the  sympathetic,  but  the  vagus. 
It  is  important  to  recognise  that  the  results  of  experiment  derive 
their  chief  weight  from  the  indications  of  physiology,  which  point 
to  the  medulla  as  the  part  to  which  the  symptoms  must  be  directly 
ascribed. 

The  negative  evidence  of  pathological  anatomy,  and  the  positive 
evidence  afforded  by  the  character  of  the  various  symptoms,  therefore, 
alike  suggest  that  the  malady  is  a  neurosis,  a  disease  of  the  nerve- 
elements  themselves,  having  its  character  determined  by  their  func- 
tional relations,  and  its  origin  in  conditions  at  present  beyond  our 
range  of  scrutiny.  We  can  thus  understand  the  multiform  derange- 
ments of  the  same  class  with  which  its  symptoms  may  be  associated. 
But  we  are  still  in  the  dark  regarding  the  way  it  is  produced.  Emotion 
may  unquestionably  excite  it  ;  that  is,  it  may  be  set  up  by  derange- 
ment of  the  cortex,  a  fact  in  harmony  with  the  influence  of  emotion  in 
exciting  the  heart,  dilating  the  vessels,  and  even  causing  a  "  staring" 
appearance  of  the  eyes.f 

*  Doudourffis,  '  Deut.  med.  Wochenschr./  1887,  and  Bienfait,  'Bull,  de  l'Aoad. 
Roy.  de  Med.  de  Beige,'  1890. 

t  The  widely  open  eye  of  an  alarmed  animal,  on  the  alert  to  perceive  danger, 
must  be  due  to  the  levator,  and  may  be  contrasted  with  the  relaxation  of  thi 
muscle  and  drooping  lid  of  the  sleep  that  mental  tranquillity  permits.     The  excited 


PATHOLOGY.  889 

The  effects  of  excision  of  the  thyroid — peculiar  nerve  depression 
and  ultimately  general  myxoedeina*  (the  "cachexia  struinipriva  "  of 
Beverdin) — and  the  coexistence  of  atrophy  of  the  thyroid  with  ordinary 
niyxoedema,  have  seemed  to  many  inseparable  from  the  pathology  of 
exophthalmic  goitre.  M61  >ius  especially  has  advocated  the  theory  that 
•a  toxic  blood-state  is  produced  by  the  enlarged  thyroid,  with  the 
excess  of  mucinoid  material  in  its  follicles,  and  has  urged,  among 
other  points,  that  the  goitrous  idiocy  of  cretinism  must  be  ascribed  to 
an  endemic  poisou.  But  even  the  last  opinion  rests  on  no  proof,  while 
the  great  discrepancy  between  the  state  of  the  thyroid  and  other 
•elements  of  the  disease  seems  to  exclude  it  from  any  direct  or  indirect 
influence  on  the  symptoms.  This  is  true  even  of  the  pyrexia,  which 
has  been  referred  to  some  toxic  material  produced  by  the  thyroid  (Betoye), 
but  may  be  due  to  the  direct  influence  of  the  disturbed  medulla. 
The  occasional  beneficial  effect  of  the  excision  of  the  thyroid  has  been 
adduced  in  support  of  the  theory  of  a  toxsemic  state,  due  to  the 
thyroid,  but  the  effect  is  open  to  too  many  possible  explanations  to 
have  appreciable  weight.  The  profound  general  influence  of  excision 
may  include  the  removal  of  the  special  disturbance,  apart  from  that  of 
a  toxic  source.  Moreover,  if  the  thyroid  can  enlarge  in  consequence 
of  disturbed  innervation  from  the  medulla,  its  removal  (as  already 
suggested)  may  influence  the  functions  of  the  latter,  also  through  the 
nervous  system.  Less  unlikely,  but  still  purely  hypothetical,  is  the 
idea  that  a  primary  blood-state  disorders  the  nervous  system,  put 
forward  by  Dr.  J.  Begbie  ('  Dublin  Hosp.  G-az.,'  1855).  It  is  necessary 
only  to  mention  the  theory  of  Liebermeister  that  the  thyroid,  by  com- 
pressing the  carotids,  lessens  the  amount  of  blood  passing  through 
them — a  mechanism  which,  if  possible,  would  tend  to  prevent  the  ex- 
ophthalmos. 

The  chief  complications,  not  already  mentioned,  admit  of  an  ex- 
planation in  harmony  with  that  of  the  leading  symptoms.  The  origin 
of  the  tremor  (which  can  scarcely  be  regarded  as  a  complication) 
is,  however,  still  obscure.  It  must  be  due  to  deranged  action  of  some 
of  the  motor  ceils,  but  whether  those  of  the  spinal  cord  or  the  motor 
cortex  of  the  brain  are  first  disturbed  is  unknown.  It  is  a  constant 
effect  of  sudden  alarm,  but,  on  the  other  hand,  the  occasional  disease 
of  the  nerve-cells  of  the  cord  may  indicate  a  more  constant  tendency 
to  derangement  of  their  nutrition  and  function. 

The  mental  disturbance  is  commonly  ascribed  to  dilatation  of  the 
intra-cranial  vessels,  but  it  has  not  been  proved  that  this  condition 
actually  exists,  or  is  capable  of  causing  the  condition,  while  other 
influences  cannot  be  excluded.  The  general  state  of  nerve  weakness 
must  be  remembered,  and  also  the  possible  action  on  the  cortex  of 

action  of  the  heart  is  chiefly  conspicuous  when  motor  action,  to  escape  the  danger, 
is  impossible,  and  gives  place  to  tremor.     An  alarmed  horse  on  a  ferry-boat  illustrates 
these  conditions  in  a  striking  manner. 
*  See  Horsley,  '  Lancet,'  18S6. 


b90  EXOPHTHALMIC    GOITRE. 

the  cause,  whatever  it  may  be,  which   disposes  to   or   excites  the 
disease. 

The  abnormal  vascular  state  of  the  shin  is  distinctly  within  the 
range  of  disturbance  of  the  sympathetic,  and  the  occasional  intes- 
tinal flux  has  suggested  a  like  derangement  of  the  intestinal  sym- 
pathetic nerves.  The  latter  symptom,  curiously  enough,  gives  us  a 
clue  to  the  pigmentation  of  the  skin,  which  has  so  often  attracted 
notice.  The  general  similarity  of  this  to  Addison's  disease  prevents 
any  weight  being  placed  on  the  common  absence,  or  occasional 
presence  of  pigineutation  of  the  mucous  membrane  of  the  mouth.  In 
Addison's  disease,  the  pigmentation  certainly  dejDends  on  disease  of 
the  abdominal  sympathetic,  and  on  the  supra-renal  bodies  only  by 
reason  of  their  connection  with  the  nerves.  In  a  case  of  typical 
Addisonian  pigmentation,  I  found  these  bodies  normal,  but  the 
sympathetic  plexuses  of  the  abdomen  involved  in  a  mass  of  cancer. 
The  effect  commonly  due  to  organic  disease  may,  apparently,  be  some- 
times produced  by  transient  derangement.  I  have  seen  a  case  in 
which  such  derangement  was  suggested  by  other  symptoms,  and  pig- 
mentation, quite  like  that  of  Addison's  disease,  passed  away  entirely. 
Hence  an  affection  of  the  abdominal  sympathetic,  similar  to  the 
constant  affection  of  the  cervical  sympathetic,  would  explain  the  pig- 
mentation, and  the  occasional  watery  diarrhoea  seems  also  to  show  that 
the  abdominal  nerves  are  sometimes  involved.* 

Diagnosis. — When  all  the  symptoms  of  the  malady  are  present, 
and  are  considerable  in  degree,  the  disease  is  one  tbat  is  easy  to 
recognise.  It  is  difficult  to  detect,  and  apt  to  be  overlooked,  only 
when  it  is  in  an  early  stage,  and  partially  developed ;  yet  it  is  in  these 
cases  that  the  diagnosis  is  of  the  greatest  importance,  since  it  is  in 
these  that  treatment  has  most  prospect  of  affording  permanent  relief. 
In  such  cases  the  chief  symptoms  are  cardiac,  and  the  malady  may  be 
mistaken  for  mere  nervous  excitement,  or  for  organic  heart  disease. 
The  strong  pulsation  of  the  arteries,  and  the  persistent  excess  and  fre- 
quency of  the  heart's  action,  are  the  most  important  diagnostic  indi- 
cations. A  pulse-rate  of  120,  maintained  even  when  the  patient  is 
tranquil,  should  always  arouse  a  suspicion  of  the  disease,  and  the 
thyroid  and  eyes  should  be  carefully  examined. 

Ordinary  goitre  is  distinguished  by  the  absence  of  the  cardiac  and 
ocular  symptoms,  by  the  degree  of  enlargement  of  the  thyroid,  and  by 
its  relation  to  endemic  influences.  But  there  is  a  class  of  cases  with 
cardiac  symptoms  which  most  authorities  consider  ought  to  be  kept 
distinct  from  the  true  exophthalmic  form.  A  large  goitre  of  endemic 
origin  becomes  associated,  after  a  time,  with  over-action  of  the  heart, 
and  exophthalmos,  in  consequence  of  the  pressure  of  the  tumour  on 
the  sympathetic,  and  perhaps  also  on  the  vagus.     The  exophthalmos 

*  Lesions  of  the  solar  plexus  are  said  to  cause  persistent  watery  diarrhoea 
(Cristiani,  '  Riforma  Med.,'  September  17th,  1891). 


TREATMENT.  891 

is  usually  one-sided,  corresponding  to  the  chief  enlargement  of  the 
thyroid,  and  is  accompanied  with  spasmodic  mydriasis,  from  irritation 
of  the  sympathetic  fibres  to  the  iris. 

Prognosis. — In  few  diseases  of  equal  severity  and  corresponding 
apparent  gravity  is  the  prognosis  so  uncertain  or  do  so  few  cases  end 
fatally  under  observation.  Yet  it  must  be  confessed  that  when  the 
eyes  are  distinctly  prominent,  the  thyroid  enlarged,  the  heart  dilated, 
and  its  habitual  frequency  much  increased,  it  is  rare  to  observe  more 
than  a  moderate  degree  of  improvement  as  the  result  of  the  most 
careful  treatment.  In  many  cases,  improvement  is  followed  by 
relapse,  and  in  some  no  amelioration  can  be  obtained.  On  the  other 
hand,  some  cases  present  a  degree  of  improvement  that  amounts  almost 
to  restoration  of  health,  and  perfect  recovery  is  occasionally  observed. 
The  prospect  is  best  in  the  slighter  and  earlier  cases,  in  which  the 
heart  disturbance  is  recent,  and  the  enlargement  of  the  thyroid  is 
slight.  The  prognosis  is,  on  the  whole,  less  favorable  the  more 
severe  the  symptoms,  also  when  there  is  conspicuous  failure  of  general 
nutrition,  or  organic  heart  disease.  It  is  better  in  women  than  in 
men ;  nevertheless  cases  of  recovery  in  men  are  sometimes  met  with.* 
It  is  better  if  the  disease  shows  a  remittent  tendency,  and  I  am  in- 
clined to  think  that,  if  the  disease  is  in  an  early  stage,  it  is  better 
when  there  is  a  family  tendency  to  the  affection  than  when  there  is 
none.  A  distinct  and  removable  exciting  cause  certainly  also  improves 
the  prognosis.  If  no  improvement  is  obtained,  an  opinion  is  often 
sought  regarding  the  probable  duration  of  life.  This  is,  however,  im- 
possible to  forecast.  The  sufferers  may  present  merely  variations  in 
the  degree  of  the  symptoms,  and  even  then  an  unexpected  improve- 
ment may  occur  for  month  after  month  and  year  after  year.  One 
patient,  when  I  saw  her,  was  in  a  condition  in  which  it  seemed  scarcely 
possible  that  she  could  live  three  months,  and  yet  three  years  after- 
wards she  was  not  only  alive,  but  so  much  better  that  she  had  become 
a  wife  and  mother.  Several  other  instances  of  similar  improvement 
have  come  under  my  notice.  On  the  other  hand,  a  case  of  only  slight 
degree  may  be  treated  sedulously  for  months  with  only  the  result 
that  the  symptoms  do  not  increase.  The  average  prognosis  is  cer- 
tainly worse  among  hospital  patients  than  in  those  of  better  position, 
in  whom  suitable  conditions  of  life  can  be  secured  and  maintained  for  a 
long  time.  But  in  this,  as  in  so  many  diseases,  the  observed  tendency 
is  the  only  trustworthy  guide  lo  prognosis,  and  it  is  never  right  to 
exclude  the  hope  of  ultimate  improvement  and  even  of  possible 
recovery. 

Treatment. — The  first  and  most  important  element  in  treatment 
is  to  secure  tranquillity  of  mind  and  rest  of  body.     Frequently  as  the 
heart,  in  this  disease,  beats  during  rest,  it  is  quickened  still  more  by 
*  See  *  Trans,  Oph.  Soc.,5  1886,  p.  26. 


892  EXOPHTHALMIC    GOITEE. 

mental  emotion  and  physical  exertion,  and  every  avoidable  contrac- 
tion should  be  prevented.  In  a  severe  case  it  is  well  to  keep  the 
patient  in  the  recumbent  posture  for  a  time — in  bed  if  the  onset  has 
teen  recent  and  acute,  or  if  the  symptoms  ai-e  severe.  Absolute  rest 
may  quickly  bring  the  pulse  down  from  120  to  90,  or  even  80.  Eest 
often  enables  drugs  to  do  good  which  before  were  powerless.  In  any 
case,  several  hours  of  each  day  should  be  spent  on  the  sofa,  and  only 
the  gentlest  exercise  should  be  permitted.  It;  perfect  rest  is  desirable, 
the  lack  of  exercise  may,  in  some  degree,  be  compensated  by  gentle 
daily  massage.  Complete  change  of  air  has  often  been  followed  by 
marked  improvement,  but  as  a  rule  mountain  air  is  not  desirable. 
Most  patients  do  best  at  the  seaside,  if  the  air  of  the  place  is  not  too 
stimulating.  A  sea  voyage  is  a  somewhat  hazardous  measure.  In 
■each  case  the  effect  of  change  must  be  carefully  watched,  since  it  is 
not  alway  possible  to  foretell  its  influence.  There  is  no  trustworthy 
evidence  that  any  particular  locality  is  specially  beneficial. 

Medicinal  treatment  is  uncertain  in  its  results.  Drugs  that  have 
clearly  done  good  in  some  instances  have  been  quite  ineffectual 
in  other  cases.  This  statement  applies  to  iron,  quinine,  arsenic, 
strychnia,  and  other  tonics.  In  spite  of  anaemia,  iron  fails  in  most 
cases  to  improve  the  condition  of  the  patient,  and  seems  sometimes 
even  to  do  harm.  Von  G-raete,  whose  experience  of  the  disease  was 
very  large,  came  to  the  conclusion  that  iron  is  useless  in  the  height 
-of  the  malady,  but  that  it  does  good  when  a  certain  amount  of 
improvement  has  occurred,  and  the  pulse  has  fallen  below  100. 
Iodine  and  iodides  have  been  thought  by  many  to  be  positively  harm- 
ful ;  nevertheless,  cases  are  occasionally  reported  in  which  benefit  has 
followed  their  internal  administration  or  external  use.  Bromides 
seldom  influence  the  disease  itself,  but  are  often  useful  for  the  purpose 
of  lessening  irritability  and  promoting  sleep.  Antipyrine  has  been 
strongly  recommended  by  Gauthier,  but  sulphonal  has  been  found  by 
many  the  most  valuable  hypnotic  (gr.  15 — 25)  ;  it  is  said  to  lessen  the 
over-action  of  the  heart,  and  to  some  extent  the  other  symptoms,  if 
given  twice  a  day  in  10  gr.  doses.  But  it  should  not  be  thus  admin- 
istered for  long. 

Drugs  that  slow  the  pulse  would  seem  to  be  specially  indicated,  but 
the  experience  of  different  observers  is  as  much  at  variance  on  this 
point  as  on  the  action  of  tonics.  It  is  certain  that  digitalis  fails,  in 
most  cases,  to  produce  any  permanent  effect,  and  yet  cases  are 
occasionally  published  in  which  digitalis  and  iron  together  have 
seemed  to  cure  the  patient.  Trousseau  thought  digitalis  useful 
when  given  in  full  doses,  so  as  to  reduce  the  pulse  to  sixty  or  seventy 
beats  per  minute.  Strophanthus  has  been  said  often  to  do  good,  and 
to  be  free  from  risk  of  harm.*  Veratrum  viride  does  not  seem  to 
possess  any  special  advantage.  Aconite  has  been  recommended  in 
doses  of  five  minims  of  the  tincture,  increased  gradually  to  twenty. 
*  Fcrgnsson,  'New  York  Med.  Rec.,'  1890;  Mobius,  loc.  cit. 


TREATMENT.  893- 

Belladonna,  however,  is  the  drug  that  has  seemed  most  often  dis- 
tinctly useful.  It  should  be  given  in  gradually  increasing  doses,  until 
the  maximum  quantity  is  reached  that  the  patient  can  bear.  Either 
the  tincture  or  the  extract  may  be  given,  or  atropine  may  be  injected. 
Pronounced  symptoms  may  disappear  entirely  under  its  use,  and  still 
more  frequently  marked  improvement  results.  Both  belladonna  and 
digitalis,  it  may  be  noted,  have  an  influence  on  the  small  arteries, 
inci'easing  their  tone.  Ergot  has  rarely  failed  to  disappoint.  Pro 
longed  hydropathic  treatment  has  been  strongly  praised,  chiefly  by 
continental  physicians. 

The  application  of  voltaism  to  the  cervical  sympathetic  has  been 
recommended,  and  often  employed.  It  is  not  certain  to  what  extent 
the  sympathetic  is  influenced,  since  we  cannot  by  such  application  to  a 
healthy  individual,  obtain  any  dilatation  of  the  pupil.  The  application 
is  followed  in  many  cases  by  a  distinct  fall  in  the  frequency  of  the 
pulse  (amounting  to  ten  or  even  twenty  beats  per  minute),  and  some- 
times by  a  slight  diminution  in  the  size  of  the  thyroid.  I  have  em- 
ployed the  treatment  in  many  cases  and  have  known  the  pulse  to  fall 
twenty  or  thirty  beats.  The  effect,  unfortunately,  is  usually  transient, 
and  although  repeated  applications  may  sometimes  cause  a  slight 
degree  of  permanent  improvement,  this  is,  as  a  rule,  trifling.  When 
all  the  symptoms  have  disappeared,  other  measures  were  generally 
employed  at  the  same  time,  and  the  treatment  continued  for  a  long 
period.  Both  electrodes  may  be  placed  along  the  anterior  edge  of  tbe 
sterno-mastoid,  one  above  and  one  below,  or  one  electrode  may  be 
placed  in  either  of  these  positions  and  the  other  on  the  lower  cervical 
spines  or  beneath  the  occiput.  A  weak  cui-rent  only  should  be  em- 
ployed, such  as  causes  a  moderate  amount  of  tingling  in  the  skin. 
Earadism  from  the  neck  to  the  face,  thyroid,  and  cardiac  region,  has 
been  advocated  by  Vigouroux  and  Charcot. 

Surgical  Treatment. — Excision  of  the  thyroid  is  scarcely  practicable- 
when  the  disease  is  fully  developed.  The  dilatation  of  the  blood- 
vessels renders  the  operation  very  formidable,  while  it  has  other 
special  risks,  immediate  and  remote.  In  a  few  cases,  chiefly  early,  it  is 
said  to  have  been  successful  in  arresting  or  curing  the  disease,  and  in 
some  other  cases  in  which  an  operation  was  justified  by  threatened 
suffocation,  but  in  most  the  enlargement  of  the  thyroid  presented  some 
peculiarity  and  differed  from  the  ordinary  extremely  vascular  form 
In  this  disease,  as  in  ordinary  goitre,  excision  of  the  isthmus  causes 
atrophy  of  the  whole  gland,  but  the  operation  has  not  been  followed 
by  permanent  results  to  the  other  symptoms  of  the  exophthalmic  form. 
Excision  has  failed  to  influence  the  symptoms  in  some  recorded  cases. 
In  one  patient  on  whom  the  operation  was  performed,  the  resulting 
atrophy  of  the  gland  did  not  materially  influence  the  exophthalmos, 
and  there  was  also  considerable  valvular  disease  of  the  heart,  which 
caused  death  four  months  later.*     The  same  may  be  said  of  setons, 

*  Bristowe,  '  Trans.  Oph.  Sec.,'  1886.     The  large  proportion  of  published  cases- 


894  PAEALYSIS   AFTER.  ACUTE    DISEASES. 

cauterisation,  and  injections  of  ergotin.  Handfield  Jones  has  seen 
injections  of  iron  into  the  thjroid  give  rise  to  alarming  symptoms. 
On  the  whole,  the  results  of  surgical  treatment  are  not  at  present  en- 
couraging, but  it  is  possible  that  the  future  may  disclose  the  means  of 
making  it  more  effectual.  Especially  it  deserves  note  that  ligature  of 
the  arteries  of  the  thyroid  is  said  to  have  the  same  effect  as  extirpation, 
and  to  augment,  to  three  times  the  normal,  both  the  absorption  of 
oxygen  and  the  formation  of  carbonic  acid.* 

Among  special  symptoms  that  may  call  for  treatment,  the  paroxysms 
of  palpitation  and  dyspnoea  are  best  relieved  by  "  derivatives,"  as  hip- 
baths and  mustard  plasters  to  the  feet,  with  cold  to  the  thyroid  (if 
its  enlargement  is  sufficient  to  be  a  cause  of  dyspnoea)  and  by  full 
doses  of  digitalis.  Ether,  chloroform,  and  morphia  also  sometimes 
give  relief  in  this  condition.  Trousseau  found  a  copious  venesection 
effectual  in  relieving  such  an  attack  when  other  measures  failed.  Any 
inflammation  of  the  eyeball  must  be  promptly  treated,  to  obviate,  if 
possible,  the  danger  to  sight. 


PAEALYSIS  AETEE  ACUTE   DISEASES. 

Many  acute  diseases,  especially  the  acute  specific  diseases,  are  occa- 
sionally accompanied  or  followed  by  symptoms  of  impairment  of  func- 
tion of  the  nervous  system.  Of  these  symptoms,  motor  palsy  is  the 
most  frequent.  One  of  these  diseases,  diphtheria,  is  followed  by  palsy 
of  a  special  character,  which  will  be  separately  described.  In  the  other 
maladies,  the  nervous  symptoms  vary  much  in  their  character,  and 
evidently  also  in  their  mechanism.  They  are  on  the  whole  rare,  but 
less  so  after  some  diseases  than  after  others. 

In  the  course  of  any  acute  disease,  sudden  symptoms  may  come  on, 
such  as  indicate  the  occurrence  of  a  vascular  lesion  in  the  brain. 
Usually  there  is  sudden  hemiplegia,  which  may  be  accompanied  by 
loss  of  speech,  and  may  persist  or  may  pass  away  according  to  the 
position  of  the  lesion.  In  some  cases,  especially  in  children,  convul- 
sions attend  the  onset,  but  chiefly  when  the  lesion  is  cortical ;  pos- 
sibly the  greater  frequency  of  convulsions  in  children  is  because  the 
central  lesion  is  in  them  more  frequently  at  the  surface.  The  morbid 
process  varies  in  different  cases.  In  some  there  is  embolism,  conse- 
quent on  endocarditis,  which  may  complicate  any  one  of  these  diseases, 
but  is  most  frequent  in  scarlet  fever.  In  other  cases,  the  lesion  is 
probably  thrombosis  in  an  artery  or  in  a  surface  vein,  and  the  latter 
is  especially  probable  in  the  case  of  children.     In  other  very  rare 

in  which  benefit  resulted  suggests  that  a  still  larger  number,  without  benefit,  have 
been  unpublished. 

*  T;\rchanoff, '  Schweiz.  Corr.-Bl.,'  1889. 


TYPHOID    FEVER.  895 

■cases,  again,  there   is   haemorrhage.      All   such   secondary   cerebral 
lesions  are  most  common  in  children. 

The  other  symptoms  met  with  present  no  general  correspondence 
in  character ;  they  may  be  cerebral  or  spinal,  or  such  as  indicate  an 
affection  of  the  peripheral  nerves.  In  other  cases  the  symptoms  are 
those  of  functional  disturbance,  sometimes  prolonged.  The  affections 
of  the  nervous  system  which  occur  during  the  acute  disease,  besides 
the  vascular  lesions  already  mentioned,  are  generally  inflammatory, 
and  seem  due  to  the  influence  of  the  virus  of  the  primary  disease, 
which  often  causes  inflammation  in  other  orgaus.  Those  that  follow 
the  disease  vary  not  only  in  their  character,  but  also  in  the  date  at 
which  they  occur.  Many  facts  make  it  probable  that  they  are  due  to 
some  product  of  the  organisms  which  may  be  safely  assumed  to 
constitute  the  virus  of  most  of  the  primary  diseases.  This  product 
or  "toxine"  has  certainly  sometimes  a  powerful  action  on  the  nervous 
system  (see  "Tetanus,  Pathology"),  and  it  is  probably  the  agent 
by  which  most  sequelae  are  produced  that  are  not  the  result  of  the 
simple  debility  caused  by  the  acute  malady. 

Typhoid  Fever. — Apart  from  the  sudden  hemiplegia  already 
mentioned,  which  is  very  rare  in  typhoid  fever,  the  most  common 
nerve- symptoms  indicate  a  special  influence  of  the  poison  on  the 
brain.  The  common  deafness  is  apparently  produced  in  this  manner 
by  an  interference  with  the  functions  of  the  auditory  nerve.  Loss  of 
speech  is  not  uncommon.  It  occurs  chiefly  towards  the  close  of  the 
disease  and  during  convalescence ;  it  may  come  on  as  the  deafness  is 
passing  off.  There  is  generally  complete  speechlessness,  and,  although 
it  is  called  aphasia,  there  is  no  disorder  of  speech,  or  partial  loss,  such 
as  occurs  in  cases  of  organic  disease  of  the  brain.  The  patient  can 
understand  perfectly  what  is  said,  and  may  be  able  to  express  assent 
and  dissent  by  signs,  or  even  to  write.  In  one  case  under  my  observa- 
tion the  condition  developed  gradually  by  a  disuse  of  the  lips,  which 
were  dry  and  cracked ;  the  loss  of  the  labial  articulation  rendered  the 
words  almost  unintelligible,  and  they  gradually  ceased  to  be  uttered. 
The  condition  may  last  for  some  weeks.  In  one  recorded  case  it  was 
associated  with  general  choreoid  movements.*  Not  unconnected, 
probably,  with  such  loss  of  speech,  is  the  mental  weakness  that  so 
often  attends  convalescence  from  typhoid  fever,  and  may  amount  to 
actual  imbecility.  Impairment  of  memory  is  common.  Occasionally 
there  is  some  more  pronounced  mental  derangement,  generally  in  the 
form  of  chronic  delusional  insauity.  These  cerebral  symptoms  always 
pass  away  in  time,  but  in  adults  the  memory  may  never  be  so  good  as 
before  the  fever. 

Paraplegic  weakness  is  not  uncommon,  and  this  also  occurs  when 
the  disease  is  on  the  decline  or  during  convalescence,  or  at  least 
is  then  recognised.  In  some  cases,  the  weakness  due  to  the  fever 
*  De  la  Harpe,  '  Rev.  med.  de  la  Suisse  Rom.,'  1883,  No.  6. 


896  PARALYSIS    AFTER  ACUTE    DISEASES. 

seems  to  persist  in  the  legs,  and,  as  in  one  case  under  my  observation, 
when  the  patient  is  seen  some  months  after,  there  is  distinct  defect  of 
power,  with  excessive  knee-jerk  and  foot-clonus.*  Money  has  indeed 
found  that  there  is  generally  an  excess  of  myotatic  irritability  during 
the  disease. f  In  other  cases  actual  paraplegia  comes  on  more 
rapidly,  although  not  suddenly,  and  may  increase  to  a  considerable 
degree  of  -weakness,  although  there  is  rarely  absolute  loss  of  power. 
The  onset  may  be  attended  with  spinal  tenderness,  and  with  hyper- 
esthesia or  various  subjective  sensations  in  the  legs,  and  these  may 
be  followed  by  defect  of  sensation.  It  is  probable  that  the  symptoms 
are  due  to  disseminated  myelitis  of  slight  intensity.  They  usually 
pass  away  in  the  course  of  a  few  weeks.  In  very  rare  cases  paralytic 
symptoms  are  of  greater  severity.  The  weakness,  commencing  in  the 
leo-s,  may  invade  the  arms,  and  when  such  extension  occurs  rapidly 
the  case  becomes  one  of  the  so-called  "  acute  ascending  paralysis," 
and  death  has  been  known  to  occur  in  the  course  of  a  few  days. 

Limited  atrophic  paralysis  occurs  in  some  cases,  especially  during 
convalescence.  It  is  sometimes  very  severe,  and  may  leave  permanent 
disability.  In  acute  cases  the  lesion  is  probably  always  spinal,  ante- 
rior polio-myelitis.  There  is  loss  of  power,  variable  in  extent,  with 
rapid  wasting  and  loss  of  faradic  irritability  in  the  muscles  most 
affected.  Although  a  considerable  amount  of  recovery  always  occurs, 
there  may  be  permanent  atrophy  of  certain  muscles.  In  one  case  of 
such  acute  atrophic  paralysis,  affecting  only  the  extensors  of  the 
wrists  and  fingers  (as  in  lead-poisoning,  &c),  with  rapid  loss  of  all 
irritability,  Shore  found  acute  inflammation  of  the  anterior  cornua 
from  the  third  to  the  eighth  cervical  nerves.  The  onset  was  three 
weeks  after  the  typhoid,  and  the  patient  died  from  pneumonia  two 
weeks  later.J  Polio-myelitis  is  more  frequently  secondary  to  typhoid 
fever  than  to  any  other  acute  specific  disease.  When  the  onset  is  sub- 
acute it  is  probable  that  in  many  cases  such  symptoms  are  due,  not  to 
polio-myelitis,  but  to  multiple  neuritis.  This  was  probably  present  in  a 
case  described  by  Alexander,  in  which  typhoid  fever,  in  a  patient  aged 
twenty,  was  followed  by  wasting  of  muscles  with  loss  of  electrical 
irritability  and  of  the  knee-jerk,  and  paralysis  of  one  vocal  cord. 
The  development  of  the  palsy  was  accompanied  by  severe  pains  in  the 
legs.§  Recovery  was  complete.  Such  symptoms  have  probably  been 
due  to  neuritis  in  cases  in  which  they  involved  all  the  extremities, 
since  this  sequel  has  also  been  proved.  The  distinction  of  the  central 
or  peripheral  nature  of  many  cases  is  very  difficult,  and  depends 
chiefly  on  the  presence  of  pains  in  the  hands  and  of  nerve  tenderness. 
In  some  cases  of  local  atrophy,  as  of  one  arm,  pains  and  tendei'ness 

*  It  is  not  uncommon  for  adults  after  typhoid  never  to  regain  the  good  walking 
powers  they  had  before  the  illness,  although  there  is  nothing  that  can  be  callcd- 
paralysis. 

t  '  Lancet,'  1885.  J  '  St.  Bartholomew's  Hosp.  Rep.,'  xxiii. 

§  Alexander,  '  Deut.  med.  Wochenschr.,'  1886,  No.  31. 


ERYSIPELAS.  897 

have  made  an  isolated  neuritis  probable,  which  may  sometimes  be 
excited  by  even  slight  pressure. 

In  very  rare  instances  paraplegic  or  general  weakness  after 
typhoid  fever  has  been  associated  with  paralysis  of  the  soft  palate, 
but  even  these  cases  do  not  resemble  closely  diphtheritic  paralysis. 
There  is  never  the  loss  of  accommodation,  or  the  slow  progress  of 
palsy  from  one  part  to  another.  * 

Paralysis  of  cranial  nerves  has  been  seen  in  a  few  instances,  and  in 
two  cases,  paralysis  of  the  abductors  of  the  vocal  cords  occurred  in  so 
complete  a  degree  as  to  necessitate  tracheotomy  (xiehn,  Villemiu). 
Optic  neuritis  is  a  very  rare  sequel  of  typhoid  fever.  Localised 
neuralgic  pains  in  the  course  of  the  spinal  nerves  are  occasionally  met 
with  during  convalescence.  They  have  been  known  to  be  accompanied 
by  spots  of  anaesthesia,  and  are  then  doubtless  due  to  neuritis. 
Laudouzy  records  a  case  in  which  a  spot  of  such  anaesthesia  in  the 
groin  was  permanent. 

The  muscular  tremor,  which  is  occasionally  so  conspicuous  during 
the  course  of  typhoid,  may  continue  during  convalescence,  and  it  has 
been  known  to  persist  and  to  be  followed  by  the  symptoms  of  dissemi- 
nated sclerosis  (Chauffard,  Ebstein,  and  Westphal).  The  tremor 
never  goes  on  to  paralysis  agitans.  In  girls,  hysterical  symptoms 
are  not  rare  during  the  course  of  the  disease  and  during  convales- 
cence; contractures,  anaesthesia,  and  even  convulsions  have  been 
met  with. 

Typhus  Fever. — After  typhus  fever,  symptoms  have  been  met 
with  very  similar  to  those  that  may  follow  typhoid.  Paraplegic 
weakness  is,  however,  less  common;  paralysis  of  cranial  nerves  occurs 
only  in  consequence  of  an  attack  of  meningitis  complicating  the  fever ; 
while  pai'alysis  of  the  palate  has  not  been  met  with.  Bernhardt  has 
recorded  a  case  of  neuritis  of  the  musculo -spiral  nerve,  which  nwy 
have  been  set  up,  as  paralysis  in  this  nerve  so  often  is,  by  pressure 
upon  it  during  the  pei'iod  of  prostration  and  inertia.  Rarely 
symptoms  of  multiple  neuritis  have  followed  typhus.  Optic  neuritis 
has  also  been  observed,  although  even  more  rarely  than  after  typhoid. 

Erysipelas  is  seldom  followed  by  paralysis.  In  one  remarkable 
case  f  paralysis  of  the  soft  palate  and  of  the  posterior  crico-arytsenoids 
(abductors  of  the  vocal  cords)  followed  facial  erysipelas  and  one-sided 

*  True  diphtheria  sometimes  complicates  typhoid  fever,  and  may  be  followed  by 
characteristic  paralysis,  as  in  a  case  related  by  Dr.  Murchison.  In  the  cases  in 
which  membrane  in  the  throat  has  been  regarded  as  an  effect  of  the  typhoid,  it  is 
possible  that  the  virus  of  diphtheria  may  have  been  also  present.  This  point  deserves 
further  consideration  in  the  cases  that  are  followed  by  palatine  palsy,  especially  when 
there  is  general  muscular  weakness.  (See  Ross,  '  Congress  American  Phy*./ 
1888.) 

t  Feith,  'Berlin,  klin.  Wochenschrift,'  1874,  No.  49. 
VOL.   II,  57 


898  PARALYSIS  AFTER   ACUTE    DISEASES. 

pneumonia.     The  paralysis  of  the  larynx  necessitated  tracheotomy, 
and  appears  to  have  been  rjerrnanent. 

Variola. — Spinal  symptoms  are  more  common  in  connection  with 
smallpox  than  -with  any  other  of  the  eruptive  fevers.  The  fact  was 
associated  by  Trousseau  with  the  severe  pain  in  the  back  which  occurs 
at  the  onset,  on  the  ground  that  this  pain  may  be  accompanied  by 
weakness,  formication,  and  tingling  iu  the  legs,  plantar  pain,  and 
retention  of  urine,  and  that  these  symptoms  pass  away  with  the  pain 
in  the  back  on  the  appearance  of  the  eruption.  More  pronounced 
spinal  symptoms  may  come  on  during  the  height  of  the  disease,  or 
especially  during  convalescence.  There  is  paraplegic  weakness,  with 
or  without  affection  of  sensation,  and  varying  much  in  degree. 
Recovery  in  severe  cases  may  be  incomplete.  The  symptoms  pro- 
bably depend  upon  myelitis,  which,  disseminated  through  the  cord, 
was  actually  found  by  Westphal  in  one  case  ;  the  grey  and  white  sub- 
stance was  occupied  by  scattered  spots  of  softening.*  Acute  atrophic 
paralysis  has  also  been  observed ;  it  is  sometimes  due  to  polio-myelitis 
(as  Roger  was  able  in  one  case  to  demonstrate),  but  probably  in  many 
cases,  and  perhaps  in  all  those  in  which  the  onset  is  subacute,  it  is  the 
result  of  neuritis.  In  a  case  of  atrophy  in  one  arm,  Joff  roy  could  find 
no  change'  in  the  cord,  but  only  an  acute  degeneration  of  the  nerves. 
In  many  other  cases,  the  characteristic  symptoms  of  multiple  neuritis, 
affecting  all  the  limbs,  and  sometimes  other  parts,  have  come  on  at 
an  interval  after  the  variola  (see  vol.  i,  p.  114).  Ataxy  of  both  arms 
and  legs,  persisting  for  a  long  time  after  the  pi*imary  disease,  but 
ultimately  passing  away,  has  probably  been  due  to  the  same  cause. 
Acute  ascending  paralysis  has  been  observed  during  convalescence, 
fatal  in  a  few  days,  and,  as  in  other  cases,  without  recognisable 
lesion.f  Occasionally  paralytic  symptoms  extend  to  the  cerebral  as 
well  as  the  spinal  functions.  The  ocular  muscles  have  been  paralysed, 
perhaps  from  neuritis.  Smallpox  has  also  been  followed  by  symptoms 
of  insular  sclerosis.  J 

Measles.— Spinal  symptoms  may  occur  during  and  after  measles, 
very  similar  in  characters  to  those  which  follow  smallpox.  Those  of 
acute  polio-myelitis  are  the  most  frequent,  but  acute  ascending  para- 
lysis has  been  met  with  (Bergeron  and  Liegeard).  A  remarkable 
case  of  disseminated  myelitis  has  been  recorded  by  Barlow.§  Hemi- 
plegia, probably  from  thrombosis  in  a  cerebral  vessel,  has  also  been 
met  with.  Optic  neuritis  has  only  been  observed  as  a  result  of 
coincident  meningitis. 

*  Foci  of  softening  have  also  been  described  by  Darnaschino,  and  by  Joffroy  and 
Hayetn. 

+  Bernhardt,  '  Berl.  klin.  Wochensch.,'  1871,  No.  47 ;  Gros  and  Beauvais, '  L'Un. 
med.,'  18S4,  No.  131. 

t  Long,  Charcot.  §  <  Med.-Chir.  Trans.,'  1885. 


SCARLET    FEVER.  899 

Scarlet  Fever. — Spinal  symptoms  are  rare  after  scarlet  fever; 
sudden  cerebral  hemiplegia  is  not  infrequent,  and  is  probably  due  to 
embolism  from  scarlatinal  endocarditis,  or  to  spontaneous  thrombosis. 
It  may  occur  during  or  apart  from  kidney  sequelae.  Convulsions, 
which  may  persist  as  epilepsy,  are  also  more  frequent  after  scarlet 
fever  than  after  any  other  acute  disease  (see  p.  733).  Neuro-retinitis 
has  been  many  times  observed  to  follow  scarlet  fever,  without  any 
renal  complication.* 

Mumps. — Palsy  of  accommodation  has  been  described,  but  was  met 
with  only  in  one  case  in  an  extensive  epidemic,  f  Joffroy  observed 
paralysis  of  the  limbs  in  one  instance  ;  there  was  loss  of  electrical 
irritability  and  of  reflex  action,  and  the  muscles  were  tender.^  It  is 
possible,  however,  that  in  each  of  these  cases  there  may  have  been 
undiscovered  diphtheria ;  in  the  second  case,  indeed,  slight  angina 
was  observed. 

Malarial  Fever. — During  the  course  of  severe  malarial  fever 
singular  paralytic  symptoms  have  been  met  with,  especially  hemi- 
plegia and  aphasia,  which  are  said  to  pass  away  under  the  influence 
of  quinine,  and  are  therefore  ascribed  to  an  effect  of  the  malarial 
poison  on  the  nerve-centres  (G-rasset).  Graver  and  more  lasting  sym- 
ptoms of  the  same  class  have  been  met  with  in  cachectic  subjects, 
and  have  been  ascribed  to  obstruction  of  cerebral  vessels  by  pigmen- 
tary matter.  The  most  frequent  paralysis  due  to  malaria  is  that  of 
the  feet,  less  commonly  also  of  the  hands,  which  is  characteristic  of 
multiple  neuritis.     This  form  has  been  described  in  vol.  i. 

Dysentery,  when  severe,  has  been  followed  by  paraplegia,  com- 
mencing with  tingling  in  the  skin,  and  pains  along  the  course  of  the 
nerves,  succeeded  by  motor  and  sensory  paralysis,  sometimes  with 
muscular  wasting.  The  arms  may  also  be  involved.  These  sym- 
ptoms sometimes  occur  during  the  course  of  the  disease.  They  are 
probably  due  to  myelitis  or  to  peripheral  neuritis.  In  one  case,  exten- 
sive softening  was  found  in  the  cervical  and  lumbar  enlargements 
(Delioux). 

Diarrhoea. — Simple  diarrhoea,  whether  spontaneous  or  the  result 
of  undue  purgation,  has  been  followed  by  spinal  symptoms,  usually 

*  In  scarlet  fever  there  is  sometimes  false  membrane  in  the  throat  like  that  of 
diphtheria,  and  the  patients  are  often  said  to  have  had  both  diseases.  My  colleague 
Dr.  Barlow,  whose  experience  of  these  cases  is  very  large,  informs  me  that  he  has 
never  known  diphtheritic  paralysis  to  follow  this  complication,  and  hence  it  is  very 
doubtful  whether  the  membrane  is  an  indication  of  true  diphtheria.  It  is  possible, 
however,  that  there  are  two  forms  of  this  complication,  one  truly  diphtheritic  (see 
Heubner,  '  Jahrb.  f.  Kinderheilk.,5  Bd.  xiv;  and  Deinme,  'Bericht  aus  d.  Jenner- 
spital,'  Berne,  1878  and  1879). 

t  Boas,  '  Kl.  Monatsbl.  f.  Augenh.,'  1886,  p.  273. 

J  Joffroy,  '  Prog,  med.,'  1886,  No.  47. 


900  PARALYSIS    AFTER   ACUTE    DISEASES. 

transient,  sometimes  more  severe.  In  women,  hysterical  symptoms 
also  result  from  the  peculiarly  depressing  effect  of  diarrhoea  on  the 
nervous  system.  Tetany  is  an  occasional  sequel,  especially  in  children, 
in  whom  exhausting  diarrhoea  sometimes  causes  also  cerebral  throm- 
bosis, or  the  symptoms  of  cerebral  anaemia  termed  "  hydrocephaloid  " 
(see  p.  370). 

Acute  Rheumatism. — ~No  palsy  is  common  in  connection  with 
acute  rheumatism,  except  the  embolic  hemiplegia  that  is  the  result 
of  endocarditis.  Myelitis,  especially  polio-myelitis,  has  been  thought 
to  be  a  frequent  sequel,  but  the  cases  on  which  this  opinion  has  been 
based  have  been,  for  the  most  part,  those  in  which  pains  in  the  limbs 
have  attended  the  onset  of  the  spinal  disease,  and  have  given  rise  to 
an  erroneous  diagnosis  of  acute  rheumatism.  It  is  possible,  however, 
that  rheumatism  and  myelitis  may  both  result  from  the  same  ex- 
posure to  cold,  which  may  certainly  cause  arthritis  and  polyneuritis  as 
coincident  effects  (see  vol.  i).  A  patient  aged  thirty  had  subacute 
articular  rheumatism  of  both  ankle-joints,  with  considerable  pain, 
and  this  was  followed  by  incomplete  palsy  of  all  limbs,  disturbance 
of  sensibility,  partial  atrophy  of  the  muscles  with  the  degenerative 
reaction,  loss  of  the  knee-jerk,  tremors,  and  involuntary  twitchings ; 
the  facial  nerves  were  also  involved,  and  some  optic  neuritis  super- 
vened.* 


INFLUENZA. 


There  is  no  acute  malady,  with  the  exception  of  diphtheria,  after 
which  disturbance  of  the  nervous  system  is  so  frequent  as  after 
influenza,  and  there  is  certainly  no  disease  that  has  such  varied 
nervous  sequelae.  This  effect  of  influenza,  although  long  known,  has 
never  been  perceived  so  distinctly  as  in  the  severe  outbreak  of  the 
last  four  years,  1890-93.  Functional  disturbance  of  the  nervous 
system  seems,  indeed,  to  be  a  direct  effect  of  the  virus  of  the  disease, 
siuce  it  forms  an  almost  constant  feature  of  the  acute  affection. 
That  which  exists  during  the  febrile  stage  may  persist  in  similar 
form  for  many  days  or  weeks  after  the  general  disturbance  is  at  an 
end.  Symptoms  of  similar  or  different  nature  may  develop  within  a 
fortnight  of  the  cessation  of  the  acute  attack  ;  and,  lastly,  duriug  this, 
or  afterwards,  organic  disease  may  develop  in  the  central  organs  or 
peripheral  nerves.  Some  of  the  most  severe  sequelae,  moreover,  have 
followed  second  or  third  attacks  of  influenza  which  were  mild,  and 
sometimes  even  trifling.  On  the  other  hand,  there  has  been  a  dis- 
position to  associate  with  influenza  affections  of  the  nervous  system 
which  have  come  on  six,  nine,  or  twelve  months  after  the  primary 
disease,  without  any  other  connection  with  this  than  some  impair- 

*  Remak,  'Near.  Centralbl.,'  1885,  No.  14. 


INFLUENZA.  90 1 

ment  of  constitutional  strength,  such  as  follows  every  depressing 
acute  illness.  Such  remote  affections  cannot  be  regarded  as  the 
specific  consequences  of  influenza.  Moreover,  many  of  the  direct 
sequelae  cannot  be  regarded  as  quite  special,  since  so  often  a  previous 
disposition  to  them  can  be  distinctly  traced. 

The  mental  state  and  physical  depression  or  inertia,  seldom 
absent,  rarely  cease  with  the  acute  attack ;  this  almost  universal 
sequel  has  become  familiar  to  every  one.  It  is  not  surprising  that, 
especially  in  predisposed  individuals,  definite  melancholia  should 
grow  out  of  it,  sometimes  of  the  hypochondriacal  type,  sometimes 
with  definite  delusions,  and  occasionally  with  suicidal  impulses. 
Delirium  occurs,  though  not  frequently,  in  the  acute  stage,  and  there 
may  be  subsequently  a  period  of  mental  derangement  with  excite- 
ment, sometimes  with  hallucinations ;  it  is  very  rare  for  this  condi- 
tion to  amount  to  actual  mania.  Mental  dulness  is  more  frequent, 
and,  in  the  old,  it  may  amount  to  positive  dementia,  which  is  some- 
times actual  mindlessness.  Very  seldom  influenza  has  been  followed 
by  advancing  symptoms  of  general  paralysis  of  the  insane,  chiefly 
when  commencing  symptoms  had  previously  existed.  With  the 
exception  of  the  last,  and  of  senile  derangement,  these  psychical 
sequelse  are  usually  transient,  melancholia  being  the  most  pro- 
longed. 

Of  other  forms  of  functional  disturbance,  hysteria  is  very  common 
in  those  who  are  predisposed  to  it,  and  has  been  met  with  in  men  and 
in  children,  and  in  almost  every  phase.  A  state  of  trance,  simple  or 
cataleptoid,  has  occurred  immediately  after  the  febrile  stage.  Con- 
vulsions of  epileptic  character  have  commenced  soon  after  influenza,  or 
have  then  recurred  after  a  long  period  of  freedom  ;  and  in  one  case 
the  acute  illness  had  scarcely  ceased  when  the  symptoms  of  idiopathic 
tetanus  developed  and  caused  death  in  seven  days. 

Corresponding  to  the  prominence  of  pain,  especially  in  the  head  and 
back,  as  a  symptom  of  influenza,  we  meet  with  various  forms  of  neu- 
ralgia as  frequent  sequelse.  Some  of  these  are  at  first  very  severe,  at- 
tended with  local  tenderness,  and  so  persistent  as  to  make  it  probable 
that  there  was,  in  the  beginning,  a  definite  neuritis.  The  intercostal 
nerves,  the  nerves  of  the  arm,  and  the  sciatic  nerve  are  not  uncommon 
seats  of  such  symptoms.  Apart  from  such  isolated  neuritis,  many  cases 
have  been  recorded  in  which  the  characteristic  indications  of  multiple 
neuritis  came  on,  one  or  two  weeks  after  the  primary  disease,  and  con- 
tinued for  several  weeks  or  even  months,  passing  away,  however,  as  a 
rule,  sooner  than  those  of  common  toxic  origin.  In  such  cases  there 
have  been,  besides  symmetrical  nerve-pains  and  tenderness,  muscular 
atrophy  with  the  reaction  of  degeneration,  loss  of  the  knee-jerk, 
paresthesia,  and  sometimes  impairment  of  sensibility ;  as  a  rule, 
however,  the  sensory  fibres  have  seemed  to  suffer  less  than  the  motor. 

Especially  in  patients  who  inherit  or  have  acquired  gout,  or  have 
suffered  from  rheumatism,  severe  and  very  obstinate  forms  of  what 


902  PAEALYSIS   AFTER   ACUTE    DISEASES. 

may  be  termed  "  fibrous  rheumatism "  are  occasionally  set  up  by 
influenza,  commencing  soon  after  the  latter  has  terminated,  but 
continuing  for  many  months,  and  even,  in  late  life,  passing  into  a 
malady  likely  to  end  only  with  life.  Pain  on  movement — in  some  part 
of  the  upper  limbs,  or  especially  of  the  trunk,  the  loins,  or  one  lumbar 
and  inguinal  region,  and  often  the  hip  and  thigh — is  associated  with 
spontaneous  pain  and  diffuse  tenderness.  There  may  be  greater  pain 
and  tenderness  along  one  or  more  nerves  in  the  region,  suggesting 
their  implication.  The  pain  and  tenderness  may  involve  the  spine, 
but  not  in  equal  degree  with  the  other  parts,  and  often  with  similar 
extensions.  Such  symptoms  continue,  but  without  any  further 
development.  In  other  cases,  moreover,  such  pains  in  the  fibrous 
tissues  become  especially  severe  about  the  joints,  and  these  may 
become  distinctly  inflamed.  In  some,  the  hip  or  knee,  in  others, 
the  finger-joints  thus  suffer;  in  the  latter  case  both  hands  are 
involved ;  there  is  arthropathic  wasting  of  the  muscles,  and  the 
malady  may  assume  the  aspect  of  pronounced  rheumatoid  arthritis. 

Grave  inflammations  occasionally  develop  in  the  nerve-centres, 
usually  during  the  febrile  stage  of  the  disease,  as  a  result  of  special 
intensity  of  its  virus.  They  are  comparable  to  the  pneumonia  that 
occurs  at,  the  same  stage,  and  is  often  associated  with  these  affections 
of  the  nerve-centres.  The  latter  comprise  cerebral  meningitis, 
hsemorrhagic  cerebritis,  myelitis, — chiefly  in  the  cervical  region  and 
associated  with  meningitis,  or  else  disseminated,  occurring  in  scattered 
foci  throughout  the  cord.  These  affections  often  cause  death. 
Although  they  commence  during  the  acute  stage  of  the  disease,  and 
occasionally  very  soon  after  its  onset,  their  effects  may  only  be 
obvious  after  that  stage  is  or  should  be  over,  by  a  persistence 
of  cerebral  disturbance — which  may  at  first  have  been  ascribed  to  the 
derangement  of  function  by  the  blood-state — or  by  the  supervention 
of  such  symptoms  when  the  patient  seems  passing  into  convalescence, 
or  of  other  symptoms,  such  as  acute  paralysis,  which  are. unlike  those 
that  are  met  with  in  the  acute  stage. 

These  nerve  disturbances  seldom  involve  the  cranial  nerves.  Only 
in  multiple  neuritis  has  facial  paralysis  and  conspicuous  difficulty  of 
swallowing  been  observed.  Although  infrequency  of  the  heart's 
action,  and  vomiting  without  nausea,  may,  during  the  febrile  stage, 
show  a  special  action  of  the  poison  on  the  centres  of  the  medulla 
oblongata,  these  effects  are  not  usually  prolonged.  In  the  eye,  how- 
ever, optic  neuritis  has  been  occasionally  observed  immediately  after 
the  acute  affection,  as  after  so  many  other  acute  diseases,  and  the 
influence  of  the  blood-state  is  also  sometimes  manifested  by  retinitis 
with  spots  like  those  of  the  renal  form,  both  when  there  is  no  albu- 
minuria and  when  there  is,  and  also  with  or  without  inflammation 
of  the  papilla.  Retro-ocular  neuritis  has  also  been  met  with,  attended 
with  only  very  slight  visible  inflammation. 

The  ti'eatnient  of  these  varied   sequelae  of  influenza  presents  no 


DIPHTHEEITIC    PARALYSIS.  90S 

special  features ;  it  is  the  sanie  as  that  of  the  same  affections  when 
they  occur  in  consequence  of  other  causes. 


DIPHTHEEITIC  PARALYSIS. 

Diphtheria  is  frequently  succeeded  by  paralysis  of  definite  and 
peculiar  character,  such  as  is  not  met  with  after  other  acute  diseases, 
or  is  met  with  only  in  extremely  rare  instances.  The  occurrence  of 
paralysis  after  low  forms  of  sore  throat  has  long  been  known,  and  was 
described  by  the  elder  Chomel  as  observed  in  an  epidemic  at  Paris  in 
1748,  by  G-hisi  in  Italy  in  1749,  and  by  Bard  at  New  York  in  1771. 
When  diphtheria  came  to  be  distinguished  from  other  forms  of 
angina,  it  alone  was  iound  to  be  succeeded  by  this  paralysis.  Hence 
it  is  almost  certain  that  the  epidemic  sore  throats  which,  in  the  last 
century,  were  followed  by  paralysis,  were  also  diphtheria.  It  is, 
indeed,  believed  by  some  that  a  similar  paralysis  occurs,  in  rare  cases, 
after  simple  or  herpetic  tonsillitis,  but  the  evidence  of  this  is  not  con- 
clusive.* It  is,  on  the  whole,  probable  that  all  sore  throats  followed 
by  paralysis  are  diphtheritic.  At  the  same  time  other  maladies  are 
occasionally  followed  by  paralysis,  due  to  a  process  similar  to  that 
which  causes  this  form,  but  the  nature  of  the  primary  disease  has 
usually  been  distinct.     They  have  been  already  mentioned. 

The  frequency  with  which  diphtheria  is  followed  by  paralysis  seems 
to  vary  in  different  epidemics  and  at  different  ages;  it  has  been 
variously  stated  at  from  8  to  66  per  cent.  It  is  probably  not  far 
from  the  truth  to  say  that,  on  an  average,  one  fourth  of  those  who  do 
not  die  from  the  primary  disease  subsequently  suffer  from  paralysis. 
Its  occurrence  is  not  influenced  by  sex,  but,  according  to  the  statistics 
collected  by  Landouzy,f  age  distinctly  increases  the  liability  to  suffer. 
The  sequel  may,  indeed,  occur  at  any  age,  from  two  years  upwards, 
but  adults  furnish  a  larger  proportion  of  the  cases  of  paralysis  than 
of  diphtheria.  Sixty-eight  cases  of  paralysis  were  distributed  as 
follows  (Landouzy)  : — Under  10,  fifteen  ;  10 — 20,  eighteen;  20 — 80, 
thirteen;  30 — 40,  eight;  40 — 50,  eight;  over  50,  six.  From  this  it 
would  seem  that  the  tendency  to  paralysis  is  very  slight  in  early 
infancy,  and  that  it  increases  the  older  the  sufferer.  I  have  seen  one 
severe  case  at  the  age  of  sixty. 

The  previous  health  of  the  patient  seems  to  have  no  influence  ; 
paralysis  does  not  occur  more  frtquently  in  the  weak  than  in  the  strong. 

*  Cases,  however,  have  heen  met  with  (see  p.  917)  that  suggest  that  a  paralysis 
closely  analogous  to  diphtheritic  paralysis  may  occur  as  a  primary  affection  without 
any  preceding  acute  disease,  and  may  run  a  course  similar  to  that  which  succeeds 
diphtheria.     I  have  seen  one  or  two  cases  suggestive  of  this  conclusion. 

t  '  Des  Paralysies  dans  les  maladies  aigues,'  Parisj  1SS0. 


904  DIPHTHERITIC    PARALYSIS. 

Nor  does  the  severity  of  the  attack  of  diphtheria  determine  the 
occurrence  of  palsy ;  it  is  equally  likely  to  follow  attacks  that  are 
severe  and  those  that  are  trifling.  It  occurs  after  diphtheria  of  the 
surface  as  well  as  after  that  of  the  throat.  The  celebrated  alienist 
Griesinger  died  from  paralysis  succeeding  a  diphtheria  limited  to  the 
wound  produced  by  opening  a  perityphlitic  abscess. 

Time  of  Onset. — As  a  rule  the  primary  disease  is  over  before  the 
paralysis  comes  on,  the  most  common  time  being  the  second  or  third 
week  after  the  termination  of  the  throat  affection.  Sometimes, 
however,  it  commences  duriug  the  course  of  the  diphtheria,  from  the 
fifth  to  the  tenth  day,  and  it  has  been  known  to  commence  as 
early  as  the  second  day.  These  statements  apply  to  definite  loss  of 
power. 

Symptoms. — The  onset  of  the  paralysis  is  usually  marked  by  no 
general  symptoms,  but  now  and  then  a  slight  elevation  of  temperature, 
and,  in  children,  restlessness  and  irritability,  may  precede  it,  and  they 
may  also  accompany  its  subsequent  extension.  The  first  part  to  be 
affected  is  usually  the  palate,  and  fluids  are  found  to  regurgitate 
through  the  nose.  Vision  for  near  objects  is  then  interfered  with,  in 
consequence  of  loss  of  power  of  accommodation.  These  two  palsies 
are  almost  invariable.  Subsequently,  and  less  frequently  (in  about 
half  the  cases),  the  limbs  become  weak,  and  often  they  are  the  seat  of 
numbness  or  tingling,  and  sensation  may  be  definitely  impaired.  Less 
frequent  are  paralyses  of  the  muscles  of  the  trunk,  neck,  and  larynx, 
disturbed  innervation  of  the  heart,  weakness  of  the  external  ocular 
muscles,  of  the  bladder  and  rectum,  and  loss  of  sexual  power. 

The  characteristic  of  diphtheritic  paralysis  is  its  gradual  onset  and 
progress  in  each  part,  and  the  way  in  which  different  and  often 
distant  parts  are  affected,  one  after  the  other.  The  loss  of  motor 
power  is  accompanied,  and  indeed  preceded,  by  a  loss  of  myotatic 
irritability,  evinced,  in  the  case  of  the  legs,  by  the  loss  of  the  knee- 
jerk.  When  the  weakness  is  considerable,  the  electric  irritability  of  the 
muscles  is  usually  changed,  and  there  is  moderate  wasting.  The  fact 
that  the  knee-jerk  disappears  before  the  onset  of  the  palsy  is  part  of 
a  wider  fact,  that  the  knee-jerk  is  often  lost  after  diphtheria  in 
cases  in  which  no  paralysis  occurs.  This  was  discovered  by 
Bernhardt,*  and  has  since  been  abundantly  confirmed.  He  found 
the  knee-jerk  was  lost  in  no  less  than  two  thirds  of  the  cases 
examined  (twenty-two  in  number),  in  which  there  was  no  definite 
palsy.  The  loss  occurred  usually  during  the  second  month, 
sometimes  towards  the  end  of  the  first  month,  i.  e.  three  or  four 
weeks  after  the  onset  of  the  primary  disease.  It  both  disap- 
peared and  returned  first  on  one  side,  and  in  one  case  the  loss  was 
unilateral. f      Sometimes,  however,  the  knee-jerk  is  lost  during  the 

*  '  Virchow's  Archiv,'  18S5,  Bd.  xcix,  p.  293. 

t  According  to  Money,  the  loss  may  be  preceded  by  a  brief  exaggeration  ('  Treat- 


SYMPTOMS.  905 

acute  disease.  Even  when  there  is  no  paralysis,  months  have  elapsed 
before  it  could  be  obtained. 

The  paralysis  of  the  palate  is  shown  by  the  voice  acquiring  a  nasal 
tone,  and  by  the  partial  regurgitation  of  liquids  through  the  nose 
during  deglutition.  The  nasal  tone  is  of  course  due  to  the  cavity  of 
the  nose  not  being  shut  off  during  phonation  ;  and  hence  also  the 
explosive  consonants  are  imperfectly  pronounced :  p,  for  instance, 
becomes  m,  and  the  patient  is  unable  to  distend  the  cheeks  or  to  blow 
out  a  candle.  The  closure  of  the  anterior  nares  at  once  removes  this 
disability.  Gurgling  also  is  no  longer  possible.  On  inspection,  the 
palate  is  seen  to  hang  more  vertically  than  normal,  and  when  the 
patient  utters  the  sound  "ah"  it  is  not  raised  as  in  health.  One 
side  is  sometimes  lower  than  the  other,  but  it  is  rare  for  one  side  to 
be  paralysed  alone.  There  is  usually  distinct  loss  of  sensibility  in  the 
palate;  the  patient  does  not  know  when  it  is  touched,  or  the  touch 
occasions  no  discomfort  or  reflex  action,  although,  if  the  back  of  the 
pharynx  is  touched,  evidence  of  sensibility  is  at  once  obvious.  Very 
rarely  anaesthesia  has  been  observed  without  motor  palsy.  When 
the  paralysis  has  lasted  some  time,  the  palatal  muscles  cannot  be 
stimulated  by  faradism  as  readily  as  in  health. 

Paralysis  of  the  pharynx  is  not  common,  but  may  occur,  and  may 
be  so  considerable  as  to  render  swallowing  almost  impossible.  The 
pharynx  has  even  been  relaxed  to  such  a  degree  as  to  form  a  pouch  in 
which  food  accumulates.  If  it  occurs  early  it  is  a  grave  sign.  In  the 
larynx,  paralysis  of  the  upper  part  (superior  laryngeal  nerve)  is  more 
frequent  than  that  of  the  vocal  cords  (inferior  laryngeal  nerve).  In 
the  former  case  the  epiglottis  stands  erect  against  the  base  of  the 
tongue,  and  does  not  descend  over  the  opening,  during  the  act  of 
deglutition,  in  consequence  of  the  weakness  of  the  depressors.  The 
upper  part  of  the  larynx  is  insensitive,  although  when  a  foreign  body 
reaches  the  vocal  cords  pain  is  felt.  Hence  food  is  apt  to  get  into  the 
larynx  and  to  cause  coughing.  The  voice  is  hoarse,  probably  in  con- 
sequence of  paralysis  of  the  crico-thyroid  muscle,  but  the  vocal  cords 
move  as  usual.  In  other  cases  there  is  paralysis  in  the  region  of  the 
inferior  laryngeal  nerve,  and  phonation  may  be  impossible.  The 
laryngoscope  then  shows  immobility  of  the  cords  and  sometimes  a 
preponderant  weakness  of  abduction,  so  that  the  cords  are  not  sepa- 
rated during  inspiration.  In  one  fatal  case,  at  the  end  of  the  first 
week,  swallowing  was  impossible,  and  there  was  complete  motor  and 
sensory  paralysis  of  the  larynx.*  One  vocal  cord  is  seldom  affected 
alone,  but  the  left  was  motionless,  while  only  the  tensors  were  feeble 
in  the  right,  in  a  case  in  which  the  palate  was  paralysed  on  the  left 
side  and  much  weakened  on  the  right. f 

ment  of  Dis.  in  Children,'  p.  515).  Bristowe  has  observed  it  to  persist  during 
paralysis,  and  afterwards  for  a  time  to  disappear,  no  doubt  on  account  of  the  special 
local  variations  in  the  incidence  of  the  toxic  influence. 

*  Caiger,  '  Lancet/  ii,  1889.  f  J.  B.  Ball,  '  Lancet,'  1890. 


906  DIPHTHERITIC   PARALYSIS. 

The  tongue  is  paralysed  only  in  rare  cases.  Paralysis  of  the  face 
is  also  rare,  but  there  is  occasionally  distinct  loss  of  power  on  one 
side,  and  the  lips  are  sometimes  weak.  Very  rarely  there  is  con- 
siderable bilateral  paralysis,  either  of  all  parts  of  the  face,  or  of  the 
lower  portion  only. 

Special  Senses. — Next  to  the  affection  of  the  palate,  both  in  fre- 
quency and  in  time,  is  loss  of  power  of  accommodation  of  the  eye, 
from  paralysis  of  the  ciliary  muscle.  This  is  always  described  by  the 
patient  as  "failure  of  sight,"  but  only  vision  for  near  objects  is 
impaired.  It  has  been  alleged  that  the  ■'  far  point "  is  more  distant 
than  under  normal  circumstances,  but  this  statement  is  probably 
erroneous.*  The  degree  to  which  sight  is  affected  depends  on  the 
refraction  of  the  eyebai.ll,  i.  e.  on  the  degree  to  which  the  power  of 
accommodation  is  habitually  employed.  With  normal  refraction, 
near  vision  is  considerably  interfered  with  ;  the  patient,  for  instance, 
cannot  read,  while  distant  vision  remains  good.  In  hypermetropia 
this  effect  is  still  more  marked ;  while  if  there  is  myopia  vision  may 
suffer  little  or  not  at  all,  because  the  patient  does  not  need  to  accom- 
modate. Before  inferring  the  absence  of  paralysis  from  the  absence 
of  affection  of  sight,  it  is  therefore  necessary  to  ascertain  that  the 
patient  is.  not  myopic.  Both  eyes  are  always  affected,  although  one 
may  suffer  before  the  other.  The  failure  of  accommodation  reaches 
its  height  in  a  few  days,  and  usually  lasts  for  two  or  three  weeks. 
The  action  of  the  pupil  to  light  may  be  sluggish,  but  is  rarely  lost ; 
usually  there  is  contraction  on  an  effort  at  accommodation,  even  when 
no  accommodation  is  possible  ;  but  occasionally  this  associated  action 
is  lost  with  accommodation,  although  the  light-reflex  remains.  The 
external  muscles  of  the  eyeball  are  also  sometimes  affected.  As  the 
ciliary  muscle  is  regaining  power  there  may  be  undue  convergence  on 
accommodation  from  the  increased  voluntary  effort  affecting  the 
internal  recti  in  undue  degree.  The  most  common  palsy  is  weakness 
of  the  internal  recti  conjoined  with  the  paralysis  of  the  ciliary  muscle, 
so  that  the  eyes  tend  to  diverge,  just  as  they  often  do  in  near-sighted 
persons  who  do  not  use  accommodation.  Occasionally  there  is  para- 
lysis of  the  external  recti.  I  have  once  seen  double  ptosis,  and  para- 
lysis of  all  the  muscles  supplied  by  one  third  nerve  has  been  observed. 
In  two  cases,  almost  all  the  muscles  of  both  eyes  became  paralysed. 
In  one  the  right  eye  was  quite  motionless,  and  in  the  left  the  only 
action  was  in  the  external  rectus  ;  the  eyelids  also  drooped :  in  the 
limbs  there  was  ataxy  and  some  loss  of  power.  The  ocular  palsy 
lasted  a  month  (Uhthoff).  In  the  other  case,  all  the  ocular  muscles 
of  both  sides  were  paralysed  and  the  fields  of  vision  were  restricted. 
There  was  also  paralysis  of  palate,  right  side  of  the  face,  and  muscles 
of  the  neck,  and  ataxy  of  the  limbs.  The  patient  died  ;  the  morbid 
appearances  will  be  mentioned  presently.f     I  have  also  seen  a  patient 

*  See  Schmidt- Riui  pier,  '  Berlin,  kiln.  Wochenschr.,'  1884,  No.  7. 
+  Mendel.     For  the  reference  to  these  cases  see  p.  190. 


SYMPTOMS.  907 

who  described,  as  part  of  the  palsy  after  diphthei'ia  at  the  age  of 
twenty-two,  double  vision  and  double  ptosis.  In  four  cases  with 
paralysis  of  some  ocular  muscles,  described  by  Morton,  these  came 
on  four  to  seven  weeks  after  the  diphtheria,  and  lasted  four  to 
twenty-six  weeks.  Sometimes  there  is  slight  paralysis  of  one  or 
another  of  the  ocular  muscles,  varying  from  day  to  day. 

There  is  not  often  any  other  obvious  affection  of  sight  than  that 
which  results  from  the  paralysis  of  accommodation.  Nevertheless  it 
is  probable  that  a  concentric  contraction  of  the  fields  of  vision  is  not 
uncommon  ;  it  is,  as  it  were,  masked  by  the  effect  of  the  cycloplegia, 
and  so  generally  escapes  notice.  An  example  of  it  has  been  published 
by  Jessop,*  and  it  was  present  in  the  case  of  ophthalmoplegia  men- 
tioned above.  It  was  found  by  Herschel  in  no  less  than  five  out  of 
thirteen  cases  of  diphtheritic  cycloplegia  examined. f  No  morbid 
change  has  been  observed  with  the  ophthalmoscope.^ 

Of  the  other  special  senses,  hearing  is  seldom  impaired,  although  a 
case  of  transient  complete  deafness  has  been  recorded  by  Tooth.  §  I 
have  twice  known  the  sense  of  taste  to  be  lost,  and  in  one  instance 
smell  was  impaired,  although  taste  was  normal. 

Limbs. — The  affection  of  the  limbs  succeeds  that  of  the  soft  palate. 
The  loss  of  motor  power  always  comes  on  gradually,  and  varies  much 
in  degree,  but  is  rarely  or  never  absolute.  It  is  usually  bilateral  and 
symmetrical ;  one  side  may  be  affected  more  than  the  other,  but  there 
is  never  limited  hemiplegic  weakness.  The  legs  commonly  suffer 
before  the  arms.  The  muscles  become  flabby  and  toneless ;  the 
common  loss  of  the  knee-jerk  has  been  already  mentioned.  The 
weakness  may  merely  be  sufficient  to  render  the  patient  unduly 
fatigued  with  slight  exertion,  or  it  may  be  such  that  standing  is 
impossible.  When  considerable,  there  is  a  peculiar  gait  that  is  very 
suggestive  ;  the  legs  are  moved  as  if  they  were  at  once  heavy  and 
limp,  and  there  is  not  the  aspect  of  stiffness  so  often  seen  in  spinal 
paraplegia.  If  the  affection  is  slight  there  may  be  no  change  in 
electric  irritability,  but  when  considerable  weakness  has  existed  for 
two  or  three  weeks  there  is  generally  a  diminution  of  irritability  to 
faradisation,  which  may  proceed  to  almost  complete  loss.  The 
muscles  still  respond  to  the  voltaic  current,  and  their  reaction  to  it 
may  be  altered  as  in  ordinary  peripheral  paralysis  (see  vol.  i,  p.  54). 
The  irritability  of  the  nerve-trunks  is  lessened  to  both  faradism  and 
voltaism.     Superficial  reflex  action  is  also  diminished  or  lost. 

In  slight  cases  sensation  may  be  unaffected,  but  it  usually  suffers 
when  the  motor  paralysis  is  severe,  and  occasionally  it  is  impaired 
when  there  is  little  motor  weakness.     Subjective  sensations  of  "  numb- 

*  '  Trans.  Ophth.  Soc.,'  1886. 
t  « Berlin,  klin.  Wochenschrift,'  1883,  No.  30. 

J  Care  must  be  taken  not  to  mistake  for  this  the  hysterical  amblyopia  which,  in 
girls,  sometimes  comes  on  during  diphtheritic  paralysis  (see  p.  909). 
§  '  Brit.  Med.  Journ./  1893. 


9Ud  DIPHTHERITIC    PARALYSIS. 

ness,"  tingling,  "  pins  aud  needles,"  formication,  &c,  and  some- 
times hyperesthesia,  may  precede  diminution,  of  sensibility,  and  are 
often  complained  of  when  there  is  no  actual  loss.  When  this  exists 
it  may  involve  equally  pain  and  touch,  or  tactile  sensibility  alone ;  it 
is  always  greatest  towards  the  extremity  of  the  limbs.  I  have  known 
anaesthesia  to  be  confined  to  the  fingers  and  thumb  of  one  hand,  in  a 
case  in  which  both  tactile  and  painful  sensibility  had  been  lost  over 
both  legs.  Sometimes  the  distribution  of  anaesthesia  is  peculiar  ;  the 
tips  of  the  fingers  may  be  alone  affected.  In  one  patient,  tactile 
sensibility  was  lost  on  the  palms  and  soles  and  preserved  elsewhere, 
even  on  the  dorsal  surfaces  of  the  hands  and  feet.  In  one  case  the 
anaesthesia  of  the  extremities  extended  to  the  middle  of  one,  and  the 
upper  part  of  the  other  forearm,  and  to  the  middle  of  each  thigh.* 
If  there  have  been  pains  in  the  limbs,  the  loss  of  sensation  may 
correspond  to  them  in  position.  Muscular  sensibility  may  also  be 
impaired. 

Often  there  is  clumsiness  or  definite  inco-ordination  of  movement, 
over  and  above  the  weakness,  and  this  may  be  marked  when  there  is 
little  or  no  loss  of  power.  In  some  cases  it  is  associated  with  cuta- 
neous anaesthesia,  but  it  is  certainly  independent  of  this,  since  it  has 
been  observed  when  sensation  was  unaffected.  The  inco-ordination 
may  involve  the  arms  or  legs  or  both.  In  the  legs  the  disorder  may 
closely  resemble  locomotor  ataxy,  for  which,  it  is  occasionally 
mistaken ;  the  anaesthesia  and  absent  knee-jerk  facilitate  the  error. 
Sometimes  in  the  arms  the  disorder  of  movement  resembles  that  of 
general  paralysis  of  the  insane— there  are  slight  irregular  twitching 
movements,  which  may  render  it  difficult  for  the  patient  to  take  hold 
of  an  object. 

The  trv/iik  muscles  are  less  frequently  affected  than  are  those  of  the 
limbs,  but  they  may  become  so  weak  that  the  patient  is  unable  to  turn 
over  in  bed.  The  paralysis  of  the  intercostals  may  interfere  seriously 
with  respiration,  and  unexpelled  mucus  may  accumulate  in  the  bron- 
chial tubes  and  give  rise  to  alarming  paroxysms  of  dyspnoea,  which 
in  children  are  often  excited  by  emotion.  Duchenne  asserted  that 
the  muscles  of  the  bronchial  tubes  are  paralysed  in  these  cases,  but 
the  fact  rests  on  inadequate  evidence,  since  there  is  usually  sufficient 
weakness  of  the  thoracic  muscles  to  explain  the  symptoms.  When 
the  weakness  invades  the  neck  muscles,  the  head  cannot  be  supported, 
and  the  diaphragm  sometimes  ceases  to  act.  The  latter  is  a  grave 
symptom,  and  if  it  supervenes  on,  or  is  quickly  followed  by,  weakness  of 
the  intercostals,  death  usually  follows.  Fortunately,  the  paralysis 
rarely  reaches  its  height  in  the  two  sets  of  respiratory  muscles  at  the 
same  time. 

Symptoms  of  cardiac  failure  are  among  the  most  grave,  but  among 
the  less  common  manifestations  of  the  disease,  and  are  supposed  to 
depend  on  paralysis  of  the  vagus.  Irregularity  of  the  action  of  the 
*  Hallager,  '  Hosp.  Tid.'  and  'Xeur.  Cent.,'  1890. 


SYMPTOMS.  909 

heart  is  not  uncommon  apart  from  graver  cardiac  symptoms.  Of 
these  the  first  indication  is  generally  retardation  of  the  pulse,  which 
may  afterwards  become  unduly  rapid,  and  irregular  or  intermittent. 
In  some  cases,  the  retardation  precedes  the  quickening  of  the  pulse. 
In  either  condition,  fatal  syncope  may  occur.  According  to  Leyden, 
these  symptoms  ought  to  be  ascribed  to  the  degeneration  of  the 
muscular  substance  of  the  heart  l'ather  than  to  true  paralysis  of 
the  pneumogastric  ;  but  it  is  more  probable  that  the  visible  changes 
in  the  cardiac  tissue  are  the  result  of  the  nerve  lesion.  Dyspnoea  and 
irregular  breathing  are  sometimes  associated  with  the  cardiac  sym- 
ptoms, and  have  been  likewise  ascribed  to  an  affection  of  the  vagus. 

The  Madder  is  affected  only  in  very  severe  cases.  There  may  be 
either  retention,  with  or  without  overflow  incontinence,  or  there  may 
be  simple  incontinence.  The  anal  sphincter  seldom  suffers,  but  the 
obstinate  constipation  sometimes  met  with  has  been  ascribed  to  a 
paralysis  of  the  muscular  coat  of  the  intestine.  Loss  of  sexual  power 
is  not  uncommon  in  adult  males.  Symptoms  of  vaso-motor  paralysis 
are  never  met  with,  nor  is  there  any  marked  tendency  to  disturbance 
of  the  nutrition  of  the  skin. 

Complications. — Convulsions  have  been  observed  in  a  few  very 
severe  cases,  in  which  the  paralysis  has  commenced  during  the  course 
of  the  primary  disease.  They  are  to  be  regarded  rather  as  a  compli- 
cation of  the  diphtheria  than  as  part  of  the  paralysis,  and  probably 
result,  in  most  cases,  from  an  organic  cerebral  lesion.  Hysterical 
paralysis,  motor  and  sensory,  occasionally  complicates  a  true  diph- 
theritic palsy  in  those  who  are  predisposed  to  hysteroid  disturbance. 
Hysterical  symptoms  may  also  succeed  the  specific  paralysis.  This 
complication  sometimes  gives  rise  to  much  difficulty  in  diagnosis,  as 
will  be  mentioned  presently. 

Three  other  forms  of  palsy  may  be  associated  with  diphtheria.  In 
the  course  of  this,  as  in  most  other  acute  specific  diseases,  sudden 
hemiplegia  may  indicate  the  occurrence  of  a  vascular  lesion  of  the 
brain,  either  thrombosis,  embolism,  or  a  haemorrhage.  Death  may 
result,  as  in  two  of  three  cases  mentioned  by  Mendel :  in  one  of 
these  a  post-mortem  examination  showed  a  small  haemorrhage,  the 
size  of  a  cherry-stone,  damaging  the  internal  capsule.*  The  para- 
lysis is  often  permanent. 

Secondly,  diphtheritic  paralysis  may  be  accompanied  by  the  rapid 
paralysis  of  the  whole  of  one  cranial  nerve,  differing  in  its  isolation 
and  rapidity  from  the  ordinary  palsy,  and  such  paralysis  may  be  per- 
manent. Paralysis  of  the  muscles  of  mastication,  so  that  the  jaw 
could  not  be  raised,  followed  ordinary  diphtheritic  paralysis  in  a  boy 
of  twelve,  and  was  unchanged  fourteen  months  afterwards. f  Such 
an  affection  is  probably  due  to  an  acute  nuclear  inflammation. 
*  eNeur.  Centralbl.,'  1885,  p.  133. 
f  Dundas  Grant,  Brit.  Laryngol.  Association,  Dec,  1892. 


910  DIPHTHERITIC    PARALYSIS. 

Thirdly,  some  time  after  diphtheria,  and  usually  after  the  ordinary 
palsy,  the  symptoms  of  slow  degeneration  of  certain  cranial  nerves 
may  develop  aud  gradually  increase  during  many  months.  In  one 
case,  weakness  of  the  lips,  tongue,  and  pharynx  had  thus  developed, 
together  with  partial  external  and  internal  ophthalmoplegia  and 
primary  atrophy  of  the  optic  nerves.  In  each  seat  the  symptoms 
became  stationary  before  they  were  complete,  and  remained  unchanged. 
In  another  case,  a  woman  of  forty,  sight  began'  to  fail  six  months 
after  diphtheria,  and  was  almost  lost  at  the  end  of  another  year. 
Two  and  a  half  years  after  the  primary  disease  there  was  grey 
atrophy  of  both  discs,  left  internal  ophthalmoplegia,  and  weakness  of 
some  of  the  movements  of  both  eyeballs,  especially  upwards. 

Albuminuria  is  very  common  in  diphtheritic  paralysis,  usually  per- 
sisting from  the  primary  disease.  In  severe  cases,  that  are  quickly 
fatal,  it  is  seldom  absent. 

Coiirse  and  Duration. — Diphtheritic  paralysis  varies  extremely  in 
its  extent,  severity,  and  course.  Motor  and  sensory  symptoms  may 
lead  the  way.  In  a  case  very  carefully  observed  by  the  sufferer,  a 
German  physician,  tingling  and  formication  were  followed  by  anaes- 
thesia, and  this  by  motor  weakness  and  ataxy,  and  the  symptoms 
passed  away  in  the  opposite  order.*  In  some  cases  the  palsy  is 
limited,  slight,  and  transient.  In  others,  region  after  region  is 
successively  attacked ;  the  parts  which  suffer  first,  as  the  palate  and 
eye,  may  recover  before  the  limbs  are  involved  ;  and  when  these  are 
improving,  and  a  speedy  convalescence  is  hoped  for,  paralysis  of  the 
trunk  and  respiratory  muscles  may  come  on  and  throw  the  patient 
into  extreme  danger.  Irregular  waves  of  palsy  seem  to  flow  through 
the  body,  sometimes  quickly,  sometimes  slowly,  and,  determined  as  it 
is  by  influences  that  we  cannot  discern,  its  course  can  never  be  fore- 
told. As  a  rule,  however,  the  palsy  does  not  return  in  a  part  which 
it  has  once  left,  and  when  local  improvement  has  set  in  it  usually 
continues,  although  other  parts  may  become  weaker.  It  has  been 
said  that  when  the  paralysis  commences  before  the  primary  disease  is 
over,  its  course  from  one  part  to  another  is  slow  and  often  discontin- 
uous, but  when  it  commences  some  time  after  the  primary  disease  it 
exhibits  a  much  slighter  tendency  to  remission  (Saune).  To  this 
rule,  however,  the  exceptions  are  very  numerous.  In  fatal  cases 
death  often  occurs  early,  even  within  the  first  week  from  the  onset. 
Sir  William  Jenner  has  pointed  out  that  in  the  most  severe  and 
serious  cases  the  interval  between  the  primary  disease  and  the  onset 
of  the  -palsy  is  usually  short.  But  the  paralysis  has  developed 
rapidly  and  in  severe  degree,  so  as  to  cause  death  within  a  week,  in 
cases  in  which  it  commenced  a  month  after  the  primary  disease 
was  over. 

The  total  duration  of  the  paralysis,  both  general  and  local,  varies 

*  Hausemaim,  *  Virehow's  Arcliiv,'  Bd.  pxv. 


PATHOLOGICAL   ANATOMY.  911 

according  to  its  extent,  but  is  generally  from  six  to  eight  weeks  in 
cases  that  recover.  A  local  paralysis  lasts  longer  if  other  parts  are 
affected  than  if  it  is  the  only  manifestation  of  the  disease.  When  the 
palate  alone  is  affected,  it  usually  recovers  in  two  or  three  weeks ;  but 
if  the  limbs  also  suffer,  the  paralysis  of  the  palate  may  last  a  much 
longer  time.  Loss  of  power  in  the  limbs  always  endures  longer  than 
the  affection  of  the  palate  or  eye ;  it  rarely  passes  away  in  less  than 
two  months,  and  may  last  for  four  or  six  months.  When  definite 
improvement  has  commenced,  it  often  proceeds  rapidly,  although  the 
paralysis  may  have  been  severe  and  of  long  duration.  Thus,  in  one 
case,  paralysis  of  the  limbs  commenced  in  the  seventh  week,  slowly 
increased  until  the  twelfth  week,  remained  almost  complete  until  the 
twentieth  week,  when  improvement  commenced,  and  in  four  weeks 
more  all  trace  of  weakness  had  passed  away.  As  power  is  regained, 
the  electric  irritability  of  the  muscles  becomes  normal.  The  loss  of 
the  knee-jerk  is  the  last  symptom  to  pass  away,  and  often  continues 
for  several  weeks  after  good  power  has  been  regained.  Ultimate 
recovery  is  almost  always  perfect.* 

Death  may  occur  during  the  course  of  the  paralysis  from  other 
sequelae  of  the  primary  disease,  especially  from  renal  mischief.  The 
palsy  is  fatal  chiefly  by  three  mechanisms.  (1)  Syncope  from  para- 
lysis of  the  heart.  (2)  Asphyxia  from  paralysis  of  the  muscles  of 
respiration.  (3)  Exhaustion  in  consequence  of  inability  to  take 
sufficient  food,  due  to  paralysis  of  the  pharynx,  or  to  the  anorexia,  and 
to  the  repugnance  to  food  produced  by  the  liability  for  it  to  get  into 
the  larynx.     The  third  mechanism  is  effective  especially  in  children. 

Pathological  Anatomy. — The  brain,  spinal  cord,  and  nerves  pre- 
sent, as  a  rule,  no  morbid  appearances  to  the  naked  eye  beyond  a 
variable  amount  of  hyperaemia  or  minute  extravasations  into  their 
substance.  Very  rarely  larger  foci  of  haemorrhage  are  met  with  in 
the  brain.  In  one  acute  case,  extravasation  existed  between  the  crura, 
together  with  many  minute  haemorrhages,  and  extensive  "  diapedesis  " 
of  the  red  corpuscles.f  Such  a  condition  suggests  that  the  intensity 
of  the  poison  had  caused  acute  degeneration  of  the  walls  of  the  vessels. 
Meningitis,  with  scattered  spots  of  exudation  around  the  spinal  cord 
and  medulla  oblongata,  was  found  by  Pierret  in  one  case,  but  in  this 
the  symptoms  were  different  from  those  of  ordinary  diphtheritic  para- 

*  In  extremely  rare  cases  some  part,  as  the  palate,  has  not  recovered,  and  other 
paralyses  have  developed  aud  persisted,  apparently  due  to  chronic  disseminated 
myelitis.  In  one  child  a  form  of  irregular  bulbar  paralysis  (lips  and  palate)  deve- 
loped after  diphtheritic  paralysis  at  four,  and  persisted  at  eleven  (Stadthagen, 
'  Archiv  f.  Kiuderh.,5  Bd.  v).  I  have  seen  one  patient  in  whom,  a  year  after  the 
diphtheria,  and  when  all  other  symptoms  had  long  ceased,  there  was  considerable 
defect  of  power  in  the  muscles  moving  the  left  foot,  with  diminution  of  faradic 
irritability. 

t  Kraus,  'Neur.  Cent.,'  1888. 


912 


DIPHTHERITIC   PARALYSIS. 


I 


■ 


I- 


lysis,  and  death  occurred  on  the  second  day.     In  the  ordinary  form 

of  palsy  the  membranes  are  always 
healthy,  except  that  there  may  be 
signs  of  congestion,  and  even,  in  some 
cases,  haemorrhage  about  the  nerve- 
roots.*  Nor  are  changes  found  in 
other  organs  with  the  exception  of  the 
heart;  when  death  occurs  with  sym- 
ptoms of  cardiac  paralysis,  the  sub- 
stance of  the  heart  may  be  pale  from 
degeneration  of  the  muscular  fibres. 

The  true  pathological  anatomy  of 
the  disease  is  revealed  only  by  the 
microscope.  The  muscles  have  some- 
times been  found  normal;  in  other 
cases,  especially  those  of  long  dura- 
tion, granular  and  fatty  degeneration 
1  .■  of  the  fibres  has  been  found,  variable 

in  degree,  even  in  the  same  part  of 

Fig.    164. — Diphtheritic    paralysis,   the  muscle  and  in   different  parts  of 

SSt  17^X»Z  ™a  «* sa™  fibre  (Fi«- 1«*)-.  This  <*«w 

fatty  degeneration.  is  usually  most  intense  in  the  palate, 

bnt  has  been  found  also  in  the 
muscles  of  the  limbs.  In  some 
cases,  however,  notably  in  a 
series  of  four,  presumably  ob- 
served in  one  epidemic,  the 
paralysed  muscles  presented  the 
signs  of  intense  parenchymatous, 
and  iuterstitial  inflammation 
and  degeneration  ;  in  those  that 
Fig.   165. — Changes  in  the  fibres  of  the  were  only  weak  the  changes  were 

??5f  iorJoots>  P^p-carmine  preparation,  slighter,    while   in    the    nerves 
(After   Meyer,   « Virchow's   Archiv,'   Bd.        ^  \  -,■-,, 

lxxxv.)  and   centres  no  morbid  change 

a.  Overgrowth  of  the  protoplasm  and   could  be  detected.f 

nuclei  of  the  sheath;  the  axis-cylinder  is        x      almost  ill  rases  dpwnpra 
continuous,  although  the  medullary  sheath      .  in    aimost  ali  cases  aegeneia- 
is  interrupted  for  a  short  distance.  tion  is  found  in  the  nerves  going 

b.  Accumulation  of  granule  masses,  in  to  the  paralysed  parts,  either 
places  interrupting  the  axis-cy Under,  frag-  .  ,,  .  -,  ■,  r.  A, 
ments  of  which  can  be  seen  between  the  1D  tne  peripheral  parts  ot  the 
globules  of  myelin.  nerves  or  in  their  whole  extent, 
*&?££.  ££  SSdXSSH  even  including  the  aateriorr00ts, 
the  axis-cylinder  only  covered  with  the  and,  in  rare  cases,  the  posterior 
thickened  sheath.                                      roots.  J      The   change   not  only 

corresponds  to  the  palsy  in  distribution,  but  is  proportioned  to  it  in 


Buhl,  '  Zeitsch.  f.  Biol./  1867,  p.  359.        f  Hochhaus,  'Virch.  Archiv,'  Bd.  cxxiv. 
%  Arnheim,  'A.  f.  Kinderheilk.,'  xiii. 


PATHOLOGICAL   AXATOMY. 


913 


degree.     It  consists  (see  Fig.  165)  in  segmentation  and  breaking  up  of 
the  white  substance  of  the  nerve-fibres,  sometimes  a  multiplication  of  the 
nuclei  of  the  sheath,  and  an  accumulation  of  granule  corpuscles  among 
the  remains  of  the  fibres.      The  axis-cylinders  usually  persist,  except 
where  the  destruction  of  the  medullary  sheath  is  most  advanced,  and 
there  they  may  be  interrupted,  and  in  some  cases  they  have  even  disap- 
peared from  the  peripheral  parts   of  many  fibres.     There  is  not,  as 
a  rule,  any  inflammatory  change  in  the  interstitial  tissue  of  the  nerves, 
and  the  primitive  sheath  is  generally  unchanged.     The  alterations  are 
very  conspicuous  in  the  nerves  of  the  palate,  where  they  were  dis- 
covered by  Charcot  and  Yulpian  in  1862,  and  to  these  nerves  it  was 
thought  the  change  was  confined,  until  it  was  found  in  the  anterior 
spinal  roots  by  Buhl  in  1867,  and  in  the  phrenic  nerve  by  Louville  in 
1872  ;  but  the  wide  extent  of  the  change,  and  its  correspondence  with 
the  position  and  degree 
of    the    paralysis,    were 
only     demonstrated     by 
Dejerine  in  1878.*     The 
alteration   (which  can  be 
best  revealed  by  treating 
recent     specimens    with 
osmic     acid)      is     thus 
limited,  as  a  rule,  to  the 
nerve-fibres.    It  is  essen- 
tially the  same  as  occurs 
in    simple    degeneration 
of  nerves,  and  is   often 
described  as  "parenchy- 
matous neuritis."     It  is 
the    more     marked    the 
longer  the  paralysis  has 
lasted.   It  has  even  been 
found  (in  one  series)  in  all 
the  cranial  nerves,  except 
the  first,  second,  seventh, 
and  eighth. f   Interstitial 
multiplication  of  nuclei  has  been    seldom   observed,  except  in   the 
nerves  of  the  palate,  but  it  was  present  in  the  case  of  ophthalmo- 
plegia mentioned  on  a  preceding  page;    the   nerves  to  the  eyeball 
muscles  presented  indications  of  interstitial  inflammation,  as  well  as 
the  acute  degenerative   changes  in  the  fibres  themselves.     Minute 
haemorrhages  were  found  in  the  sixth  nerves.     In  one  exceptional 
case,  Meyer  found   nodular  swellings  of  various   nerves,  formed  by 
cellular  elements  which  separated  the  nerve-fibres  (Fig.  166,  lowest 
figure) . 

*  Since   corroborated   by  Meyer,  Gaucher,  Arnheiin,  Martin,  and   many    other 
observers.  f  Avuheim,  loc.  cit. 

VOL.  11.  ^o 


Fig.  166. — Interstitial  and  parenchymatous  changes 
in  the  phrenic  nerve :  osmic  acid  preparations. 
(After  Meyer,  loc.  cit.) 

The  three  separate  fibres  show  degeneration  of 
the  nerve-fibres  (segmentation  of  the  myelin, 
&c),  with  some  increase  of  the  nuclei. 

The  lower  group  of  fibres  is  from  one  of  the 
nodular  swellings  on  the  same  nerve,  and  shows, 
in  addition  to  the  degeneration  of  the  fibres, 
considerable  increase  in  the  interstitial  tissue. 


914 


DIPHTHERITIC    PARALYSIS. 


If  the  elements  of  the  spinal  cord  are  treated  with  osmic  acid  in  the 
recent  state,  the  motor  cells  are  sometimes  found  in  a  state  of  intense 
granular  and  fatty  degeneration,  such  as  is  shown  in  Fig.  167.     In  the 

hardened  spinal  cord  the  white 
columns  are  always  normal,  and 
in  many  cases  no  change  has 
been  found  in  the  grey  substance. 
In  others,  however,  the  motor 
nerve-cells  of  the  anterior  cornua 
have  been  found  altered,  either 
swollen,  and  unduly  homogeneous 
or  vitreous  in  aspect,  or  smaller 
than  normal,  and  often  with 
shrunken  processes.*  In  rare  in- 
stances collections  of  nuclei  have 
been  found  in  the  grey  substance. 
Of  other  changes  which  have  been 
described,  the  significance  is  very 
doubtful ;  such  are  "  rarefaction 
of  the  grey  substance  "  (Vulpian) 
and  an  increase  of  nuclei  around 
the  central  canal,  often  filling  up  its 
ve-cells  from  the  lumen — an    appearance  frequently 


f 


"% 


i 


...A 


^& 


Fig-.  167. — Motor  ner 


anterior  cornu  of  the  spinal  cord  in  a  seen    in    cords    from  healthy   sub- 
fatal    case    of    diphtheritic    paralvsis. 
Recent  preparation  treated  with  osmic 


fatal   case   of   diphtheritic   paralvsis.  ^  ^  which   .g  probablj  with 


acid. 


in    this   or    air 


out   significance 

other  disease. 
As  a  rule,  no  organisms  can  be  found  in  the  nerve-centres, 
although  accumulations  of  micrococci  in  the  vessels  were  described 
by  Oertel.f  and  of  rod-shaped  bacteria  by  Klebs.J  A  remarkable  case 
has  been  described  by  Buhl,§  in  which  the  nerve-sheaths,  &c,  were  in- 
filtrated with  bodies  described  as  like  those  in  the  false  membrane. 
In  this  case  there  were  also  numerous  infai-cts  in  the  brain,  as  if  from 
extensive  vascular  obstruction. 


Pathology. — The  alterations  in  the  nerves  agree  perfectly  with  the 
indications  afforded  by  the  electrical  reactions  in  severe  cases.  ||     There 

*  Vulpian,  'Mai.  du  Syst.  Nerv.,'  1878;  Dejerine,  'Gaz.  des  Hop.,'  1880,  No.  42; 
Abercrombie,  'Trans.  Internat.  Med.  Congress,'  1881;  Percy  Kidd,  'Med.-Chir. 
Trans.,'  1883;  Sharkey,  'Brain,'  1890.  Kidd  observed  extensive  vacuolation  of  the 
cells.  The  probable  significance  of  this  change  has  been  already  mentioned;  it 
seems  to  occur  in  cells  the  nutrition  of  which  is  gravely  altered.  Kidd's  figures  of 
the  vacuolated  cells  are  almost  exactly  like  those  found  by  Sankey  and  myself  in  the 
dog  in  chorea  ('Med.-Chir.  Trans.,'  1879). 

t  '  Ziemsseu's  Handb.,'  ii,  1876,  p.  608. 

X  Eulenburg's  'Real-Eucyclop.,'  iv,  p.  167.  §  'Zeitsch.f.  Biol.,'  1867. 

||  The  significance  of  the  electrical  reactions  was  pointed  out  as  long  ago  as  1866 
by  Ziemssen  ('  Berl.  kl.  Woehenschrift,'  1866,  Nos.  43  and  44). 


PATHOLOGY.  915 

is  the  loss  of  fafadic  irritability  which,  always  indicates  degeneration  of 
the  nerve-fibres,  and  the  persistence  of  voltaic  irritability  which  shows 
that  the  muscular  tissue  still  preserves  its  contractile  power.  The 
alterations  in  the  nutrition  of  the  muscular  fibres,  sometimes  found, 
are  those  that  may  occur  in  other  forms  of  nerve  degeneration  and 
neuritis,  and  correspond  to  this  also  in  their  inconstancy  and  variations.* 
In  such  cases  it  is  probable  that  the  muscular  changes  are  purely 
secondary  to  those  of  the  motor  nerve-fibres.  But  in  other  cases  it 
would  seem  as  if  the  cause  of  the  palsy  had  acted  solely  on  the 
muscles,  since  changes  were  found  in  these  alone  (see  p.  912). 

The  degeneration  of  the  nerve-fibres  is  certainly,  in  most  cases,  in- 
dependent of  any  alteration  of  the  cells  of  the  spinal  cord ;  it  is  most 
intense  at  or  near  the  periphery,  extending  upwards  for  a  variable  dis- 
tance, and  thus  it  agrees  with  the  alterations  so  often  found  in  cases  in 
which  a  primary  degenerative  neuritis  has  resulted  from  the  influence  of 
a  toxic  agent.  But  in  other  cases  considerable  change  in  the  nerve-roots 
has  been  associated  with  slighter  but  unequivocal  alterations  in  the 
motor  cells  of  the  spinal  cord.  A  transient  and  slight  lesion  of  the 
eells  often  causes  a  greater  degeneration  in  the  fibres,  but  the  fact 
that  perfect  recovery  and  regeneration  of  the  nerves  occurs  in  diph- 
theritic paralysis,  shows  that  its  cause  cannot  be  an  actually  destructive 
alteration,  and  its  peripheral  intensity  shows  that  it  is  there  in- 
dependent of  changes  in  the  cells. 

Thus  the  facts  of  pathological  anatomy  show  that  the  motor  palsy  de- 
pends essentially  on  acute  alterations  in  the  nutrition  (revealed  by 
changes  in  the  structure)  of  the  lower  segment  of  the  motor  path  (see 
vol.  i,  p.  176),  essentially  "parenchymatous,"  beginning  in  the  nerve- 
elements  themselves,  although  vascular  disturbance  may  be  associated 
with  it,  as  it  so  often  is  with  various  acute  derangements  of  nutrition. 
But  the  facts  also  show  that  the  three  motor  structures,  the  nerve-cells, 
the  fibres,  and  the  muscles,  suffer  in  various  degrees.  The  affection 
of  the  fibres  is  by  far  the  most  frequent ;  that  of  the  cells  is  slighter, 
inconstant,  and  independent;  that  of  the  muscles  is  usually  moderate 
and  secondary  to  that  of  the  nerves,  but  occasionally  is  primary, 
intense,  and  almost  or  quite  isolated.  To  the  rule  that  the  neuritis 
is  not  interstitial,  one  frequent  exception  should  be  noted,  that 
of  the  nerves  of  the  palate.  The  palatine  nerves  are  contiguous 
to  the  inflammation  of  the  primary  disease,  and  it  is  probable  that 
they  are  influenced  by  the  abundant  growth  of  organisms  in  the 
false  membrane,  which  often  penetrate  into  the  substance  of  the 
mucous  membrane,  and  even  into  the  tissue  beneath.  Interstitial 
inflammation  may  ascend  nerves,  although  the  purely  parenchymatous 
neuritis  only  descends  them  ;  hence  it  is  not  surprising  that  the  pala- 
tine nerves  should  sometimes  present  evidence  of  inflammation  through 
a  considerable   extent.      Their   affection  was   long   held  to  be  the 

*  Occasionally  in  injuries  to  nerves  or  in  disease  of  the  anterior  grey  matter  of 
the  cord,  the  muscular  fibres  present  very  intense  granular  and  fatty  degeneration. 


916  DIPHTHEEITIO    PAEALYS1S. 

mechanism  by  which,  the  whole  of  the  nervous  lesion  was  produced. 
It  was  thought  that  the  inflammation  ascends  these  nerves  to  the 
centre,  and  there  spreads.  But  the  discovery  of  the  lesion,  and  the 
demonstration  that  it  is  as  discontinuous  as  the  palsy,  have  rendered 
the  theory  chiefly  of  historical  interest,  although  it  has  been  even 
lately  maintained  that  palatine  anaesthesia  may  be  caused  by  the 
compression  of  the  nerves  by  inflammatory  products. 

The  special  susceptibility  of  the  palate  is  not.  however,  altogether 
explained  by  the  fact  that  the  local  inflammation  may  extend  to  the 
sheaths  of  the  palatine  nerves.  A  considerable  time  usually  inter- 
venes between  the  primary  angina  and  the  palsy  of  the  palate,  and  the 
latter  may  be  the  first  symptom  of  the  palsy  that  follows  diphtheria 
of  a  surface  wound,  when  the  throat  affection  is  altogether  wanting. 
From  this  it  is  evident  that  there  is  a  special  susceptibility  of  the- 
centres  or  nerves  of  the  palate.  If  this  is  true,  it  becomes  a  question 
whether  the  local  inflammation  has  as  much  to  do  with  the  occurrence 
of  palsy  of  the  palate  as  the  state  of  its  nerves  would  suggest.  The 
peculiar  influence  of  some  poisons  on  certain  parts  of  the  nerve- 
centres  is  well  known,  and  is  illustrated  in  this  disease  by  the  para- 
lysis of  accommodation — a  phenomenon  as  remarkable,  if  not  more 
remarkable,  than  the  paralysis  of  the  palate.  The  lesion  underlying 
the  cycloplegia  has  not  yet  been  discovered,  and  we  do  not  know 
whether  it  is  central  or  peripheral.  In  the  association  of  the  changes 
in  the  medulla,  in  hydrophobia,  with  the  affinity  of  the  virus  for  the 
salivary  gland,  we  have  a  peculiar  and  significant  central  and  peri- 
pheral correspondence. 

The  impairment  of  sensation  is  certainly  due,  in  many,  and  probably 
in  most  cases,  to  the  degeneration  of  the  sensory  nerve-fibres. 
Whether  an  affection  of  the  nerve-cells  of  the  cord,  in  which  the 
fibres  end,  co-operates  in  producing  the  symptom  we  do  not  know.. 
It  is  not  improbable,  but  the  evidence  on  which  such  a  central  cause 
of  anaesthesia  has  been  assumed  (even  recently)  is  invalid.  It  is  the 
symmetry  and  limitation  of  the  loss,  in  such  cases  as  that  in  which  it 
involved  only  the  palms  and  soles.  Peripheral  fibres  possess  a  sus- 
ceptibility related  to  their  position,  which,  alike  mysterious  and  certain,, 
gives  rise  to  a  distribution  of  symptoms  suggestive  of  a  central 
disorder.  It  is  possible,  indeed,  that,  as  is  certainly  the  case  with 
the  motor  structures,  the  central  and  peripheral  sensory  elements  may 
possess  a  corresponding  local  instability  of  resistance  to  the  action  of 
a  special  virus. 

The  isolated  loss  of  the  knee-jerk  may  be  due  to  impairment  of  the 
motor  cells  or  fibres ;  when  there  is  actual  palsy,  the  motor  lesion 
affords  an  ample  explanation  of  the  loss,  since  the  symptom  would 
certainly  result  from  the  structural  changes  discovered  in  these  cases. 
An  alternative  explanation  of  the  isolated  loss  is  that  there  is  an 
affection  of  the  sensory  muscle-nerves  analogous  to  that  which 
probably  causes  the  symptom  in  tabes  (see  vol.  i,  p.  428).     Distinct- 


DIAGNOSIS.  917 

muscular  anaesthesia  has  been  observed  in  diphtheritic  palsy,  and  an 
affection  of  these  nerves,  or  of  their  central  cells,  is  the  probable 
explanation  of  the  ataxy  that  is  sometimes  so  conspicuous.  According 
to  this  theory,  the  resemblance  between  post-diphtheritic  ataxy  and 
the  condition  of  the  tabetic  patient  is  more  than  superficial,  since  the 
inco- ordination  of  tabes  is  chiefly  due  to  an  affection  of  these  nerves. 
The  relation  of  diphtheritic  paralysis  to  the  primary  disease  is  a 
subject  on  which  recent  investigations  have  thrown  much  light, 
direct  and  indirect.  Such  changes  as  underlie  the  symptoms  bave 
always  been  found,  when  their  cause  could  be  ascertained,  to  be  due 
to  the  action,  on  the  structures,  of  a  poison  circulating  in  the  blood. 
It  is  thus  brought  into  contact  with  the  nerves,  of  which  some  are 
especially  susceptible  to  its  influence.  Of  this  many  instances  have 
been  adduced  ("  Multiple  Neuritis,"  in  vol.  i).  The  poison  seems  to  be, 
as  a  rule,  a  chemical  substance,  and,  when  due  to  a  specific  disease,  is 
produced  by  the  organisms,  directly  or  indirectly.  Very  clear  proof 
of  this  has  been  furnished  in  the  case  of  tetanus,  and  a  similar,  if 
less  complete  proof,  in  the  case  of  diphtheria,  bas  been  supplied  by 
the  important  investigations  of  Martin.*  He  finds  that  an  albuminose 
is  present  in  the  blood  in  diphtheria  which,  injected  into  rabbits, 
causes  not  only  the  same  symptoms,  but  also  the  same  nerve  lesions 
as  are  met  with  in  diphtheritic  palsy  in  man.  He  believes  that  it  is 
not  due  directly  to  the  bacilli  of  diphtheria,  but  that  these  produce  a 
ferment,  which  acting  on  proteids  in  the  tissues,  especially  in  the 
spleen,  convert  them  into  the  toxic  albuminose.  It  is  probable,  bowever, 
that  more  facts  have  yet  to  be  discovered  regarding  the  "toxine." 
The  differences  in  the  structure  that  suffers  in  different  cases  of 
paralysis,  and  perhaps  in  different  epidemics,  suggest  that  the 
material  varies  in  precise  character  and  action,  and  that  more  than 
one  may  be  formed,  as  in  the  case  of  tetanus. f  Moreover  other 
varieties  in  the  agents  may  occasionally  exist,  and  may  explain  such 
facts  as  the  remarkable  series  recorded  by  Boissarie.J  In  a  certain 
district  of  Paris  there  occurred  a  series  of  cases  of  severe  diphtheria, 
a,ud  at  the  same  time  a  series  of  cases  of  paralysis  of  the  palate 
eyes,  limbs,  heart,  &c,  perfectly  like  that  which  occurs  after  diph- 
theria, and  accompanied  by  albuminuria.  The  remarkable  fact  is  that 
in  these  cases  of  primary  palsy,  there  was  no  history  of  preceding 
sore  throat,  and  in  several  of  the  cases  distinct  diphtheria  followed 
the  paralysis,  which  lessened  during  the  throat  affection.  Some  of 
tbe  cases  of  primary  palsy  seemed  distinctly  to  arise  by  infection. 

Diagnosis. — A  definite  attack  of  diphtheria,  and  the  characteristic 
onset  of  the  subsequent  paralysis,  render  the  diagnosis  as  a  rule  a 

*  S.  Martin, '  Gulstonian  Lectures,'  1892. 

+  Martin  assumes  that  the  bacilli  of  diphtheria  do  not  enter  the  blood,  but  organ- 
isms have  been  occasionally  found,  as  we  have  seen,  in  the  nerve-structures. 
I  '  Gaz.  Hebd.,'  1881,  Nos.  20  and  21. 


918  DIPHTHEEITIC    PARALYSIS. 

simple  matter.  It  is  only  when  the  nature  of  the  preceding  disease 
has  escaped  recognition  that  any  real  difficulty  occurs.  It  must  be 
remembered  that  an  offensive  discharge  from  the  nose  is  Sometimes 
the  chief  indication  of  diphtheria.  But  the  onset  by  an  affection  of 
the  throat  and  eye,  and  the  subsequent  progressive  paralysis  in  the 
limbs,  are  so  distinctive  as  to  indicate  at  once  the  nature  of  the 
symptoms,  and  often  also  that  of  the  preceding  sore  throat.  In  most 
cases  of  this  character  in  which  a  mistake  is  made  there  has  been  a 
considerable  interval  between  the  throat  affection  and  the  palsy.* 
Greater  difficulty  is  preseuted  by  those  cases  in  which  little  attention 
has  been  paid,  not  only  to  the  primary  disease,  but  also  to  the  early 
symptoms,  which  may  pass  away  before  the  limbs  become  affected. 
In  such  a  case  the  later  symptoms  may  be  ascribed  to  a  primary 
disease  of  the  spinal  cord.  The  absent  knee-jerk  and  iuco-ordination 
may  simulate  locomotor  ataxy,  or  the  weakness  may  be  mistaken  for 
simple  paraplegia,  or  the  wasting  be  ascribed  to  a  subacute  polio- 
myelitis. An  important  distinctive  feature  is  the  manner  in  which 
the  weakness  spreads  slowly  from  one  part  to  another,  often  lessening 
in  the  part  first  attacked.  In  such  cases  careful  inquiry  will  gene- 
rally elicit  a  history  of  transient  difficulty  in  swallowing  and  in  read- 
ing, commencing  not  long  after  a  sore  throat.  The  change  in  elec- 
trical irritability  is  usually  much  slighter  than  in  acute  atrophic 
paralysis,  while  in  the  latter  there  is  no  affection  of  sensation,  and 
there  is  a  more  sudden  onset.  The  onset  of  diphtheritic  paralysis 
is  more  rapid  than  is  common  in  ataxy,  from  which  also  the  marked 
weakness  and  the  absence  of  much  pain  help  to  distinguish  it.  In 
simple  spinal  paraplegia  the  knee-jerk  is  usually  excessive,  and  it  is 
never  absent  unless  there  is  marked  wasting  or  anesthesia  in  the  thigh.. 
It  is  not  often  that  there  is  any  difficulty  in  distinguishing  between 
diphtheritic  paralysis  and  hysteria.  The  affection  of  the  palate,  almost 
invariable  in  the  former,  is  never  met  with  in  the  latter  disease.  A. 
difficulty  is  sometimes  occasioned  by  the  fact  that  a  true  diphtheritic 
paralysis  may  be  succeeded  by  hysterical  palsy  or  accompanied  by 
other  hysterical  symptoms.  Thus,  in  one  case,  paralysis  of  the  palate 
and  ciliary  muscle  had  ceased,  but  was  succeeded  by  general  loss  of 
power  and  of  sensation,  supposed  also  to  be  diphtheritic.  The  girl 
was  lying  in  bed  almost  motionless,  with  universal  anaesthesia  and 
convergent  strabismus  from,  it  was  assumed,  paralysis  of  both  sixth 
nerves.  Under  emotional  excitement,  however,  the  limbs  could  be 
moved  with  considerable  force.  The  anesthesia  was  universal  in 
extent,  a  most  unusual  symptom  in  diphtheritic  paralysis.  Moreover, 
the  eyes  could  be  moved  to  right  and  left,  but  the  convergence  was 

*  Thus  a  young  man  came  to  me  with  distinct  symptoms  of  diphtheritic  para- 
lysis, the  nature  of  which  had  not  been  recognised.  He  had  lost  a  brother  from 
diphtheria  three  months  before,  and  the  patient  himself  had  suffered  from  a  sore 
throat  ten  days  hefore  his  brother  was  taken  ill.  He  had  not  seen  a  doctor,  con- 
sidering: that  such  affections  "  were  better  left  alone." 


PROGNOSIS.  919 

maintained  during  the  movement  and  was  thus  clearly  due  to  con- 
siderable spasm  of  the  internal  recti ;  all  the  symptoms  passed  away 
after  a  few  days'  "moral  treatment."  In  such  cases  the  knee-jerk 
may  give  important  guidance.  Thus  a  girl  presented  herself  with 
weakness  of  the  left  leg,  and  anaesthesia  of  both  leg  and  arm,  sym- 
ptoms that  had  existed  since  an  attack  of  diphtheria  six  months 
before.  There  was  also  loss  of  accommodation  and  of  converg- 
ence. The  latter  were  no  doubt  diphtheritic,  but  the  knee-jerk  in 
the  leg  was  normal,  and  this  made  it  probable  that  the  weakness  and 
the  anaesthesia  were  purely  functional — an  opinion  confirmed  by  the 
previous  history  of  the  patient  aud  the  subsequent  progress  of  the 
case.  She  had  had  a  similar  transient  hemiplegic  attack  two  years 
before,  and  faradism  removed  the  palsy  in  a  few  days. 

The  Prognosis  in  diphtheritic  paralysis  is,  on  the  whole,  good  in 
cases  of  deliberate  onset,  so  long  as  there  is  not  grave  exhaustion 
from  the  preceding  disease,  evidence  of  cardiac  paralysis,  weakness  of 
the  muscles  of  respiration,  or  inability  to  take  food.  In  each  of  these 
conditions  there  is  danger.  Considerable  retardation  in  the  heart's 
action  is  also  a  very  serious  symptom,  and  so  is  extreme  frequency  or 
irregularity.  The  failure  of  respiratory  power  is  most  grave  when 
both  the  intercostal s  and  the  diaphragm  become  weak  at  the  same 
time  ;  the  amount  of  mucus  accumulating  in  the  chest  is  an  accurate 
indication  of  the  degree  of  danger.  Paralysis  of  the  vocal  cords  is 
rarely  a  cause  of  death,  because  it  is  usually  incomplete,  but  paralysis 
in  the  region  of  the  superior  laryngeal  nerve  is  serious,  because  it  is 
so  often  associated  with  pharyngeal  paralysis ;  food  readily  enters  the 
insensitive  opening  to  the  larynx,  and  may  thus  cause  great  distress, 
and  even  reach  the  lungs  and  set  up  a  form  of  pneumonia.  Paralysis 
of  the  muscles  of  the  neck  is  a  rather  grave  symptom,  because  paralysis 
of  the  diaphragm  and  pharynx  so  often  occur  in  conjunction  with  it. 
The  sooner  the  paralysis  comes  on  after  the  primary  disease,  and  the 
more  rapidly  it  develops  to  severe  degree,  the  greater  is  the  danger 
to  life. 

The  duration  of  an  attack  is  difficult  to  foretell.  As  a  rule,  the  more 
severe  the  palsy,  the  longer  will  it  last.  If  the  paralysis  of  the  palate 
is  considerable  and  lasts  some  weeks,  it  is  improbable  that  the  limbs 
will  escape,  or  that  the  attack  will  be  over  in  less  than  two  months. 
If  the  legs  become  very  feeble,  the  arms  will  almost  certainly  suffer  also. 
On  the  other  hand,  if  the  paralysis  of  the  palate  is  brief  in  duration 
there  is  a  fair  prospect  that  the  limbs  may  escape.  It  must,  however, 
be  remembered  that  complete  recovery  from  the  early  initial  sym- 
ptoms does  not  preclude  the  occurrence  of  others,  but  it  is  not  proba- 
ble that,  in  such  a  case,  they  will  be  severe.  Loss  of  faradic  irritability 
in  any  region  is  proof  that  the  palsy  there  will  last  for  many  weeks ; 
and  if  to  this  is  added  the  loss  of  voltaic  irritability  in  many  muscles 
the  danger  to  life  is  considerable,  because  the  poison  is  intense. 


920  DIPHTHERITIC   PARALYSIS. 

The  prognosis  is  more  serious  in  children  than  in  adults,  chiefly  on 
account  of  their  smaller  reserve  of  strength,  and  the  greater  diffi- 
culty of  feeding  them  if  complications  interfere  with  the  ordinary 
method. 

Treatment. — Of  first  importance  in  the  treatment  of  diphtheritic 
paralysis  is  restoration  and  maintenance  of  the  patient's  strength, 
already  weakened  by  the  previous  disease.  For  this  end  feeding  is  at 
once  the  most  important  and  the  most  difficult  measure.  Easily 
digested  nourishment  should  be  given  at  frequent  intervals,  with  wine 
or  brandy  if  the  pulse  indicates  it.  When  the  palate  is  paralysed, 
pulpy  foods  are  swallowed  much  better  than  liquids,  and  the  affection 
of  the  palate  does  not  usually  interfere  with  a  due  amount  being 
taken.  A  much  more  serious  obstacle  is  the  paralysis  of  the  pharynx 
or  of  the  epiglottis  and  upper  part  of  the  larynx.  In  the  former, 
deglutition  may  be  difficult  or  impossible  ;  in  the  latter,  food  cannot 
be  kept  out  of  the  larynx,  and  attempts  to  swallow  occasion  so  much 
distress  that  mental  repugnance  is  added  to  the  physical  difficulty, 
and  it  may  be  impossible  to  give  food  in  the  ordinary  way.  It  is, 
indeed,  inadvisable  to  do  so  if  particles  of  food  and  drink  constantly 
get  into  the  larynx,  on  account  of  the  danger  of  pulmonary  complica- 
tion. Food  must  therefore  be  injected  into  the  rectum,  or  given  by 
means  of  a  small  oesophageal  tube  or  large  gum-elastic  catheter.  A 
flexible  tube  passed  through  the  nose  does  not  answer  so  well  in  these 
cases,  because  the  paralysis  often  extends  to  the  lower  part  of  the 
pharynx,  and  it  is  absolutely  necessary  that  the  extremity  of  the 
tube  should  be  below  the  paratysed  portion.  Which  method,  rectal 
or  oesophageal,  should  be  adopted  must  depend  on  age  and  condi- 
tion, but  it  is  essential  that  the  patient  should  not  be  allowed  to  pass 
more  than  twelve  hours  without  food  being  given,  in  sufficient  quan- 
tity, by  one  or  the  other  method.  It  is  unwise,  in  the  case  of  children 
especially,  to  wait,  in  the  hope  that  the  child  may  presently  be  induced 
to  take  food.  Few  cases  of  severe  diphtheritic  paralysis  can  survive 
forty-eight  hours'  complete  fasting,  and  the  danger  of  producing 
exhaustion  by  the  procedure  of  forced  feeding  is  greater  the  longer 
the  abstinence  has  continued. 

The  variable  course  of  diphtheritic  paralysis,  and  its  ultimate  ten- 
dency to  recovery,  render  the  influence  of  drugs  upon  it  very  difficult 
to  ascertain.  There  is  no  evidence,  at  present,  that  any  agent  has  a 
considerable  influence  on  the  morbid  process  itself.  We  have  at 
least  no  means  of  renderiug  inert  the  cause  of  the  palsy.  Tonics, 
especially  iron  and  quinine,  often  seem  to  be  useful.  Strychnine  has 
been  largely  employed,  and  sometimes  seems  of  actual  service,  but 
it  is  certainly  powerless  to  neutralise  the  morbid  process  in  its  early 
stages,  and  seems  to  be  without  influence  on  the  spread  of  the  disease. 
Moreover,  it  is  not  wise  to  give  large  doses  of  a  drug  that  stimulates 
so  powerfully  the  affected  nerve-cells.     Recovery  has  been  ascribed  to 


TREATMENT.  921 

its  hypodermic  use,  but  the  evidence  of  a  relation  between  the  two 
has  in  published  cases,  been  no  more  distinct  than  when  the  drug  has 
been  given  by  the  mouth.  Belladonna  in  large  and  frequent  doses 
has  been  thought  by  Abercrombie  to  do  good. 

Of  local  treatment  the  most  important  measures  are  rubbing 
and  electricity.  The  slowly  interrupted  voltaic  current  should  be 
used,  to  which  alone  the  muscular  fibres  are  capable  of  responding  if 
the  paralysis  is  severe.  The  current  should,  if  possible,  be  of  such  a 
strength  as  will  cause  the  muscles  to  contract,  but,  in  the  case  of 
children,  if  an  adequate  strength  causes  severe  emotional  disturbance, 
it  is  far  better  to  be  content  with  a  weaker  current,  as  strong  as  can 
be  borne  without  distress  or  alarm.  The  utmost  good  electricity  can 
do,  is,  in  this  disease,  extremely  small  compared  with  the  harmful 
influence  of  a  daily  fright. 

Among  special  symptoms  which  may  require  treatment,  the  paralysis 
of  the  pharynx  has  been  already  considered.  The  loss  of  accommoda- 
tion scarcely  calls  for  treatment,  and  it  is  doubtful  whether  anything 
can  be  done  for  it,  although  the  application  of  eserine  (a  half  per 
cent,  solution  in  water)  twice  a  day,  has  been  recommended  by 
Herschel.  If  there  are  symptoms  of  cardiac  failure,  the  patient 
should  be  kept  in  the  recumbent  posture,  since  fatal  syncope  has 
occurred  on  sudden  rising.  For  undue  frequency  of  action,  small 
doses  of  digitalis  may  be  given,  the  effect  being  carefully  watched. 
Duchenne  recommends  faradism  to  the  precordial  region  as  a  power- 
ful means  of  stimulating  a  failing  heart,  and  several  other  French 
writers  have  endorsed  his  recommendation. 

Failure  of  the  muscles  of  respiration  is  rarely  so  complete  as  to 
cause  death  directly,  but  when  mucus  accumulates  in  the  chest, 
suffocating  paroxysms  are  apt  to  occur,  which  are  attended  with  some 
danger.  If  life  is  threatened  in  one  of  these,  artificial  respiration 
may  carry  the  patient  over  the  attack,  and  Duchenne  advised  reflex 
stimulation  of  the  respiratory  centre  by  faradism  to  the  back  of  the 
chest.  An  account  of  a  case  in  which  the  method  was  employed  with 
success  has  been  given  by  Millard.*  The  patient  was  a  man  aged 
thirty,  and  paralysis  of  the  palate,  diplopia,  and  weakness  of  the 
limbs  had  existed  for  about  three  weeks,  when  distress  in  breathing 
suddenly  came  on ;  expiration  was  short  and  sudden ;  mucus  accumu- 
lated in  the  air-passages,  causing  a  loud  tracheal  rale ;  the  patient 
could  not  expel  it,  and  asphyxia  seemed  imminent.  Duchenne  was 
called  in,  and,  noting  that  the  diaphragm  acted  well,  and  that  the 
source  of  the  trouble  was  the  deficient  expiration,  faradised  the  skin 
at  the  back  of  the  thorax,  and  thus  "rapidly  re-established  the 
expiratory  power,  and  caused  the  immediate  expulsion  of  a  quantity 
of  bronchial  mucus.  The  patient  was  immediately  relieved,  and,  the 
application  being  repeated  during  the  next  few  days,  all  alarming 
symptoms  passed  away,  and  he  ultimately  recovered." 
*  Quoted  by  Landouzy,  loc.  cit.,  p.  87. 


922  HYDROPHOBIA. 


HYDKOPHOBIA. 


Hydrophobia  is  the  name  given  to  a  malady,  when  it  affects  mail, 
which  is  called  rabies  when  an  animal  is  the  subject  of  it.  It  is  a 
specific  disease,  always  due  to  a  specific  poison,  always  contracted 
from  an  animal,  and,  like  syphilis,  transmissible  only  by  inoculation. 
It  is  manifested  by  symptoms  that  are  chiefly  due  to  disturbance  of 
the  nervous  system,  and  it  is  almost  always  fatal. 

Babies  in  Animals. 

Before  describing  the  disease  as  it  occurs  in  man,  it  will  be  well  to 
give  a  brief  outline  of  the  characters  of  the  affection  in  animals.  The 
fullest  description  of  it  is  that  given  by  Fleming  in  his  work  on  the 
disease  *  The  malady  is  almost  invariably  due  to  inoculation  by  a  bite. 
It  is  the  opiuion  of  Fleming  that  it  arises  spontaneously  in  very  rare 
instances,  but  this  is  not  certain. f  It  occurs  chiefly  in  dogs,  wolves, 
foxes,  and  cats,  and  by  these  it  is  commonly  transmitted,  especially 
by  the  first  two.  It  may  also  be  produced  in  the  herbivora  and  some 
rodents,  but  it  is  probably  very  seldom  transmitted  by  them.  In  the 
dog  the  first  symptom  is  dulness,  with  an  indisposition  to  move. 
Then  the  animal  becomes  shy  and  suspicious  or  threatening  in 
manner,  and  afterwards  irritable  and  restless,  with  a  strong  tendency 
to  bite.  Throughout  the  early  period  there  is  a  depraved  appetite ; 
ordinary  food  is  rejected,  and  hay,  straw,  cloth,  wood,  and  cinders, 
and  even  the  animal's  own  hair,  are  eaten.  This  is  an  important 
characteristic,  because  the  presence  of  such  substances  in  the  stomach 
constitutes  one  of  the  signs  by  which  the  disease  can  be  recognised 
after  death.  J  The  bark  usually  becomes  changed  into  a  peculiar 
howl,  which  begins  with  a  short  low  note  and  ends  with  a  long  higher 
note  ;  it  has  also  a  peculiar  metallic  ring.  There  may  be  drooping  of 
the  lower  jaw  and  weakness  of  the  muscles  of  deglutition  ;  this  may 
prevent  swallowing,  but  there  is  no  dread  of  water.  Ultimately, 
palsy  always  comes  on  ;  it  is  first  manifested  by  unsteadiness  of 
movement,  then  by  increasing  weakness  of  the  legs,  and  at  last  there 

*  Some  additional  facts,  observed  during  a  long  series  of  investigations,  are 
described  by  Dowdeswell  ('  Proc.  Royal  Society,'  vol.  xliii,  p.  48).  His  description 
has  been  chiefly  followed  in  the  above  account. 

t  See  p.  925. 

J  This  sign  has,  indeed,  been  regarded  as  pathognomonic,  but  doubts  have  been 
thrown  on  its  value.  Gibier  ('  Gaz.  Heb.,'  1884,  No.  29,  &c.)  states  that  he  has 
repeatedly  failed  to  obtain  evidence  of  the  rabid  state  of  animals  in  whose  stomach 
hay  and  straw  were  found,  when  he  employed  the  test  of  subdural  inoculation. 
Mr.  E.  Batt,  Vet.  Surgeon  to  the  Brown  Institution,  informs  me  that  this  feature  is 
not  uncommon  apart  from  rabies,  and  that  it  is  very  difficult  to  feel  confident,  from 
post-mortem  signs  alone,  that  an  animal  has  died  from  this  disease. 


RABIES    IN   ANIMALS.  023 

is  inability  to  stand.  The  animal  then  usually  becomes  comatose 
and  dies.  A  distinction  has  been  made  between  "  dumb  or  paralytic 
rabies  "  and  "  furious  rabies,"  but  the  difference  depends  only  on  the 
degree  of  excitement ;  all  cases,  if  permitted  to  run  their  course,  end 
in  paralysis,  but  in  the  "  paralytic  "  form  this  is  an  early  symptom, 
and  the  stage  of  excitement  may  be  represented  only  by  quickened 
breathing.*  After  death,  distinct  changes  are  often  to  be  found  in 
the  nerve-centres.  There  is  congestion  of  the  membranes  and  in  the 
cortex,  with  accumulations  of  lymphoid  cells  about  the  vessels, 
especially  intense  beneath  the  lower  part  of  the  fourth  ventricle,  where 
I  have  found  the  tissue  in  a  state  indistinguishable  from  that  of  acute 
inflammation.  The  changes  are  essentially  the  same  as  those  to  be 
described  as  often  present  in  man.  Thei'e  may  be  minute  extrava- 
sations, and  sometimes  hemorrhage  visible  to  the  naked  eye.  Similar 
but  usually  slighter  changes  are  often  found  in  the  grey  matter  of  the 
spinal  cord.  The  larynx  and  trachea  are  usually  congested,  and  so 
also  are  the  lungs. 

In  the  stomach,  besides  the  peculiar  contents  already  mentioned, 
minute  extravasations  are  commonly  seen  in  the  mucous  membrane. 
The  salivary  glands  present  no  constant  changes,  nor  do  other  organs. 

In  the  rabbit,  according  to  Dowdeswell,  the  symptoms  are  dulness, 
followed  by  excitement,  transient  pyrexia,  and  progressive  paralysis, 
which  is  the  cause  of  death.  The  post-mortem  changes  are  similar  to 
those  in  the  dog,  but  the  stomach  contains  ordinary  food. 

Pasteur  has  discovered  that  the  virus  exists,  after  death,  in  the 
central  nervous  system  as  well  as  in  the  salivary  glands,  and  Dowdes- 
well has  found  that  it  is  also  abundant  in  the  peripheral  nerves. 
Inoculation  with  the  tissue  of  the  brain  and  spinal  cord  produces  the 
disease*  even  more  certainly  thau  does  that  of  the  salivary  glands. 
Pasteur  has  also  proved  that,  in  animals,  the  disease  is  produced  far 
more  surely,  and  with  a  more  uniform  incubation  period,  when  the 
inoculation  is  made  beneath  the  dura  mater,  by  trephining  the  skull, 
than  when  it  is  beneath  the  skin. 

The  period  of  incubation  is  very  variable  in  animals,  especially 
when  the  inoculation  is  subcutaneous.  In  intra-cranial  inoculation  it 
is  generally  from  seventeen  to  nineteen  days,  and  this  whatever  is  the 
source  of  the  virus.  By  passing  the  virus  through  a  series  of  rabbits, 
the  period  becomes  shortened  to  six  or  seven  days,  and  remarkably 
uniform — the  "  fixed  virus  "  of  Pasteur.  The  poison  exists  in  the 
tissues  only  towards  the  end  of  the  period  of  incubation.  The  nature 
of  the  virus  has  not  yet  been  demonstrated,  but  that  it  is  a  micro- 
organism  scarcely  admits  of  doubt. f      Its   activity   appears   to    be 

*  Ferree,  'Compt.  rend.,'  cvi,  No.  12. 

t  Gibier  ('  Comptes  rend.,'  1884,  vol.  xcviii,  and  'Thele  de  Paris,'  1884)  and  also- 
Dowdeswell  (loc.  cit.)  found  an  organism  in  abundance  in  the  central  nervous  system 
in  some  cases;  it  was  extremely  difficult  to  stain  and  recognise,  and  this,  if  it  was- 
really  the  microbe  of  rabies,  exp.ains  the  frequent  failure  to  discover  it.     Dowd.es- 


924  HYDROPHOBIA. 

rapidly  destroyed  by  decomposition,  yet  it  has  been  found  very  active 
in  a  dog  that  had  been  buried  fourteen  days.*  It  is  certain,  also, 
that  the  saliva,  dried  before  decomposition,  retains  its  virulence  for 
many  days.  In  the  dried  spinal  cord  the  virus  gradually  loses  its 
power,  which  becomes  extinct  at  the  end  of  ten  days,  even  in  the 
case  of  the  "fixed"  virus  of  the  rabbit.  The  pathology  of  the 
disease  will  be  again  considered. 

Babies  in  Man. 

The  disease  in  man  is  commonly  called  "  hydrophobia,"  because  the 
difficulty  in  swallowing  induces  a  sort  of  reflected  mental  dread  of 
water.  Although  this  dread  may  be  absent,  and  the  name  at  best 
designates  only  one  symptom,  it  is  so  firmly  established  that  an 
attempt  to  change  it  would  be  futile.  The  features  of  the  disease  are 
occasionally  simulated  by  other  maladies,  and  this  fact  has  been 
made,  by  certain  lay  writers,  the  ground  for  denying  the  occurrence  of 
rabies  in  man ;  but  such  denial  is  only  possible  through  ignorance, 
and  its  refutation  is  needless. 

In  man,  the  disease  is  invariably  acquired  from  a  rabid  animal,  and 
is  almost  invariably  due  to  inoculation  with  the  saliva  by  means  of  a 
bite.  In  nine  tenths  of  the  cases  the  disease  is  contracted  from  a  dog, 
in  a  few  cases  from  cats,  very  seldom  from  a  fox  or  a  wolf.  It  has  been 
due  to  a  wound  received  in  the  dissection  of  a  rabid  animal, f  but  it  is 
not  certain  that  inoculation  with  the  blood  alone  will  produce  the 
disease. 

A  bite  is  more  effective  if  upon  an  uncovered  part  of  the  body,  as 
the  face  or  hand,  than  if  inflicted  through  the  clothes,  by  which  the 
saliva  may  be  wiped  from  the  teeth.  Children  are  often  bitten  about 
the  face,  and  a  large  proportion  of  those  who  are  so  bitten  are  infected. 
It  is  said  that  a  bite  inflicted  immediately  after  a  preceding  bite  is 
less  likely  to  infect,  as  the  teeth  may  have  been  cleaned  by  the 
preceding  bite.  The  disease  may  also  be  caused  by  a  rabid  dog 
merely  licking  a  scratch  upon  the  hand'  (and  may  be  thus  produced 
more  often  than  remembered  and  recorded  facts  suggest),  and'  it  has 
resulted  from  the  teeth  having  been  used  to  loosen  a  knot  upon  a  rope 
with  which  a  rabid  dog  has  been  tied  up.  A  person  has  been 
inoculated  by  a  bite  from  a  healthy  dog,  inflicted  immediately  after  it 
had  been  fighting  with  a  rabid  animal,  the  saliva  of  which  was  no 
doubt  inoculated.  The  malady  has  followed  the  scratch  of  a  cat,  but 
probably  by  the  animal's  saliva  having  thus  been  introduced. 

It  has  been  said  that  hydrophobia  has  been  produced  by  the  bite  of 

well  obtained  some  cultivations  from  it,  and  one  animal  inoculated  with  the  cultivated 
organism  seemed  to  be  protected  from  the  effects  of  the  active  virus  ('Lancet/ 
1886,  vol.  i,  p.  1112). 

*  Galtier,  '  Comptes  rend.,'  cvi,  1888. 

f  For  an  instance,  see  Bollinger,  '  Ziemssen's  Handbuch,'  Bd.  iii,  p.  542. 


CAUSES.  925 

an  animal  not  suffering  from  rabies.  This  is  opposed  to  all  that  we 
know  of  the  origin  of  other  diseases.  The  statement  rests  upon 
some  facts  which  seem  to  establish  that  hydrophobia  may  result  from 
the  bite  of  a  dog  which  did  not  at  the  time,  or  for  several  weeks 
afterwards,  present  the  recognised  symptoms  of  the  disorder.  The 
best  explanation  of  these  cases  is  probably  that,  in  some  rare  and 
exceptional  circumstances,  rabies  may  affect  a  dog  as  a  malady  that 
is  transient  and  insignificant,  but  communicable.  Examples  of  this 
are  seen  in  most  infectious  diseases.  The  fact  that  dogs  may  recover 
from  rabies,*  makes  it  probable  that  the  disease  is  sometimes  slight. 

The  facts  mentioned  show  that  only  some  of  those  who  are  bitten 
by  a  rabid  animal  contract  the  disease.  The  difficulty  of  ascertaining 
the  proportion  is  great,  on  account  of  the  frequent  uncertainty 
whether  the  dog  was  really  rabid.  It  has  been  calculated  that,  of  all 
those  bitten  by  certainly  rabid  dogs,  47  per  cent,  suffer;  of  those 
whose  wounds  were  uncauterised,  83  per  cent.  ;  of  those  promptly 
cauterised,  only  33  per  cent.f  On  the  other  hand,  of  persons  bitten  by 
dogs  merely  suspected  to  be  mad,  only  8  per  cent,  suffer.^  The 
immunity  of  some  persons  is  perhaps  due  to  bites  having  been 
inflicted  through  the  clothes,  or  to  the  animal's  teeth  having  been 
otherwise  freed  from  saliva.  The  poison  may  also  vary  in  virulence  at 
different  stages. 

The  general  incidence  of  rabies  can  be  traced  to  the  exposure  to  the 
risk  of  bites,  their  character  and  position.  Hence  more  males  than 
females  suffer,  the  proportion  being  about  four  to  one.  Most  males 
are  in  the  middle  period  of  life.  Very  few  adult  women  are  affected, 
but  children  of  both  sexes  often  suffer ;  they  are  much  exposed  to 
the  risk  of  bites  on  the  face  and  hand  from  straying  dogs.  No  less 
then  two  fifths  of  all  cases  are  under  fifteen. § 

The  period  of  "  incubation  "  varies  between  wide  limits,  and  is  longer 
and  more  variable  than  that  of  any  other  known  acute  specific  disease. 
The  common  period  is  from  six  to  ten  weeks.     Bauer  has  calculated 

*  Observed  by  Pasteur  and  Azary.  The  latter  proved  the  disease  to  be  rabies  by 
inoculation  from  the  body  of  the  person  who  was  bitten  and  died  ("  Buda-Pest  Coinin. 
Rep.,"  by  Laufenhain,  'Cent.  f.  Nervenkr./  1889,  p.  293). 

f  We  need  more  facts  as  to  the  actual  interval  before  cauterisation.  Many 
persons  suffer  whose  wounds  are  cauterised  in  a  quarter  of  an  hour — ample  time  for 
the  virus  to  pass  beyond  the  reach  of  caustics.  But  it  is  doubtful  whether  the 
disease  ever  occurs  if  a  stick  of  nitrate  of  silver  is  immediately  plunged  into  a  small 
wound. 

X  Bollinger,  loc.  cit.,  from  the  statistics  of  Tardieu,  Thamhayn,  and  Bouley. 

§  During  the  twenty-five  years  ending  1872  ('  Reg.-Gen.  Rep.,'  1875),  299  males 
and  74  females  died  from  hydrophobia.  89  males  and  33  females  were  under  15, 
=  one  third  of  tbe  males,  and  four  sevenths  of  the  females.  The  greater  relative 
male  liability  is  least  (but  still  considerable)  in  childhood,  and  increases  up  to  45; 
the  ratio  between  the  sexes  is  2  to  1  in  the  first  five  years,  and  3  to  1  in  the  third; 
during  the  thirty  years  15—45  it  is  8£  to  1.  In  later  life  the  preponderance  of 
males  is  not  so  great,  but  the  cases  are  few. 


926  HYDEOPHOBIA. 

the  average  period  of  510  cases  to  have  been  seventy-two  days,  and 
rather  longer  in  men  (eighty-five  days)  than  in  women  (sixty-five  days). 
It  is  shorter  when  the  bite  is  on  the  head  or  neck  than  when  on  the 
limbs.*  In  at  least  half  the  cases,  the  disease  develops  in  from  one  to 
three  months  after  infection.  In  a  few  cases,  the  period  is  less  than  a 
month,  the  shortest  observed  having  been  about  twelve  days.  Cases  are 
not  uncommon  in  which  the  period  is  more  than  three  months — six, 
nine,  and  in  some  cases  even  twelve  or  eighteen,  f  Instances  have,  in- 
deed, been  recorded  in  which  five,  ten,  or  twelve  years  are  said  to  have 
passed  ;  most  authorities  consider  that  in  such  cases  there  has  probably 
been  a  second  unnoticed  infection.  It  is,  however,  certain  that  the 
disease  may  occur  after  an  interval  of  a  year  or  of  eighteen  months, 
and  it  is  difficult,  therefore,  to  deny  the  possibility  of  a  longer  interval. 
Although  it  is  common  to  speak  of  the  interval  as  the  "  incubation  " 
period,  it  is  probable  that  only  the  shorter  periods  really  correspond 
to  what  we  understand  by  the  term  in  the  case  of  other  diseases. 

Symptoms. — During  the  interval  after  the  bite  there  are  commonly 
no  symptoms.  Occasionally,  towards  the  end  of  the  period,  pain  or 
unpleasant  sensations  are  felt  at  the  seat  of  the  wound,  explicable  in 
part  (but  not  altogether)  by  the  attention  which  is  directed  to  it. 
Mental  depression  is  occasionally  conspicuous,  but  is  commonly  the 
result  of  the  sufferer's  knowledge  and  anticipation  of  the  possible 
consequences  of  the  bite.  At  the  onset  of  the  acute  symptoms  there 
may  be  considerable  local  pain,  occasionally  radiating  up  the  limb. 
It  may  exist  for  a  few  days  or  a  week  before  other  symptoms.  Even 
more  frequently,  all  local  symptoms  are  absent.  Slight  preceding 
fever  (even  with  a  rigor)  has  sometimes  been  observed  for  a  day  or 
two,  but  usually  the  first  indications  of  the  impending  malady  are  a 
sense  of  general  malaise,  mental  depression,  and  disturbed  sleep.  These 
may  exist  for  a  few  days,  even  for  a  week  or  more,  before  the  actual 
onset,  which  is  indicated  by  some  discomfort  about  the  throat,  an 
occasional  sense  of  choking,  or  a  little  difficulty  in  swallowing  liquids. 
The  effort,  if  successful,  has  been  aptly  compared  to  that  of  a  child 
taking  a  nauseous  draught  (Handford).  The  spasm  in  the  pharynx, 
produced  by  the  attempt,  increases  in  the  course  of  a  few  hours,  and 
spreads  to  the  muscles  of  respiration,  causing  a  short,  quick  inspira- 
tion, a  "  catch  in  the  breath,"  resembling  that  which  is  produced  in 
health  by  an  affusion  of  water.  This  soon  becomes  a  strong  inspira- 
tory effort,  in  which  the  "  extraordinary  muscles  of  respi ration," 
sterno-mastoid,  scaleni,  &c,  and  even  the  facial  muscles,  take  part; 
the  shoulders  are  raised,  and  the  angles  of  the  mouth  drawn  outwards. 
Very  rarely  sudden  severe  throat-spasm  has  been  the  first  symptom. 

*  Bauer,  'Munch,  med.  Wochensch./  1886.  If  27  doubtful  cases  of  alleged  very 
long  incubation  were  included,  he  found  the  average  of  537  cases  to  be  126  days. 
The  period  presents  very  little  variation  in  the  case  of  bites  by  different  animals. 

t  Many  well-authenticated  instances  of  eighteen  months'  duration  are  on  record. 


SYMPTOMS.  927 

As  the  intensity  of  the  spasm  increases,  so  does  the  readiness  with 
•which  it  is  excited.  It  may  be  caused  by  the  mere  contact  of  water 
with  the  lips,  and  a  state  of  cutaneous  hyperesthesia  develops,  so 
that  various  impressions,  such  as  a  draught  of  air,  which  normally 
excite  a  respiratory  effort,  bring  on  the  spasm.  The  mere  movement 
of  air  caused  by  raising  the  bedclothes  may  be  sufficient.  The  patient 
is  often  unable  to  swallow  the  saliva,  which  is  usually  abundant  and 
viscid,  so  that  it  hangs  about  the  mouth  and  is  expelled  with  diffi- 
culty ;  this  greatly  increases  the  patient's  discomfort.  Vomiting  is 
common,  a  greenish-brown  liquid  being  ejected.  The  attacks  of 
spasm  are  very  distressing  to  the  patient ;  the  mental  state  which 
they  occasion  increases  the  readiness  with  which  they  are  produced, 
and  in  some  cases  the  mere  sight  of  water  or  the  sound  of  dropping 
water  will  cause  an  attack.  It  may  even  be  excited  by  visual  impres- 
sions which  cause  a  similar  sensation,  as  the  reflection  from  a  looking- 
glass,  or  even  a  strong  light.  The  sufferer's  horror  and  dread  of 
these  excitants  becomes  intense.  Thus  the  disturbance  in  the  act  of 
swallowing  liquids,  which  constitutes  as  it  were  the  first  symptom  and 
key-note  of  the  disease,  spreads,  on  the  one  hand,  to  mental  disturbance, 
and  on  the  other  to  extensive  muscular  spasm. 

In  each  of  these  directions  further  symptoms  develop.  The  spasm, 
at  first  confined  to  the  muscles  of  deglutition  and  respiration,  spreads 
to  the  other  muscles  of  the  body,  and  the  paroxysms,  at  first  respii*- 
atory,  afterwards  become  general,  and  assume  a  convulsive  character, 
although  still  excited  by  the  same  causes.  The  convulsions  may 
consist  of  general  muscular  rigidity,  sometimes  tetanoid  in  character, 
with  actual  opisthotonos,  or  they  may  be  co-ordinated  and  closely 
resemble  hysteroid  convulsions.  During  this  stage  the  knee-jerk  is 
commonly  increased  and  also  reflex  action  from  the  skin.  All  the 
cerebral  centres  may  share  the  over-action,  and  auditory  hyper- 
esthesia is  sometimes  very  distressing.  In  other  cases  the  mental 
distress  passes  into  delirious  disturbance,  in  which,  at  times,  the 
balance  of  reason  is  lost,  and  the  distress  gets  command  over  the 
mind.  The  horror  with  which  the  attempts  to  drink  and  the  causes  of 
the  distress  are  regarded,  becomes  transferred  to  the  attendants  by 
whom  they  may  have  been  produced.  Actual  delusions  may  super- 
vene, and  may  even  pass  into  a  state  of  positive  mania.  The  mental 
derangement  is  most  intense  during  the  paroxysms  of  spasm,  and 
the  frenzied  patient  may  spit  his  saliva  at  those  about  him,  and 
often  attempts  to  bite  them  with  his  teeth,  making  occasionally  strange 
noises  in  his  throat  which  have  been  thought  to  resemble  the  barking 
of  a  dog.  The  sight  of  a  dog  has  been  known  greatly  to  intensify 
the  mental  excitement,  and  this,  strangely  enough,  in  cases  in  which 
the  sufferer  had  no  suspicion  of  the  nature  of  this  affection.  It  often 
happens,  however,  that  the  very  anxiety  itself  deters  the  bitten  person 
from  alluding  to  its  cause,  until  his  mental  processes  are  exposed  by 
the  withdrawal  of  the  previous  control.     The  idea  of  a  dog  may  enter 


928  HYDROPHOBIA. 

into  the  delusions  in  strange  ways.  One  patient  will  think  a  dog  is 
under  the  bed,  or  that  he  sees  one  in  the  room.  Another  is  seized 
with  so  intense  a  fear  of  being  mistaken  for  a  dog  that  at  last  he 
fancies  he  is  one,  and  goes  on  "  all  fours."  But  there  is  much  that 
is  mysterious  in  these  delusions,  as  will  be  pointed  out  in  the  section 
on  Pathology. 

The  mental  disturbance  is  not  always  thus  subordinate,  as  it  were, 
to  the  other  symptoms.  There  may  be  a  variable  amount  of  mental 
derangement  almost  from  the  first, — an  unnatural  suspicion,  with 
manifestations  of  ill  temper,  succeeeded  by  a  curious  mental  rest- 
lessness and  loquacity,  and  some  incoherence  in  the  sequence  of 
ideas.  Delusions  and  hallucinations  are  usually  late  symptoms, 
but  occasionally  some  false  ideas  are  manifested  early  in  the  affec- 
tion. Throughout  its  course  there  are  sudden  variations  in  the 
mental  state,  which  are  almost  characteristic  of  the  disease  ;  a  com- 
plaint, perhaps  couched  in  indignant  language,  is  succeeded  by  an 
apology,  and  the  frenzied  patient  may  alternately  attempt  to  bite  his 
attendants  and  beseech  them  to  keep  out  of  his  way,  or  to  hold  him  fast 
that  he  may  not  hurt  them.  Similar  mental  disturbance  may  be 
present  in  children,  although  its  details  necessarily  differ,  but  in  them 
it  is  especially  common  for  initial  fear  of  liquids  to  be  lost  in  early 
delirium. 

In  adults  also,  as  the  mental  disturbance  increases,  the  respiratory 
spasm  and  difficulty  in  swallowing  often  lessen,  and  sometimes  cease. 
The  convulsive  attacks  may  also  cease.  The  patient  may  die,  appa- 
rently exhausted  by  the  attacks  of  fury,  or,  if  life  is  prolonged  long 
enough,  the  mental  and  muscular  excitement  may  give  place  to  a  state 
of  paralytic  exhaustion,  which  seems  to  represent  the  paralysis  that  is  so- 
prominent  in  animals.  Coma  may  come  on,  but  the  patient  usually 
dies  within  a  few  hours  of  the  diminution  in  the  symptoms  of  excite- 
ment. Death,  however,  sometimes  occurs  earlier,  from  asphyxia  during 
a  violent  paroxysm  of  respiratory  spasm,  or  from  sudden  failure  of  the 
action  of  the  heart,  a  result  that  is  explained  by  the  lesions  found  in 
the  medulla  oblongata. 

Among  occasional  symptoms  priapism  deserves  mention  ;  it  is  not- 
very  common,  but  has  attracted  attention  from  ancient  times. 

The  temperature  is  almost  always  raised.  At  the  outset  the  eleva- 
tion is  trifling  (occasionally,  indeed,  absent),  and  throughout  the  dis- 
ease it  may  remain  moderate,  100°  or  101°.  More  frequently,  as  the  sym- 
ptoms increase,  so  does  the  pyrexia,  and  it  amounts  to  103°,  104°,  or  105°, 
and  may  even  reach  a  still  greater  height  just  before  death,  and  may 
continue  to  rise  for  a  short  time  after  death.  A  rectal  temperature  of 
108  8°  has  been  observed  twenty  minutes  after  death  (Handford).  The 
urine  very  often  contains  albumen,  sometimes  as  much  as  a  quarter 
or  a  third.  Sugar  has  been  found  in  a  few  cases.  The  scar  of  the 
bite  is  said  sometimes  to  become  livid  in  the  course  of  the  disease. 

The  duration  of  the  disease  has  varied  in  fatal  cases  from  twelve- 


SYMPTOMS.  929 

hours  to  ten  days.  The  usual  duration  is  from  two  to  four  days  ; 
one  tenth  of  the  patients  die  in  the  first  tweuty-four  hours,  three 
fifths  die  within  three  days.  Cases  exceeding  four  days  in  duration 
are  rare. 

The  course  of  the  disease  has  been  divided  into  two  stages,  the  first 
distinguished  by  the  respiratory  spasm,  the  second  by  the  mental  dis- 
turbance and  convulsions.  By  others,  an  initial  stage  of  depression 
has  been  distinguished  from  the  later  stage  of  excitement.  The  final 
exhaustion  is  also  regarded  as  a  third  or  paralytic  stage.  But  these 
stages  are  often  not  well  marked  ;  the  elements  that  distinguish  them 
may  be  combined  in  various  degrees,  and  those  of  the  later  period  are 
sometimes  conspicuous  from  the  first. 

The  special  predominance  of  certain  symptoms  sometimes  impresses 
a  definite  character  on  the  attack,  so  that  certain  varieties  may  be  dis- 
tinguished. Their  recognition  is  of  some  practical  value,  since  it  may 
prevent  some  of  the  frequent  diagnostic  doubts.  The  most  important 
of  these  varieties  depend  on  the  predominance  of  meutal  symptoms  on 
the  one  hand,  and  of  convulsions  on  the  other.  Delirious  and  mental 
excitement  may  exist  from  the  onset  of  the  affection,  and  in  such 
cases  the  respiratory  spasm  may  be  less  pronounced  in  the  early 
period  than  is  usually  the  case.  The  special  character  of  the  mental 
derangement  varies  greatly  according  to  the  mental  condition  of  the 
patient,  and  the  amount  of  special  anxiety  he  has  previously  felt. 
There  is  almost  always  very  marked  mental  distress,  and  the  dread 
of  the  disease  rather  determines  the  direction  of  the  morbid  emotion 
than  causes  it.  If  there  has  been  no  apprehension  of  hydrophobia, 
as  is  often  the  case  in  children  and  occasionally  in  adults  (especially 
of  the  lower  classes),  some  peculiar  delusion  may  be  associated  with 
the  emotion,  and  may  seem  to  be  its  cause  when  it  is  probably  its 
consequence. 

In  other  cases  the  convulsive  symptoms  predominate  ;  the  spasm 
induced  by  attempts  to  swallow  quickly  spreads  to  other  muscles 
besides  those  immediately  concerned,  and  the  tetanoid  character  may 
be  early  assumed.  In  some  instances,  again,  hysteroid  convulsions 
occur  almost  from  the  first,  and  the  respiratory  spasm  or  mere  emotion 
excites  the  co-ordinated  convulsive  movement  seen  in  severe  hysterical 
fits.     This  feature  of  the  spasm  may  lessen  as  the  disease  develops.* 

*  Boerhaave,  in  his  '  Aphorisms,'  gave,  nearly  200  years  ago,  a  description  of  the 
disease  so  graphic  and  accurate  that  it  is  worth  quoting  in  full  from  the  English 
translation  of  Delacoste,  published  in  1715 : 

"  Of  the  dog-madness. — When  a  man  in  perfect  health  is  infected  with  this  poison, 
after  different  distances  of  time  he  begins  to  be  disordered  much  after  the  following 
manner: — The  place  pains  him  where  he  first  receivM  the  injury;  then  follow 
wandering  uncertain  pains  in  other,  but  chiefly  the  nearest  parts;  a  weariness, 
heaviness,  slowness  succeeds  in  the  whole  system  of  the  muscles;  his  sleeps  are 
disturb'd,  uneasie,  full  of  frights,  convulsions,  and  catching  in  the  tendons;  he  is 
continually  restless,  sighs,  looks  dejected,  and  affects  to  he  alone;  and  it  is  much 
after  this  manner  that  the  disease  begins  and  finishes  its  first  stage.     If  you  bleed 

vol.  ii.  59 


930  HYDROPHOBIA. 

In  animals,  as  we  have  seen,  symptoms  of  paralysis  are  much  more 
prominent  than  they  are  in  man,  and  sometimes  they  give  a  special 
character  to  the  attack.  Examples  of  the  true  paralytic  form  in  man 
are  not  common,  although  twenty  cases  have  been  collected  by 
G-amaleia.*  The  cause  is  usually  an  extensive  bite,  but  the  duration 
of  the  symptoms  is  nearly  that  of  the  common  form ;  sensibility  is 
generally  preserved,  the  sphincters  involved.  The  chief  morbid 
changes  are  in  the  spinal  cord.  The  onset  has  been  sometimes  by 
sudden  paraplegia,!  as  in  the  well-known  case  of  the  man  G-offi.  The 
nature  of  this  case  would  not  have  been  suspected  had  not  the  inocula- 
tion test  been  employed.  The  symptoms  closely  resembled  those  of 
"acute  ascending  paralysis. "J  It  is  important  not  to  mistake,  for  a 
peculiar  manifestation  of  the  disease,  the  effects  of  any  potent  agent 
employed  in  its  treatment.  The  depressing  influence  of  curara  on  the 
motor  structures  has  probably  been  thus  mistaken  ;  §  and  some  other 
instances  of  this  mysterious  form  of  palsy  may  have  been  paralytic 
rabies. 

Pathological  Anatomy. — The  blood  is  generally  fluid,  as  in  many 
acute  diseases.  The  throat  and  pharynx  are  commonly  congested; 
and  so,  in  many  cases,  are  other  organs,  especially  the  spleen  and 
kidneys.  The  brain  and  spinal  cord  often  present  conspicuous  con- 
gestion.    The  most  important  morbid  changes  are  revealed  only  by  the 

him,  then  the  blood  doth  not  carry  the  face  of  any  defect.  Then  are  all  the  fore- 
going symptoms  increased,  and  there  follows  besides  a  prodigious  narrowness  and 
pressure  about  the  heart  and  chest ;  breathing  is  difficult,  and  accompanied  with 
sighs ;  he  frequently  shakes  all  over ;  his  hairs  stand  an  end,  and  trembles  all  over 
at  the  sight  of  water,  of  any  sort  of  liquors,  or  even  upcn  the  sight  of  transparent 
things,  or  reflecting  like  looking-glasses;  he  loses  his  appetite  entirely,  yet  he  can 
swallow  anything  that  is  very  dry  and  solid.  The  touch  of  any  moisture,  chiefly 
with  his  lips  or  tongue,  creates  an  incredible  anguish,  tremors,  violent  convulsions, 
and  a  raving ;  he  vomits  tawny,  glewish  choler  or  green-like  leeks ;  he  grows  very 
hot,  feverish,  sleepless ;  is  troubled  with  a  priapisme ;  and  he  thinks  very  disorderly 
of  things  quite  foreign  and  unusual.  Thus  doth  it  go  on,  and  here  absolves  its 
second  stage.  Afterwards  doth  everything  constantly  grow  worse,  and  you'll  soon 
see  him  loll  out  his  rough  and  dry  tongue,  gape  wide,  speak  hoarse,  have  a  great 
drought,  grow  raving  at  every  attempt  to  drink,  at  the  sight  or  touch  of  any  liquor; 
gather  froth  in  or  about  his  mouth;  to  endeavour  the  spitting  of  the  same  upon  the 
bystanders,  even  against  his  will ;  to  bite  and  snap  at  everything  within  his  reach, 
and  that  involuntarily, nor  yet  to  be  withheld  from  those  attempts;  he  gnashes  his 
teeth  with  froth,  snarling  like  a  dog;  his  pulse  now  and  breathing  begin  to  fail, 
cold  sweats  break  out  on  all  sides,  raves  in  the  highest  degree,  notwithstanding 
which  he  is  all  the  while  sensible,  and  is  afraid  for  the  bystanders  that  he  shall 
unwillingly  hurt  'em.  Hence  you  may  always  reckon  upon  his  dying  -vwito:n  the 
fourth  day  from  the  first  state  of  his  illness)  convulsed  with  a  most  terrible  anguish 
upon  drawing  his  breath." 

*  See  Le  Gendre,  'L'Ann.  med.,'  1887,  No.  40. 

t  Eicochon,  '  Gaz.  hebd.,'  1887,  No.  10. 

I  See  the  '  Brit.  Med.  Journal,'  1886,  vol.  ii,  p.  830. 

§  See  the  comments  of  Ostermayer  in  his  abstract  of  an  "  untypical "  case  described 
by  Schaffer  ('  Cent.  f.  Nervenkr.,'  1891,  p.  27). 


PATHOLOGICAL   ANATOMY. 


931 


microscope,*  and  are  found  in  the  central  nervous  system.  They  are 
very  variable  in  their  degree,  and  are  sometimes,  although  seldom, 
absent.  Of  nine  cases  I  have  examined,  morbid  changes  were  distinct 
in  seven.     These  were  indications  of  vascular  disturbance ;  dilatation 


#&1 


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i 


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If  3*0*9  «' 


FlO.  168. — Hydrophobia;  perivascular  sheath  distended  with  leucocytes; 
from  the  hypoglossal  nucleus. 


of  small  vessels,  accumulations  of  leucocyte-like  corpuscles  around 
them  and  in  the  tissues,  clots  in  the  small  vessels  evidently  formed 
during  life,  and  minute  haemorrhages.  These  changes  are  met  with 
in  various  parts,  especially  in 

the  cortex  of  the  hemispheres,  .  v#tf?#$3v{  \'~^^%^M 

the  medulla  oblongata,  and  the  ':■}.  ji$  ■  •  •'•£  ';'■•  ---^Se5^.,C • ';': 

spinal  coi'd.  They  are  always 
most  intense  in  the  medulla, 
between  the  eminentia  teres 
above  and  the  decussation  of 
the  pyramids  below,  and  espe- 
cially in  the  neighbourhood  of 
the  pneumogastric,  hypoglossal, 
and  spinal  accessory  nuclei.  The 
accumulations  of  leucocytes 
about  the  vessels  is  a  very  con- 
spicuous change ;  they  surround 
the  outer  wall,  and  may  be  so 
numerous  as  to  fill  up  the  whole  space  within  the  lymphatic  sheath 
(Fig.  168);  they  may  extend  along  the  vessel  for  a  considerable 
distance,  and  even  pass  into  the  adjacent  tissue    (Fig.  169).     The 

*  They  have  been  investigated  and  described  by  Coats,  Clifford  Allbutt,  Benedikt, 
myself,  and  others.  The  figures  here  given  are  from  a  paper  of  my  own,  published 
in  the  '  Path.  Trans.,'  vol.  xxviii. 


Fig.  169.  —  Hypoglossal  nucleus ;  leuco- 
cytes around  a  vessel,  and  extending  into 
the  adjacent  tissue. 


932  HYDROPHOBIA. 

nuclei  contain  a  much  larger  number  of  such  corpuscles  than  normal 
and  in  places  they  may  be  aggregated  and  form  dense  masses 
(Fig.  170),  which,  since  the  corpuscles  may  be  regarded  as  identical 
with   pus  cells,   are  in  fact  "  miliary  abscesses."     These  collections 


Pig.  170. — Cells  of  the  hypoglossal  nucleus  on  the  right,  of  the  pneumo- 
gastric  nucleus  on  the  left.  Dense  infilti-ation  of  the  tissue  with 
leucocytes. 

may   sometimes  also  be  seen  outside  the  grey  matter,  scattered  at 
random,   as  it  were,  especially  abont   the   root-fibres  of  the  nerves 

(Fig.  170).  The  thrombi  within 
,,jr,f  the  vessels  fill  their  cavity,  and 

//  ///,•„•■'"''?. '  ■'  ■'-•'v=- ■'■',;'■  ';,•■•.,  :  may  present  curved  lines  as  if 

// ■'■'..  \        .    ■"}'.  -    .,    ■       ■  ;'  they  had  been  exposed  to   the 

V";-;         :  ">--'/,  \[  \'i'.. ;.  \  pressure  of  the  blood.     At  the 

•?  r    .  .:■';,'  •':"   seat  of  these  clots  the  walls  of 

'/.;'.      -  ;,        '  '    the    vessel  may    be    distinctly 

f .  ,.••'""-'  thickened.         The     nerve-cells 

{>  /  "../  '■'  sometimes   appear  swollen   and 

_:'  ."  ■  _ ;■;■■-■'        \        ,,;';-         slightly    more     granular     than 

^}  ".-■  \     ,:/'<'"  under    normal     circumscancesr 

but  their  alterations  are  trifling 

Fl£   ^',~tTU^t{^  fi°K    C07usc,.es  in  the   hardened    specimens   in 
("miliary  abscess   )  in  the  fibres  of  origin  r 

of  the  hypoglossal  nerve.  which  they  are  commonly  exa- 

mined. The  haemorrhages  are 
usually  small,  and  only  rarely  sufficiently  large  to  be  visible  to  the 
naked  eye.  In  the  spinal  cord  the  alterations  are  usually  much 
slighter,  and  are  confined  to  encrustation  of  the  vessels  with  leuco- 
cytes and  to  an  increase  in  the  number  within  the  grey  matter ;  in 
this  the  changes  are  usually  greater  than  in  the  white  columns, 
although  they  involve  these  in  severe  forms.  They  may,  indeed, 
be  so  intense  as  to  constitute  a  condition  practically  of  acute 
myelitis.  Even  when  a  case  has  run  so  rapid  a  course  as  to  be 
fatal  in  three  days  such  myelitic  changes  may  be  conspicuous.* 
*  Schaffer,  '  A.  f.  Psych./  xix. 


PATHOLOGY.  933 

The  "  miliary  abscesses "  are  very  seldom  seen  in  the  cord.  On 
the  other  hand,  the  central  nervous  system  may  present  no  other 
alterations  than  are  common  after  death  from  asphyxia,  and  this  even 
in  an  animal  inoculated  with  rabies,*  as  well  as  in  man.  Outside  the 
nervous  system  leucocytal  infiltration  has  been  seen  in  the  salivary 
glands  and  in  the  kidneys. f 

Pathology. — It  may  be  well,  in  considering  the  pathology  of  the 
■disease,  to  distinguish  the  facts  that  are  certain,  or  possess  a  proba- 
bility almost  equivalent  to  certainty,  from  the  mere  hypotheses  that 
afford  at  present  the  best  explanation  of  the  phenomena  observed. 

(1)  It  is  certain  that  the  disease  is  the  result  of  a  virus,  not 
volatile,  and  transmissible  only  by  inoculation.  That  it  is  a  micro- 
organism has  not  yet  been  demonstrated,  but  does  not  admit  of 
doubt.  The  virus  seems  to  increase  within  the  body,  and  so  causes 
the  disease ;  Pasteur  has  shown  that  it  develops  best  and  chiefly  in 
the  central  nervous  system,  where  inoculation  (in  rabbits)  never 
fails,  as  it  sometimes  does  beneath  the  skin.  The  virus  certainly 
varies  in  intensity,  within  limits,  and  so  (inversely)  does  the  period 
of  incubation.  Such  increase  in  intensity  may  be  produced  by  the 
successive  inoculation  of  a  series  of  animals  with  full  doses.  The 
position  of  the  anatomical  changes,  coupled  with  the  character  of  the 
symptoms,  shows  that  the  virus  acts  most  intensely  on  certain  parts 
of  the  medulla  oblongata,  next  on  the  spinal  cord,  next  on  the  cortex 
of  the  brain.  But  the  variable  degree  of  the  changes,  and  their 
occasional  absence,  prove  that  they  are  secondary  effects  of  the 
disturbance  of  the  function  of  the  nerve-elements  by  the  virus,  an 
influence  known  in  other  diseases  to  have  vascular  disturbance  as  its 
consequence,  although  the  latter,  if  intense,  may  have  its  own  effects. 

(2)  We  must  regard  as  hypothetical  the  explanations  that  have 
been  given  of  the  variable  and  often  long  interval  between  the  bite 
and  the  symptoms.  The  minimum  interval  may  fairly  be  regarded 
as  a  true  "incubation"  period,  and  slight  variations  in  it  may  be 
referred  to  the  intensity  of  the  virus  ;  but  for  the  much  longer  period 
that  is  so  common  we  are  still  without  any  better  explanation  than 
the  old  one,  that  the  virus  is  lodged  for  a  time  in  the  vicinity  of  the 
wound,  and  at  last  dislodged  by  some  accidental  influence,  such  as 
gymnastic  exertion,  to  which  this  effect  was  ascribed  in  one  case.  But 
two,  if  not  three,  questions  need  consideration  in  connection  with  this 
problem.  We  must  assume  that  both  organisms  and  germs  are 
introduced  ;  that  the  symptoms,  since  they  never  occur  at  once,  are  not 
clue  to  the  former,  which  perish,  probably  often  leaving  other  germs; 
and  that  the  shorter  "  incubation  "  period  is  the  time  needed  for  the 
development  of  a  sufficient  number  of  organisms  from  the  germs, 
perhaps  within  the  nerve-centres.  The  localisation  of  the  germs 
near   the   wound,  but   beyond  the  reach  of   tardy  cauterisation,  is 

*  Eoviglii,  <  Riv.  Clin.,'  1886.  t  Coats,  Hale  White,  &c. 


934  HYDKOPHOBIA. 

easier  to  conceive  than  local  persistence  of  developed  organisms. 
When  malaise,  &c,  precede  the  onset  for  some  weeks,  it  is  possible  that 
the  organisms  first  developed  are  too  few  to  produce  the  disease,  which 
only  results  from  the  maturity  of  a  second,  far  more  numerous  "brood." 
Many  forms  of  organised  virus  seem  only  to  break  down  the  resistance 
of  normal  function  where  they  possess  a  certain  degree  of  intensity. 

It  has  been  extensively  held  (by  Pasteur  and  others)  that  the  path 
of  the  organisms  from  the  wound  to  the  nerve-centres  is  by  the  nerves, 
and  by  this  slower  transit  the  long  interval  is  explained ;  but  the  theory 
is  improbable,  and  the  interval  is  too  variable  to  be  thus  explained. 
Such  a  transit  would  certainly  entail  indications  of  intense  neuritis, 
invariable  and  preceding  the  onset.  All  facts  suggest  that  the 
organisms  introduced  soon  die,  and  that  germs  introduced  or  gene- 
rated are  effective  by  their  development  in  the  nerve-centres.  There 
is  no  difficulty  in  conceiving  that  they  reach  these  by  the  blood.  The 
entrance  of  a  few  germs  into  the  peripheral  nerves,  and  development 
there  at  the  same  time  as  (or  a  little  before)  the  chief  development 
takes  place  in  the  central  organs,  is  a  possible  explanation  of  the  local 
nerve-pains  experienced  in  some  cases. 

From  the  facts  of  the  disease,  and  from  what  we  have  learned  of 
analogous  maladies,  we  may  assume  that  the  symptoms  are  due  to  the 
direct  action  of  the  virus  on  certain  parts  of  the  nervous  system. 
The  active  agent,  in  some  allied  diseases  (as  tetanus),  is  a  chemical 
product  of  the  organisms.  No  facts  have  yet  been  ascertained  to 
suggest  that  this  is  true  of  rabies,  although  it  cannot  be  considered 
unlikely.  There  is  reason  to  believe  that  the  organisms,  by  their  growth, 
produce  a  material  incompatible  with  their  continued  existence  in  the 
system.  It  is  on  the  latter  theory  that  Pasteur  bases  the  explanation 
of  his  prophylactic  treatment,  and  we  shall  have  to  return  to  it  in 
considering  the  latter. 

The  way  in  which  the  virus  acts  is  suggested  by  the  character  of 
the  symptoms.  Its  primary  effect  on  the  nerve-centres  seems  to  be 
to  increase  their  activity,  and  especially  to  augment  the  reflex  ex- 
citability of  the  medulla  oblongata  and  of  the  spinal  cord,  while 
corresponding  disturbance  of  the  cortex  causes  the  delirium,  &c. ;  the 
effect  on  the  medulla  oblongata  increases  the  excitability  of  the  respir- 
atory centre ;  and,  as  the  extraordinary  muscles  of  inspiration  (not 
the  diaphragm)  are  chiefly  excited  by  reflex  influences,  the  inspiratory 
efforts  are  of  the  "  costo-superior  "  type.  The  centre  for  these  move- 
ments is  adjacent  to  that  for  deglutition,  and  the  region  of  the 
medulla  in  which  the  changes  are  most  intense  is  that  in  which 
the  glosso-pharyngeal,  pneumogastric,  and  hypoglossal  nerves  are 
situated.  The  effect  of  the  poison  seems  to  be  chiefly  on  these  centres, 
just  as  other  organic  poisons  have  specific  actions  on  other  parts  of 
the  nervous  system.  The  period  of  excitement  is  often  succeeded  by 
the  opposite  condition,  shown  by  the  paraplegic  weakness  and  coma 
that  may  supervene.     But  another  agency  may  be  concerned  in  the 


PATHOLOGY.  935 

abolition  of  function,  viz.  the  vascular  changes  that  are  revealed  by 
the  microscope,  and  which,  as  we  have  just  seen,  must  be  regarded  as 
secondary  results  of  the  functional  over-action.*  These  are  some- 
what random  in  distribution ;  the  exact  points  at  which  they  occur 
are  apparently  influenced  by  conditions  which  are,  so  far  as  the 
disease  is  concerned,  accidental,  the  specific  poison  only  determining 
their  general  situation.  When  they  do  occur,  however,  the  leucocytal 
infiltration  may  be  so  great  as  to  break  up  the  tissue,  and  even  to 
constitute  a  minute  point  of  suppuration;  and  if  the  point  thus 
affected  is  important,  grave  paralytic  consequences  may  ensue  in  both 
the  medulla  oblongata  and  the  spinal  cord.  Further,  it  is  probable  also 
that  the  cortical  excitement  acts  upon  the  centres  of  the  medulla 
oblongata  and  increases  their  disturbance.  We  know  how  much  the 
functions  of  the  pneumogastric  are  under  mental  influence  ;  the  sigh, 
and  vomiting  from  disgust,  are  examples.  On  the  other  hand,  it  is 
possible  that  the  disturbance  of  the  medulla  may  determine  the  direc- 
tion of  the  cerebral  derangement.  We  may  often  trace,  in  the 
symptoms,  evidence  of  this  peculiar  mutual  interaction  of  the  bulbar 
and  cortical  disturbance. 

It  is  important  to  note  that  some  of  the  symptoms  of  hydrophobia 
not  only  resemble,  but  are  identical  with  those  of  hysteria.  The  con- 
vulsion may  be  distinctly  of  hysteroid  character,  and  the  frenzied 
horror  at  the  sight  of  water  has  a  close  parallel  in  the  maniacal  stage 
of  many  hysterical  attacks.  In  connection  with  the  barking  and  bit- 
ing of  the  hydrophobic  patient,  it  should  be  remembered  that  both 
actions  may  occur  during  the  attacks  of  pure  hysteria ;  the  biting  is 
especially  common. f  There  is  nothing  in  itself  extraordinary  in 
hysteroid  disturbance  forming  part  of  the  functional  disturbance  of 
the  brain  that  results  from  a  different  cause,  but  the  therio-mimicry 
of  hysteria  is  a  mysterious  phenomenon,  the  significance  of  which  is 
doubtless  great,  though  at  present  beyond  our  observation.  It  is  not 
lessened  by  the  prominence  of  the  condition  in  a  malady  due  to  a 
virus  exclusively  animal,  especially  since  it  cannot  be  altogether  ex- 
plained by  the  assumption  of  mental  preoccupation. 

The  special  paralytic  form  seems  to  be  due  to  the  action  of  the  virus 
being  primarily  aud  specially  on  the  spinal  cord,  and  being  from  the 
first  depressant  in  its  influence.  We  cannot  at  present  explain  the  last 
fact,  but  some  light  is  thrown  on  the  first  by  the  factj  that  injection 
of  the  virus  into  the  veins  causes  the  paralytic  form,  while  subdural 
inoculation  always  gives  rise  to  the  ordinary  vaiiety  with  initial  excite- 
ment. Through  the  blood  the  virus  can  evidently  have  free  access  to 
the  spinal  cord.     But  the  difference  in  its  influence  in  the  two  cases 

*  Hence  it  is  incorrect  to  speak  of  inflammation  of  the  medulla  as  the  effect  of  the 
poison  and  the  cause  of  the  symptoms,  and  to  make  a  comparison,  as  has  been  done, 
between  the  condition  of  the  medulla  in  hydrophobia  and  that  of  Peyer's  patches  ia 
typhoid  fever. 

f  See  the  description  of  this  disease.  J  Pasteur,  confirmed  by  Szpilmann. 


936  HYDEOPHOBIA. 

suggests   some   difference  in  the  virus,  and  in  the  character  of  its 
action  on  the  nerve-elements,  to  which  we  have  at  present  no  clue. 

Diagnosis. — The  symptom  of  greatest  value,  as  indicative  of  the 
nature  of  the  affection,  is  unquestionably  the  peculiar  respiratory 
spasm  excited  by  attempts  to  swallow  liquids.  The  history  of  a  bite 
usually  gives  significance  to  definite  symptoms,  but  occasionally  mis- 
leads when  these  are  equivocal. 

In  certain  acute  diseases  of  the  throat  and  chest,  sudden  dysphagia 
has  given  rise  to  a  suspicion  of  hydrophobia,  chiefly  when  the 
dysphagia  is  not  due  to  pain,  but  is  leflex,  a  throat  spasm.  Such 
cases  are,  however,  very  rare,  and  the  history  and  other  symptoms  are 
distinctive  if  oi'dinary  care  is  used.  It  is  more  likely  that  these 
affections  should  be  mistaken  for  hydrophobia  than  that  the  latter 
disease  should  be  overlooked.  The  chief  diagnostic  difficulty  is  in 
connection  with  nervous  disorders.  Cases  in  which  the  mental 
disturbance  preponderates  may  be  mistaken  for  simple  insanity,  but 
the  associated  spasm,  significant  even  if  slight,  and  the  onset  after  a 
suspicious  bite,  generally  prevent  error.  If  there  is  a  form  in  which 
spasm  is  absent,  the  distinction  from  simple  insanity  may  be  only 
possible  by  the  extremely  rapid  course  of  the  affection.  No  patient 
ever  passed  from  mental  health  to  a  state  of  imminent  danger  in  two 
or  three  days  in  consequence  of  simple  insanity.  The  oj^posite 
mistake  is  far  more  common ;  a  previous  bite  leads  to  an  erroneous 
diagnosis  of  rabies. 

Organic  brain  diseases — meningeal  haemorrhage,  for  instance — occur- 
ring in  a  person  who  had  been  bitten  by  a  dog,  have  been  mistaken  for 
hydrophobia.  One  case  is  recorded  in  which  the  mistake  was  only 
discovered  at  the  post-mortem  examination.  The  character  of  the 
convulsions  and  delirium,  and  the  absence  of  respiratory  spasm, 
should  prevent  the  error.  From  tetanus,  hydrophobia  is  distinguished 
by  the  late  period  after  the  bite  at  which  the  symptoms  develop.  A 
difficulty  can  scarcely  arise  (except  in  the  case  of  idiopathic  tetanus) 
unless  the  patient  has  received  some  recent  wound  of  another  nature. 
The  respiratory  spasm,  and  aversion  to  liquids  in  the  one  case,  and 
the  eariy  trismus  in  the  other,  almost  always  suffice  for  the  diagnosis. 
If  the  symptoms  of  hydrophobia  are  present,  the  association  of 
general  tetanic  spasm  with  the  respiratory  disturbance  is  quite  com- 
patible with  the  hydrophobic  nature  of  the  case. 

Symptoms  bearing  a  superficial  resemblance  to  hydrophobia  some- 
times occur  in  those  who  have  been  in  great  dread  of  the  disease,  in 
consequence  of  a  bite  from  an  animal  possibly  or  certainly  rabid. 
The  knowledge  that  difficulty  in  swallowing  is  a  symptom  of  the 
disease,  determines  the  occurrence  of  spasm  in  the  throat  on  degluti- 
tion, perhaps  analogous  to  the  "  globus  hystericus."  The  patient's 
fears  are  intensified  as  the  spasm  increases  in  degree,  and  a  dread 
of  water  may  come  on.     Hysterical  convulsion  may  be  added,  and  the 


PEOGNOSIS.  937 

group  of  symptoms  produced  may  deceive  even  the  medical  attendant. 
In  this  "  lyssophobia,"  or  "pseudo-hydrophobia,"  as  it  has  been 
termed,  the  most  important  diagnostic  element  is  the  absence  of  all 
true  respiratory  spasm  ;  there  is  not  the  peculiar  '.'  catch  in  the 
breath "  that  characterises  the  genuine  disease.  There  has  always 
been  much  preceding  mental  alarm,  but  too  much  weight  must  not  be 
placed  on  this,  because  great  anxiety  of  necessity  often  precedes  true 
hydrophobia.*  The  symptoms  of  the  spurious  form  commonly  soon 
subside  if  the  mind  of  the  patient  can  be  tranquillised,  or  if  the 
patient  has  recourse  to  some  method  of  ti'eatment  in  which  he  can  be 
induced  to  place  confidence.  An  instance  of  this  is  afforded  by  the 
nase  of  Dr.  Buisson,  who  after  receiving  on  a  scar  some  saliva  from  a 
patient  who  was  suffering  from  hydrophobia  (real,  or  more  probably 
supposed)  thought,  himself  suffering  from  the  disease.  He  took  a 
vapour-bath  and  was  well.  He  afterwards  treated  forty  cases  of  the 
same  character  successfully  in  this  manner !  But  there  are  other 
cases,  regarded  as  spurious,  in  which  the  mental  disturbance  is 
intense,  spasm  distinct,  and  the  patient  passes  into  a  state  of  exhaus- 
tion and  dies  in  a  few  days.  It  is  probable  that  most  of  these  cases 
are  genuine,  although  they  have  been  published  as  spurious. f 

I  have  more  than  once  known  a  first  attack  of  hysteroid  convulsion, 
in  a  lad  who  had  been  bitten  by  a  dog  some  time  before,  to  be  mistaken 
for  hydrophobia  on  account  of  the  barking  and  biting  and  general 
convulsion.  The  absence  of  the  respiratory  spasm,  and  the  intermit- 
ting character  of  the  disturbance,  should  prevent  error,  which,  indeed, 
can  only  occur  if  the  characteristics  of  severe  hysteria  are  not 
known. 

Prognosis. — Attacks  of  hydrophobia  differ  in  their  intensity  and  in 
the  rapidity  of  their  course,  but  at  present  all  we  can  say  is  that  in 
any  given  case,  however  mild,  only  one  issue  can  be  looked  for.  It  is 
to  be  hoped  that  the  future  may  render  the  prognosis  less  grave ; 
although  we  seem  as  far  as  ever  from  an  actual  cure  for  the  developed 
disease,  we  may  still  echo  the  hope,  expressed  by  Boerhaave  nearly 
two  hundred  years  ago,  "  Nor  ought  we  yet  to  despair  of  finding  out, 

*  There  has  more  often  been  a  tendency  to  regard  the  genuine  disease  as  imagi- 
nary than  to  mistake  the  spurious  for  the  genuine.  This  tendency  is  especially 
marked  among  critics  who  have  not  seen  the  case,  who  do  not  scruple  to  cast  doubts 
on  the  nature  of  even  fatal  cases.  It  is  not  certain  that  death  has  ever  occurred 
from  mere  "lyssophobia." 

f  The  diagnosis  of  the  spurious  from  the  genuine  form  of  the  disease  is  thus  a 
matter  on  which  there  is  very  wide  difference  of  opinion,  which  involves  also  the 
diagnostic  indications.  This  difference  will  probably  be  lessened  considerably  now 
that  we  have  an  apparently  crucial  test  in  the  results  of  inoculation.  Two  fatal 
cases  described  as  "  pseudo-hydrophobia  "  have  been  published  by  Broadbent  ('Clin. 
Soc.  Trans.,'  Feb.  23rd,  1883),  the  spurious  character  of  which  appears  to  me  to  be 
open  to  question.  In  one  case  it  is  true  the  bite  was  received  five  years  before,  but 
this  ought  not  to  be  allowed  to  determine  the  diagnosis  (see  p.  926). 


938  HYDROPHOBIA. 

some  time  or  other,  a  peculiar  antidote  for  this  poison,  seeing  we  have 
succeeded  in  poisons  thought  formerly  as  destructive." 

Treatment. — Preventive. — The  prevention  of  a  disease  is  important 
in  proportion  as  its  treatment  is  ineffectual;  and  the  fatality  of 
hydrophobia   renders   its    prophylaxis  of   paramount  urgency,     The 

prevention  of  hydrophobia  is  the  prevention  of  rabies,  and  this  could 
be  readily  effected  in  Great  Britain  on  account  of  our  insular  position. 
The  enforced  muzzling  of  all  dogs  for  a  period  of  one  year  would 
almost  certainly  stamp  out  the  disease.*  It  cannot  be  doubted,  also, 
that  the  number  of  dogs  is  vastly  in  excess  of  any  real  need  of  the 
community.  Most  cases  of  hydrophobia  are  due  to  animals  kept  for 
pleasure,  not  for  use,  and  often  ill-kept.  More  might  also  be  done  to 
make  those  who  keep  dogs  familiar  with  the  early  symptoms  of  rabies, 
and  to  render  it  a  criminal  offence  to  permit  a  dog  that  presents  such 
symptoms  to  be  at  large. 

Until  this  wise  and  humane  measure,  the  universal  use  of  the  muzzle, 
is  adopted,  the  prevention  of  hydrophobia  centres  in  the  method  devised 
by  Pasteur,  and  in  the  cauterisation  of  the  bite.  Pasteur's  system  of 
prevention  depends  on  the  fact  that  by  drying  the  spinal  cord  of 
rabbits  that  have  beeu  rendered  rabid  by  inoculation,  the  virus 
becomes  less  active;  the  subcutaneous  injection  of  an  emulsion  of  such 
a  cord  (dried  for  fourteen  days)  causes  no  definite  symptoms  of  the 
disease,  nor  do  subsequent  inoculations  or  injections  made  with  cords 
dried  for  a  less  time.  After  such  iuoculatious  an  animal  is 
"protected."  and  does  not  suffer  from  rabies  if  afterwards  bitten  by 
a  rabid  animal,  or  even  if  inoculated  with  the  virus  in  its  most  active 
state.f  These  conclusions  have  been  confirmed  by  Horsley,*  in  a 
series  of  experiments  on  dogs,  which  seem  to  be  free  from  any  source 
of  fallacy.  In  these  experiments  the  preventive  treatment  was  carried 
out  before  the  infection.     Pasteur  further  believes  that  such  a  course 

*  That  such  a  measure  is  not  adopted  is  a  national  disgrace,  which  is  accentuated 
by  the  (act  that  the  Government  derives  part  of  its  revenue  from  a  tax  upon  dogs. 
The  opposition  to  the  use  of  the  muzzle  is  one  of  the  strangest  developments  of 
morbid  sentiment.  There  are  apparently  thousands  of  veil-meaning  people  who 
would  prefer  that  hundreds  of  dogs  should  perish  every  year  of  a  painful  malady, 
that  many  human  lives  should  be  annually  lost,  and  scores  of  persons  should  be  sub- 
jected for  mouths  to  acute  mental  agony — rather  than  that  dogs  should  be  made  to 
wear  an  apparatus  which  causes  them  a  trifling  annoyance  for  a  few  days.  This 
perverted  sentiment  ought  to  be  met  with  universal  abhorrence,  as  a  disgrace  to 
humanity. 

t  Pasteur  puts  forward  the  theory,  already  refered  to — which  has  however,  no- 
thing to  do  with  the  accuracy  of  his  facts — that  the  virus,  a  mid  a,  pro- 
duces, in  its  development,  some  substance  by  which  its  growth  is  checked,  as  is  the 
growth  of  yeast  by  the  alcohol  produced.  He  thinks  that  the  spinal  cord  contains 
both  the  virus  and  the  antidotal  product,  and  that  the  antidote  is  much  less  influ- 
enced by  the  process  of  drying  than  is  the  virus. 

X  '  Report  of  Committee  of  Inquiry  into  M.  Pasteur's  Treatment  of  Hydro- 
phobia,' ls>7. 


TEEATMENT.  939 

of  injections  is  effective  in  preventing  the  occurrence  of  tbe  disease 
in  a  person  who  has  been  already  inoculated  with  rabies,  and  he  has 
treated  thus  many  thousands  of  bitten  persons.  The  efficacy  of  the 
treatment  has  been  the  subject  of  much  discussion,  and  so  also  has  its 
safety.  Two  facts  only  are  certain.  First,  the  danger  that  rabies  may 
be  communicated  by  the  treatment  is  very  small.  There  is,  indeed, 
one  case  in  which  this  result  is  rendered  probable  by  the  very  unusual 
character  of  the  symptom,  the  case  of  the  man  Groffi,  who  was  bitten 
by  a  rabid  cat,  and  died  of  paralytic  rabies  in  St.  Thomas's  Hospital 
(see  p.  930).*  But  this  case  only  brings  into  relief  the  immunity  with 
which  the  course  of  treatment  has  been  pursued  in  an  enormous  number 
of  cases. f  The  other  fact  is  that  the  treatment  is  not  invariably 
successful.  In  several  instances,  rabies  has  developed  at  about  the 
same  time,  after  the  original  bite,  that  it  might  be  expected  to  develop 
had  the  treatment  not  been  adopted,  and  its  severity  has  not  apparently 
been  modified.  The  efficacy  of  the  treatment  has  therefore  to  be 
judged  from  statistics,  and  the  difficulty  of  drawing  a  conclusion  is 
great,  and  is  increased  by  the  fact  that,  of  a  given  number  of  persons 
bitten  by  a  mad  dog,  only  a  proportion,  sometimes  small,  suffer  after- 
wards from  the  disease  (see  p.  925) .  But  the  proportion  who  have 
suffered  after  undergoing  the  Pasteurian  treatment  is  certainly  far 
smaller  than  it  would  be  in  a  like  number  of  persons  who  had  not  been 
thus  treated.  Up  to  the  end  of  1886,  2682  persons  had  been  inocu- 
lated, and  the  subsequent  mortality  from  rabies  among  them  was 
between  1  and  1*2  per  cent.  Even  allowing  largely  for  doubtful  bites 
it  is  estimated  that  not  less  than  5  per  cent,  of  such  a  series  would  have 
died  without  the  treatment. £      We  cannot  feel  sure  that  in  all  cases 

*  The  result  has  been  ascribed  to  the  circumstance  that  the  man  was  almost  con- 
stantly drunk  while  undergoing  the  treatment. 

t  It  has  been  suggested  that  some  of  the  deaths  from  the  ordinary  form  of  rabies, 
after  the  treatment,  were  due  to  the  inoculations,  but  the  case  referred  to  renders 
this  doubtful.  It  suggests  that  the  inoculation  with  the  rabbit's  cord  would  produce 
the  paralytic,  and  not  the  ordinary  form. 

X  '  Report  of  Hydrophobia  Committee,'  p.  3.  Some  further  facts  are  very  im- 
portant. Of  233  persons  bitten  by  animals  in  which  rabies  was  certain  (either  by 
inoculation  from  the  spinal  cord  or  from  the  occurrence  of  rabies  in  other  animals 
or  persons  bitten)  only  4  died,  while  without  inoculation  40  would  probably  have 
died.  The  mortality  among  persons  bitten  by  rabid  wolves  is  exceedingly  high ;  the 
bites  are  generally  severe,  and  prompt  cauterisation  is  impossible :  48  persons  so 
bitten  were  treated ;  a  mortality  of  30  would  have  been  almost  certain,  but  only  91 
died,  and  in  3  of  these  the  symptoms  commenced  while  under  treatment.  One  very 
striking  group  of  cases  is  that  of  six  children  bitten  at  Bradford,  January  24th, 
1886,  by  a  dog  proved  to  be  rabid  by  experimental  inoculation,  and  by  the  fact  that 
another  person  who  had  been  bitten  by  the  same  dog  died  of  hydrophobia  on  March 
4th  of  the  same  year.  The  six  children  who  were  treated  were  perfectly  well  at  the 
date  of  the  report,  eighteen  months  after  the  bites.  A  more  crucial  test  could 
hardly  be  devised.  Equally  strong  is  the  instance  of  three  children  bitten  at 
Shipley,  Yorkshire,  in  March,  1886,  and  treated  by  Pasteur,  all  of  whom  remained 
well  a  year  later,  while  another  person  bitten  by  the  same  dog,  and  not  treated,  died 
from  hydrophobia  seven  weeks  after  the  bite. 


940  HYDROPHOBIA. 

the  animal  that  inflicted  the  bite  was  actually  rabid,  and  hence  a  new 
source  of  uncertainty  is  introduced,  the  influence  of  which  cannot  be 
accurately  assessed.  The  Committee  on  Hydrophobia  investigated 
the  facts  of  ninety  unselected  cases  treated  by  Pasteur,  and  in  two 
thirds  of  these  there  was  evidence  which  satisfied  the  committee  that 
the  dog  was  rabid.  In  no  less  than  twenty-four  the  bites  were  on 
naked  parts,  and  the  wounds  were  not  cauterised  or  treated  in  any 
way  likely  to  prevent  the  action  of  the  virus.  Every  one  of  these 
ninety  patients  had  continued  well,  although  all  had  been  bitten  more 
than  six  months,  and  most  of  them  more  than  a  year  before.  In  such 
a  number  of  cases  of  this  character  it  was  calculated  by  the  committee, 
on  the  lowest  estimate,  that  not  less  than  eight  would  have  suffered 
from  hydrophobia.  The  conclusion  from  the  facts  at  present  available 
seems,  therefore,  to  be  that  the  treatment  is  of  great  value,  although 
it  does  not  secure  absolute  safety,  and  that  the  method  is  not  attended 
by  more  than  an  extremely  small  risk  of  the  production  of  rabies. 

Treatment  of  the  Bite. — The  poison  is  deposited  in  a  wound,  and  if 
it  can  be  destroyed  before  it  passes  into  the  blood,*  the  disease  will 
be  prevented.  The  measures  to  be  adopted  for  this  purpose  belong 
to  the  province  of  surgery,  but  may  be  briefly  mentioned.  If  the 
wound  is  on  a  limb,  the  circulation  should,  if  possible,  be  arrested  by 
a  ligature  arouud  the  limb,  applied  immediately.  Free  bleeding 
should  be  encouraged  and  the  wound  should  be  well  washed.  These 
measures  are  most  important,  because  it  is  not  often  that  the  cautery 
can  be  immediately  applied.  The  use  of  these  measures  in  the  case 
of  bites  of  every  kind  ought  to  be  part  of  the  education  of  children. 
The  wound  may  be  sucked,  if  there  is  no  abrasion  in  the  mouth, 
which  should  be  washed  out  each  time.  Absorption  of  poison  through 
a  mucous  membrane  (to  judge  from  experiments  on  the  conjunctiva) 
occupies  several  minutes.  As  soon  as  possible,  the  wound  should  be 
thoroughly  cauterised  by  the  actual  cautery,  nitric  acid,  or  nitrate  of 
silver.     Whenever  practicable  the  bitten  part  should  be  excised. 

The  treatment  of  the  developed  disease  has  to  be  directed  chiefly  to 
the  diminution  of  the  suffering  of  the  patient.  At  the  same  time 
recovery  cannot  be  said  to  be  impossible.  It  is  certain  that  cases  have 
recovered  in  the  past,  and  it  seems  therefore  certain  that  cases  will 
recover  in  the  future.  However  slender  may  be  the  hope  of  doing 
more  than  lessen  suffering,  the  patient  should  not  be  given  over  into 
the  hands  of  death,  even  indirectly  by  efforts  exclusively  directed 
to  the  euthanasia,  still  less  ostensibly,  as  by  the  feather  beds  of  old.f 

*  This  is  the  common  theory  of  cauterisation,  but  is  hardly  consistent  with  the 
assumed  localisation  of  the  poison  in  the  wound  during  the  period  of  incubation.  It 
is,  however,  certain  that  cauterisation  is  of  little  value  unless  it  is  almost  imme- 
diate. Promptness  is  of  more  importance  than  the  agent  employed.  A  smoker's 
"  vesuvian"  would  probably  be  quite  effectual  if  instantly  used. 

t  It  is  curious  to  note  how  the  name  of  the  disease  preserves  the  fact  that  the 
horror  of  water  was  formerly  regarded  not  only  as  a  characteristic  of  the  disease, 


TEEATMENT.  941 

The  pathological  lesions  show  that  the  functional  nervous  excite- 
ment has  organic  consequences,  and  it  is  important,  in  order  to  lessen 
these,  and  to  maintain  the  strength  of  the  patient,  that  whatever 
excites  the  paroxysmal  disturbance  of  the  nervous  system  should  be 
carefully  avoided.  A  dimly  lighted,  quiet  room  should  be  secured,  and 
only  the  necessary  attendants  should  be  admitted  into  it.  Every  sight 
or  sound  likely  to  disturb  should  be  avoided,  and  it  would  probably  be 
wise,  if  the  spasmodic  dysphagia  is  great,  to  feed  only  by  peptonised 
enemata. 

The  drugs  that  have  been  employed  in  the  treatment  of  the  disease 
are  innumerable,  and  embrace  (besides  most  known  sedatives)  a 
number  of  alleged  specifics,  all  of  which  have  been  abundantly  proved 
to  be  useless.  The  treatment  employed  in  the  few  cases  in  which 
recovery  has  taken  place,  has  generally  been  found  powerless  in  other 
instances. 

One  case  is  said  to  have  recovered  under  the  influence  of  mercury, 
but  this  has  been  tried  since  in  numberless  instances  without  result. 
Curara,  however,  has  been  credited  with  three  cures  (Offenburg, 
Polli,  and  Watson),  of  which  one  case,  that  of  Offenburg,'  seems 
undoubtedly  genuine.  The  drug  was  first  recommended  half  a  century 
ago  by  an  Englishman,  Sewell,*  but  tried  in  small  doses  it  failed.  It 
arrests  the  hydrophobic  spasms  by  paralysing  the  motor  nerves,  and 
this  may  render  artificial  respiration  necessary.  There  seems  to  be  a. 
remarkable  tolerance  of  curara  in  this  disorder.  The  dose  commonly 
employed  has  been  from  -^  to  %  of  a  grain  repeated  every  quarter 
or  half  hour  until  there  is  general  muscular  paralysis,  and  renewed  as 
this  effect  passes  off.  Polli  administered  in  all  three  grains  in  five 
and  a  half  hours  to  a  child  twelve  years  old.  Even  grain  doses  have 
failed  to  cause  paralysis.f  One  case,  probably  genuine,  has  been 
recorded,  in  which  recovery  occurred  under  the  use  of  Calabar  bean  and 
hypodermic  injections  of  morphia  (Nicholls).  Bromide  of  potassium 
has  very  little  influence ;  if  given  at  all  it  should  be  in  large  doses, 
one  or  two  drachms.  Chloral  gives  some  relief,  and,  in  a  case  recorded 
by  Sansom,  life  was  prolonged  for  ten  days  under  its  use.  It  is  pro- 
bable that  the  combination  of  chloral  and  morphia,  which  has  a  special 

but  as  the  predominant  element  in  its  pathology,  which  afforded  the  chief  therapeu- 
tical indication.  "In  the  intervals"  (of  venesection,  says  Boerhaave)  "he  must  be 
blinded  and  thrown  into  a  cold  pond,  or  be  made  wet  with  the  continual  throwing 
of  water  upon  him,  till  he  doth  not  seem  any  more  to  be  afraid  of  water,  or  but 
little,"  a  final  reservation  that  was  at  least  prudent. 

*  And  also  by  Waterton,  the  naturalist,  who  brought  to  England  a  supply  of  the 
drug  (see  'Dolan's  Hydrophobia,'  2nd  ed.,  p.  170,  and  Waterton's  'Travels'). 

f  But  it  is  possible  that  in  some  cases  the  agent  has  not  been  very  active.  Thus, 
in  a  case  recorded  by  Bristowe,  in  which  as  much  as  1J  grains  were  injected  at  a  time, 
and  8  grains  in  twenty-four  hours  produced  very  little  effect,  the  curara  "  had  been 
in  stock  some  time,  and  there  was  reason  to  believe  that  it  had  deteriorated  in 
quality"  ('Brit.  Med.  Journ.,'  April  28th,  1885).  The  activity  of  the  specimen 
should  always  be  tested. 


942  METALLIC    POISONING. 

influence  on  the  respiratory  centre,  deserves  further  trial,  and  on  the 
whole  constitutes,  as  far  as  is  at  present  known,  the  wisest  treatment. 

Tracheotomy  was  suggested  by  Marshall  Hall  as  a  means  of  averting 
death  during  an  asphyxiating  attack  of  spasm,  but  it  is  probably 
powerless.  The  spasm  involves  the  chest  wall,  and,  according  to  Pitt,* 
the  glottis  is  widely  open  during  the  attack. 

Of  the  various  remedies  that  have  been  held  in  popular  esteem 
or  vaunted  as  private  specifics,  little  need  be  said.  They  furnish 
a  curious  chapter  in  the  history  of  charlatanism  and  credulity. 
"  Hitherto,"  we  may  still  say  with  Boerhaave,  "  we  have  not  met  with 
any  one  which  deserves  credit  enough  to  be  entrusted  with  the  life  of 
people  thus  miserably  afflicted,  for  no  one  is  known  whereof  the  ex- 
periments be  certain,  but  they  owe  their  birth  either  to  speculation, 
or  they  have  been  copied  from  others  and  taken  upon  trust."  The 
list  of  reputed  remedies  that  he  gives  has  received  a  long  addition 
since  his  time.  Persons  who  fancy  that  they  are  suffering  from  the 
disease  are  cured  by  these  measures,  and  their  recommendations  are 
repeated  with  confidence  by  those  whose  readiness  to  express  an  opinion 
is  inversely' proportioned  to  their  capacity  for  forming  a  judgment. 
Foremost  among  these  measures  is  the  vapour-bath  of  Buisson,  the 
origin  of  which  has  been  already  mentioned  (p.  937),  and  which  every 
few  years  makes  its  reappearance  in  the  public  papers. 

The  saliva  of  persons  suffering  from  hydrophobia  has  been  proved 
to  be  capable  of  communicating  the  disease  to  animals.  Hence  the 
attendants  should  be  cautioned  to  have  no  uncovered  abrasions  on  the 
hands,  and  to  wash  from  the  eyes  and  face  any  saliva  that  may  have 
been  spit  on  them.  If  they  are  bitten  by  the  patient,  the  wound 
should  be  treated  as  if  it  had  been  inflicted  by  a  rabid  animal.  These 
precautions  remove  all  danger,  and  any  anxiety  that  is  felt  may  be 
removed  by  the  assurance  that,  of  the  thousands  of  persons  who  have 
attended  on  patients  with  hydrophobia,  no  authentic  instance  has 
been  recorded  in  which  the  malady  was  thus  contracted. f  Nor  has  it 
ever  been  known  to  have  been  acquired  through  making  a  post-mortem 
examination  on  the  bodies  of  persons  who  have  died  from  the  disease. 


METALLIC  POISONING. 


Many  metals,  when  taken  into  the  body,  cause  chronic  disturbance 
of  the  nervous  system,  in  addition  to  the  acute  symptoms  that  are 
produced  by  a  considerable  dose  of  the  poison.     The  latter  are  not 

*  G.  N.  Pitt, «  Med.  Times,'  June  20th,  1885. 

t  Indeed,  even  the  danger  of  hites  seems  small.  A  child,  whose  malady  was 
verified  by  the  inoculation  test,  bit  two  persons  whose  wounds  were  uncauterised,  and 
at  the  end  of  sis  months  they  were  still  well  ('  Riv.  Clin,  di  Bologna,'  Aug.,  18S6). 


LEAD-POISONING. 

considered  here,  since  they  belong  to  the  province  of  toxicology.     The 
more  chronic  disturbance  generally  results  from  the  often  repeated 
entrance    of    small    quantities   of    the    metal,    and    seldom    sue 
a  single  large    dose.     The  chief   metals  that  influence   the    nervous 
system  are  lead,  arsenic,  silver,  and  mercury. 

Lead-poisoning. 

Etiology. — The  occurrence  of  symptoms  of  lead-poisoning  seems 
to  be,  to  some  extent,  determined  by  individual  peculiarities.  Of  a 
given  number  of  persons,  all  of  whom  have  been  exposed  to  the  same 
influence,  and  exhibit  indications  of  the  presence  of  lead  in  the  system, 
some  will  suffer  considerably,  some  slightly,  others  not  at  all.  Little 
is  known  of  the  conditions  which  thus  influence  the  result,  but  females 
seem  more  prone  to  suffer  than  males,  the  weaklv  than  the  strou<*. 
and  those  who  inherit  a  tendency  to  gout,  especially  if  the  affection, 
thus  inherited,  was  due  to  the  same  cause.  Disturbances  of  the 
nervous  system  are  much  increased  by  intemperance;  the  influence  of 
alcohol  in  evoking  cerebral  symptoms  is  not  only  observed  in  man, 
but  has  been  noted  in  animals. 

The  duration  of  exposure,  before  symptoms  occur,  varies,  and  is 
chiefly  determined  by  the  amount  of  lead  daily  absorbed.  When  this 
is  large,  severe  symptoms  are  often  induced  in  a  few  weeks.  Some  of 
the  most  acute  forms  occur  in  youug  persons  whose  exposure  has  been 
brief.  It  is  probable  that,  when  the  daily  dose  of  the  poison  is  small, 
a  certain  amount  of  tolerance  is  sometimes  established,  which  may  be 
ultimately  overcome  in  consequence  of  the  accumulation  of  lead  in  the. 
system,  or  in  consequence  of  some  impairment  of  the  general  health.* 

The  sources  of  lead-poisoning  are  very  numerous,  but  may  be 
divided  into  two  groups,  the  industrial  and  the  accidental.  Of  the 
former,  the  most  potent  are  lead-works,  especially  those  in  which 
white-lead  is  prepared,  but  more  frequent  are  the  various  industries 
in  which  prepared  lead  is  used.  Painters,  plumbers,  type-founders, 
compositors,  and  those  who  glaze  pottery  with  lead,  are  the  most 
frequent  sufferers.  Glass  grinders  may  also  suffer,  lead  being  a  con- 
stituent of  most  kinds  of  glass.  Various  other  occupations  involve 
liability  to  poisoning,  often  unsuspected.  Licking  gummed  paper, 
tinted  with  colouring  matter  containing  lead,  and  the  process  of 
preparing  cards  with  a  lead  glaze,  have  been  effective.  The  accidental 
sources  are  extremely  numerous;  the  most  frequent  is  the  contamina- 
tion of  drinking-water  by  leaden  pipes,  or  by  lead-lined  cisterns. f 

*  Oa  these  and  most  other  facts  relating  to  the  subject,  numerous  original  obser- 
vations, clinical  and  experimental,  will  be  found  in  '  Lead  Poisoning,'  by  T.  Oliver, 
M.D.,  Edinburgh,  1891. 

f  Various  chemical  peculiarities  of  water  will  make  it  take  up  lead  more  readily. 
For  particulars  the  reader  is  referred  to  works  on  hygiene.  A  curious  instance  is 
related  by  Thome  in  which  lead-poisoning  at  Sheffield  was  due  to  the  presence  in  the 
water  of  a  peculiar  acid  derived  from  the  soil  ('  Practitioner/  Dec,  1886,  p.  465). 
This  danger  from  water  was  known  two  thousand  years  ago. 


944  LEAD-POISONING. 

Acid  fruits,  cooked  in  glazed  earthenware  vessels,  have  become 
charged  with  lead;  shot  left  in  wine  bottles,  after  cleaning,  has  been 
dissolved  by  the  wine  or  "  mineral  water ;  "  snuff  may  be  contaminated 
in  consequence  of  being  packed  in  lead-paper.  Lead  enters  into  the 
composition  of  some  hair  dyes  and  cosmetics,  and  cases  of  lead- 
poisoning  have  occurred  from  their  use.  Infants  at  the  breast  have 
been  poisoned  by  a  lead  ointment  applied  to  excoriated  nipples. 
Lastly,  symptoms  of  chronic  poisoning  have  occurred  from  the 
continued  medicinal  administration  of  lead. 

The  most  frequent  path  by  which  lead  enters  the  system  is  the 
alimentary  canal,  not  only  by  the  accidental  contamination  of  articles 
of  food,  but  also  through  un cleanliness.  Workers  with  lead  often 
neglect  to  remove  all  trace  of  lead  from  their  hands  before  taking  food, 
and  thus  become  poisoned.  This  is  shown  by  the  influence  of  enforced 
cleanliness,  which  lessens  the  amount  of  lead-poisoning  among  such 
artisans.  The  saliva  dissolves  but  little  of  the  carbonate  of  lead  (the 
form  in  which  the  metal  is  most  frequently  received).  The  hydro- 
chloric acid  of  the  gastric  juice  transforms  it  into  soluble  chloride,, 
and  the  bile  also  dissolves  it,  but  in  each  case  products  of  digestion 
hinder  the  process,  insoluble  albuminates  being  formed,  and,  as  a  rule, 
most  of  the  lead  passes  away  by  the  bowel  (Oliver).  When  lead 
enters  through  the  skin,  as  in  poisoning  from  the  use  of  cosmetics  and 
hair  dyes,  it  may  be  dissolved  by  some  of  the  organic  acids  secreted 
by  the  cutaneous  glands,  or  get  through  the  skin  in  consequence  of 
the  friction  employed  in  rubbing  hair  dyes  into  the  roots  of  the  hair. 
•Lead-poisoning  has  been  produced  in  children  by  the  continued 
use  of  Goulard's  lotion.*  Lead  may  be  thus  absorbed  by  those  who 
work  with  the  hands  immersed  in  preparation  of  the  metal.  It  may 
certainly  enter  by  the  mucous  membrane  of  the  nose  (in  the  case  of 
poisoning  by  contaminated  snuff),  and  probably  also  by  that  of  the 
other  air-passages  ;  inhaled  particles  are  dissolved  by  the  alkaline 
secretion,  or  enter  the  blood  and  are  transformed  into  soluble 
bicarbonate  by  the  carbonic  acid  contained  in  it.  No  doubt,  however, 
some  lead,  entering  by  the  air,  is  carried  by  the  buccal  secretions  to 
the  stomach. 

It  is  commonly  believed  that,  however  lead  enters  the  system,  it 
acts  on  the  tissues  through  the  blood,  permeating  the  whole  body  and 
influencing  chiefly  certain  structures.  Unquestionably,  many  of  the 
symptoms  must  be  thus  produced.f  But  lead  has  been  said  also  to 
have  a  local  influence  on  the  part  where  it  comes  in  contact  with  the 
skin.  This  opinion,  although  based  on  some  curious  facts,  has  not 
received  general  confirmation.  J 

*  It  has  been  readily  produced  in  animals  by  an  ointment  of  oleate  of  lead  and 
lanoline  (Oliver). 

t  Although  some  are  ascribed  to  indirect  effects,  due  to  the  deranged  action  of 
the  liver  and  kidneys  (Oliver). 

X  The  facts  that  suggest  a  local  influence  are  mentioned  at  a  later  page. 


SYMPTOMS.  945 

The  lend  which  has  entered  the  system  collects  in  the  various  tissues 
and  organs,  but  not  in  the  same  degree  in  all.  In  dogs,  to  "which 
lead  is  given  in  food,  the  organs  have  been  found  to  contain  the 
metal  in  the  following  order: — bones,  kidneys,  liver,  spinal  cord,  brain, 
muscles,  intestine ;  elsewhere  there  is  only  a  trace  (Heubel).  It  is  not 
certain  that  this  order  is  always  the  same  in  man.  In  one  case,  for 
instance,  much  more  lead  was  found  in  the  brain  than  in  the  liver, 
and  none  in  the  spinal  cord  (Troisier  and  Lagrange)  ;  while  in  another 
case  the  liver  contained  much  and  the  brain  none.*  In  even  acute 
cases  lead  has  been  sometimes  absent  in  the  brain. f 

Lead  is  excreted  by  the  liver ;  also,  it  is  said,  by  the  intestinal 
mucons  membrane,  but  in  man  chiefly  by  the  kidneys.  The  urine 
always  contains  lead,  when  this  is  present  in  the  blood ;  the  quantity 
of  urine  is  at  first  increased  and  subsequently  lessened  ;  at  the  last, 
there  may  even  be  anuria,  and  with  it  intense  disturbance.  As  a  rule, 
the  amount  of  uric  acid  excreted  bears  an  inverse  relation  to  the 
amount  of  lead.  When  injected  under  the  skin  of  an  animal,  almost 
all  has  been  said  to  pass  away  by  the  bile,J  but  this  does  not  seem  to 
be  the  case  in  man.  Once  combined  in  the  organs,  it  is  very  slowly 
eliminated,  and  its  presence  may  be  detected  years  after  it  has  ceased 
to  be  taken  in.  It  probably  exists  in  them  in  some  combination  with 
albumen,  which  may  not  be  always  the  same.  But  the  amount  fixed 
in  the  tissues  is  very  small  compared  with  that  which  is  eliminated 
from  the  blood,  and  the  quantity  that  enters  the  blood  is  small  com- 
pared with  that  which  enters  the  stomach. 

Symptoms. — Disturbance  of  the  general  nutrition  usually  precedes 
other  symptoms,  although  it  may  escape  observation.  There  is 
anaemia,  often  considerable,  depending  on  an  actual  diminution  in 
the  number  of  blood- corpuscles.  The  hsemoglobin  is  reduced  in 
proportion  to  the  corpuscles,  and  the  anaemia  of  lead  thus  differs  from 
that  of  chlorosis,  in  which  the  reduction  is  much  greater  in  the  haemo- 
globin than  in  the  corpuscles.  Lead-anaemia  resembles  in  this  respect 
pernicious  anaemia,  and  the  resemblance  is  not  merely  superficial. 
The  condition  (which  is  readily  produced  in  animals)  is  probably  due 
to  accumulation  of  lead  in  the  bones,  the  medulla  of  which  is  known 
to  be  an  important  blood-making  tissue.  Atrophy  and  degeneration 
of  the  marrow  have  actually  been  found  (Eaimondi).  The  general 
nutrition  and  muscular  strength  are  much  impaired.  As  a  rule  the 
temperature  is  normal,  but  now  and  then  there  is  slight  continuous 
pyrexia ;   in  one  case  under  my   observation  the  temperature  was 

*  Pye-Smith,  in  Fagge's  'Manual/  ii,  163. 

t  Comby,  Oliver. 

X  Lehmann,  'Diss.  Berl.,'  1882;  Prevosfc  and  Binet,  'Rev.  Suisse/  1889.  Lead 
may  also  be  eliminated  by  the  skin,  as  is  proved  by  a  case  of  poisoning  by  red-lead, 
recorded  by  Oliver,  in  which  the  linen  in  contact  with  the  skin  was  reddened  by  the 
perspiration. 

VOL.  II.  60 


946  LEAD-POISONING. 

constantly  raised  to  99°  or  100°.  When  acute  nervous  symptoms  occur, 
elevation  of  temperature  is  common.  In  a  few  cases  endocai'ditis 
has  been  observed ;  degeneration  of  the  cardiac  valves  may  occur  in 
chronic  cases,  as  part  of  the  slow  changes  in  the  vascular  system. 

The  subjects  of  lead-poisoning  often  suffer  from  gout  when  they 
have  reached  middle  or  later  life* — an  important  fact,  alike  from  a 
diagnostic  and  pathological  point  of  view.  It  must  be  associated  with 
the  lessened  elimination  of  urio  acid,  although  the  nature  of  the 
association  is  not  certain,  and  will  be  again  referred  to.  The  kidneys 
soon  become  diseased,  first  from  a  form  of  parenchymatous  nephritis, 
which  tends  to  become  interstitial,  and  at  last,  as  in  ordinary  gout, 
the  kidneys  are  often  indurated  and  granular.  Apart  from  actual 
kidney  disease,  albumen  may  be  present  in  the  urine  at  times,  as,  for 
instance,  during  attacks  of  colic  (Seguin).  The  effect  on  the  kidneys 
is  very  important,  since  it  leads  to  cardiac  and  arterial  disease,  and 
thus  to  cerebral  lesions.  By  this  mechanism,  more  frequently  than 
by  any  other,  lead-poisoning  causes  death.  Kidney  disease  may 
slowly  follow  lead-poisoning  which  has  ceased.  A  gentleman  suffered 
from  wrist-drop  due  to  lead-poisoning  from  drinking-water;  his  urine 
was  then  normal.  There  was  no  further  ingestion  of  lead,  and  he 
recovered  perfectly,  but  six  years  later  presented  all  the  signs  of 
organic  kidney  disease. 

A  characteristic  symptom  is  a  narrow,  bluish -black  line  on  the 
gums,  close  to  the  teeth,  distinguished  by  its  narrowness  and  tint 
from  the  more  common  zone  of  purplish  congestion.  The  lead  line 
forms  where  the  gum  is  not  in  perfect  connection  with  the  tooth,  and 
it  is  really  the  edge  of  a  layer  of  deposit  beneath  the  inner,  detached 
surface  of  the  gum  (Cras).  It  may  be  first  seen  on  the  projections 
of  the  gum  between  the  teeth.  It  consists  of  sulphide  of  lead, 
deposited  chiefly  outside  loops  of  blood-vessels,  and  hence,  when 
viewed  with  a  lens,  it  often  has  a  punctate  appearance.  The  sulphur 
comes  from  albuminous  matters  which  accumulate  between  the  gum 
and  the  tooth.  If  the  gums  are  not  detached  from  the  teeth,  and 
these  are  kept  scrupulously  clean,  the  lead  line  may  be  visible  only 
between  the  teeth,  or  it  may  even  be  absent  entirely.  A  punctate 
deposit  of  sulphide  of  lead  may  form  in  the  mucous  membrane  of  the 
lip,  upper  or  lower  (as  Grarrod  first  pointed  out).  It  is  only  seen 
when  tbere  is  an  accumulation  of  tartar  on  the  teeth  with  which  the 
stained  lip  has  been  in  contact.  A  low  form  of  stomatitis  has  been 
occasionally  observed,  and  sometimes  ulceration  occurs  on  the  inner 
surface  of  the  cheek  and  elsewhere. 

*  This  was  originally  pointed  out  by  Garrod.  "Saturnine  gout"  is  invariable  in 
those  whose  parents  were  gouty,  and  bo  frequent  that  most  sufferers  from  chronic 
lead-poisoning  are  distinctly  gouty.  This  is  at  least  the  case  in  the  south  of  England. 
It  is  said  not  to  be  so  in  the  north,  where  gout  is  both  uncommon  and  a  rare  effect 
of  lead-poisoning,  unless  the  latter  is  reinforced  by  an  inherited  tendency  to  gout 
(Oliver). 


SYMPTOMS.  947^ 

Severe  abdominal  pain,  "  lead  colic,"  is  another  frequent  symptom. 
It  is  a  paroxysmal  pain,  felt  chiefly  in  the  region  of  the  umbilicus, 
sometimes  over  a  more  extensive  area,  and  accompanied  with  obsti- 
nate constipation.  During  the  paroxysms  there  is  retraction  of  the 
abdominal  wall,  sometimes  vomiting,  and  usually  retardation  and 
increased  tension  of  the  pulse.  The  constant  constipation  proves 
that  the  pain  is  not  (as  has  been  sometimes  maintained)  in  the 
abdominal  wall.  It  is  apparently  due  to  a  time  "  colic,"  the  result  of 
a  spasmodic  contraction  of  the  bowel,  probably  the  colon — a  contrac- 
tion which  is  tetanic  and  not  peristaltic,  and  therefore  arrests,  instead 
of  promoting,  the  movement  of  the  intestinal  contents.  The  consti- 
pation may  be  facilitated  by  a  diminution  in  the  secretion  from  the 
mucous  membrane,  degenerative  changes  in  which  have  been  found. 
Such  tetanic  contraction  has  also  been  produced  in  animals.  Its 
mechauism  is  uncertain.  It  has  been  ascribed  to  the  influence  of  lead 
on  the  sympathetic  ganglia,  especially  the  mesenteric  and  cceliac 
plexuses,  on  the  nervous  ganglia  within  the  intestinal  wall,  on  the 
muscular  fibres  of  the  bowel  itself,  and  it  has  also  been  supposed  to  be 
connected  with  the  accumulation  of  sulphide  of  lead  in  the  mucous 
membrane,  sometimes  visible  after  death.*  At  present  there  is  no 
evidence  to  show  which  of  these  theories  is  correct,  and  it  is  therefore 
uncertain  whether  lead  colic  should  or  should  not  be  classed  among 
the  nervous  effects  of  lead-poisoning.  The  retardation  of  the  heart's 
action,  and  the  increased  tension  of  the  pulse,  associated  with  the 
colic,  are  doubtless,  in  part  at  least,  reflex  effects  of  the  strong  afferent 
impression.  Severe  paroxysms  of  epigastric  pain  have  also  occurred, 
associated  with  inaction  of  the  intercostal  muscles,  apparently 
inhibitory. 

Nervous  Symptoms. — The  definite  nervous  symptoms  produced  by 
lead-poisoning  are  of  five  chief  classes  :  (1)  Pains  in  various  situa- 
tions. (2)  Muscular  paralyses  with  wasting,  acute  or  chronic.  (3) 
Paraplegic  symptoms.  (4)  Cerebral  disturbance,  acute  and  chronic, 
transient  or  increasing ;  convulsions,  delirium,  coma,  amaurosis, 
hemiansesthesia.     (5)  Affections  of  certain  cranial  nerves. 

1.  Pains  in  the  limbs  are  very  common,  and  may  be  referred  to  the 
muscles  or  the  joints,  or  may  be  vague  in  seat.  They  are  usually  dull, 
aching,  "rheumatic"  pains,  but  sometimes  sharper  and  neuralgic 
in  character.  The  joint  pains  have  been  called  "  saturnine  arthralgias," 
but,  apart  from  gout,  articular  pain  is  not  usually  prominent. 
There  is  often  tenderness  of  the  muscles,  and  occasionally  tingling 
of  the  extremities,  rarely  areas  of  anaesthesia.     I  have   seen,  for 

*  Maier  ('  Virch.  Arch.,'  Bd.  xc)  found  degeneration  of  the  nervous  ganglia  in  the 
wall  of  the  intestine,  and  in  the  abdominal  sympathetic,  in  rabbits  in  which  chronic 
lead-poisoning  had  been  experimentally  produced.  He  also  found  similar  changes 
in  a  case  of  saturnism  in  man.  The  cceliac  plexus  was  surrounded  by,  and  infiltrated 
with,  connective  tissue,  and  the  sympathetic  cells  were  in  part  atrophied,  but  the 
fibres  were  little  changed. 


943 


LEAD-POISOXING. 


instance,  diminished  sensibility  to  touch  in  the  back  of  one  forearm 
and  the  front  of  the  opposite  leg,  and,  in  another  case,  anaesthesia 
around  the  anus.  Such  symptoms  are  sometimes  the  result  of 
neuritis.  Muscular  "stiffness"  may  be  associated  with  the  pain, 
and  now  and  then  there -is  painful  cramp  in  the  calves.  When 
the  pains  have  a  well-marked  neuralgic  character  in  the  arm  or 
leg,  they  may  follow  the  course  of  the  nerves,  and  tenderness  may 
accompany  them.     Epigastric  pain  has  been  already  mentioned. 

2.  Local  muscular  paralysis  with  wasting  is  a  very  common  con- 
sequence of  lead-poisoning.  It  presents  two  forms.  In  one,  the  most 
frequent,  loss  of  power  precedes  wasting,  and  the  muscles  present  the 
"  degenerative  reaction,"  i.  e.  loss  of  faradic  irritability  (from  acute 
degeneration  of  the  nerve-fibres)  and  preservation  of  the  voltaic  irri- 
tability of  the  muscular  tissue, 
just  as  in  a  traumatic  lesion 
of  a  nerve.  The  common  seat 
of  this  form  is  the  extensor 
muscles  of  the  wrist  and  fin- 
gers, and  "wrist-drop"  results. 
In  the  other  form  of  saturnine 
atrophic  paralysis  the  weakness 
and  wasting  come  on  simulta- 
neously and  proceed  pari  passu ; 
faradic  and  voltaic  irritability 
are  both  lessened  in  proportion 
to  the  wasting,  just  as  in  pro- 
gressive muscular  atrophy.  This 
form  may  affect  any  part,  but 
is  most  common  in  the  small 
muscles  of  the  hand.  Between 
these  two,  intermediate  forms 
are  sometimes  met  with,  in 
which  a  slight  increase  and 
qualitative  change  in  voltaic 
irritability  accompanies  a  mode- 
rate diminution  in  that  to  fara- 
dism. 

In  the  acute  form,  not  only  is  the  wasting  secondary  to  the  weak- 
ness, but  some  muscles  may  be  merely  weak,  and  may  recover  without 
undergoing  atrophy.  In  the  muscles  at  the  back  of  the  forearm 
wasting  is  almost  invariable.  This  extensor  paralysis  is  usually 
bilateral,  although  one  arm  is  often  affected  a  little  earlier  than  the 
other.  The  right  arm  is  generally  (but  not  always)  the  first  to 
suffer,  perhaps  in  consequence  of  the  greater  use  of  the  right  hand, 
since  the  left  arm  has  been  first  affected  in  a  left-handed  man.*  The 
interval  between  the  affection  of  the  two  arms  seldom  exceeds  two  or 
*  Bernhardt,  '  Deut.  Arch.  f.  Kl.,'  Band  xxii,  363. 


Fig.  172. — Wrist-drop  from  lead-poisoning. 
(From  a  photograph.) 


SYMPTOMS.  949 

three  weeks ;  occasionally  both  are  affected  together.  The  para- 
lysis reaches  a  considerable  degree  in  a  few  days  or  a  fortnight. 
The  onset  is  more  rapid  in  second  than  in  first  attacks,  but 
it  is  never  actually  sudden.  The  first  difficulty  is  in  the  extension  of 
the  fingers,  often  of  the  two  middle  fingers,  sometimes  of  the  first 
and  second ;  but  it  soon  extends  to  the  others.  The  loss  is  that  of 
extension  at  the  metacarpophalangeal  joints  (by  the  long  extensors)  ; 
if  the  first  phalanges  are  passively  straightened,  the  distal  pbalanges 
can  be  extended  without  difficulty  by  the  unaffected  interossei  and 
lumbricales.  The  thumb  also  suffers;  extension  of  the  phalanges 
(by  the  E.  primi  and  E.  secundi  internodii  pollicis)  is  lost,  while  its 
metacarpal  bone  can  be  still  extended  (or  rather  abducted)  by  the 
E.  ossis  metacarpi  pollicis  (Abductor  pollicis  of  the  Germans).  The 
weakness  of  the  extensors  of  the  fingers  is  usually  greatest  towards 
the  ulnar  side ;  the  first  finger  may  be  extended  best,  and  the  little 
finger  least.  Soon  the  extensors  of  the  wrist  become  weak  ;  some- 
times the  radial,  sometimes  the  ulnar  extensor  suffers  first,  with  a 
corresponding  defect  in  the  lateral  movement  of  the  hand,  and  devia- 
tion in  the  attempt  to  extend  it.  The  hand  ultimately  "  drops,"  and 
cannot  be  brought  up  to  the  level  of  the  forearm.  As  long  as  the 
special  extensors  of  the  wrist  retain  power,  this  joint  can  still  be 
extended  when  the  fingers  are  flexed  so  as  to  close  the  fist,  although 
the  wrist  cannot  be  extended  when  the  fingers  are  also  .extended. 
The  reason  for  tbis  seems  to  be  physiological.  When  in  health  the 
hand  and  fingers  are  both  extended  ;  the  special  extensors  of  the  wrist 
act  very  little  if  at  all ;  the  movement  at  the  wrist-joint  is  effected 
by  the  long  extensor  of  the  fingers.  If,  however,  the  fingers  are 
flexed,  the  extension  of  the  wrist  is  effected  by  the  special  extensors. 
These  facts  may  readily  be  verified  by  placing  a  finger  on  the  tendon 
of  the  E.  carpi  ulnaris  or  radialis  during  these  movements.  When 
the  two  muscles  are  paralysed  the  wrist  cannot  be  extended,  even 
with  the  fingers  flexed. 

The  flexors  of  the  fingers  are  unaffected.     Nevertheless  their  action 
is  seriously  impaired  by  the  inability  of  the  extensors  of  the  wrist  to 

Fig.  173.  Fig.  174. 


Figs.  173  and  174. — Wrist-drop  from  lead-poisoning.  Fig.  173  shows  the 
maximum  extension  of  the  wrists  and  fingers  ;  Fig.  174  the  extension  by 
the  proper  extensors  of  the  wrist  when  the  fingers  are  flexed. 


950  LEAD-POISONING. 

co-operate  with  them,  and  to  maintain  the  extension  of  the  carpus 
necessary  for  forcible  flexion.  Hence  flexion  of  the  fingers  flexes  also 
the  wrist,  and  the  course  of  the  tendons  is  thus  so  shortened  that  the 
maximum  contraction  of  the  flexor  muscles  exerts  but  little  force. 
The  repeated  flexion  of  the  carpus  produces  a  slight  displacement 
backwards  of  the  carpal  bones,  and  probably  also  a  distension  of  the 
synovial  sacs  connected  with  them,  so  that  a  prominence  forms  over 
the  carpus  on  the  dorsum  of  the  hand.  It  often  alarms  the*  patient, 
but  is  of  no  real  consequence.* 

In  most  cases  of  wrist-drop  the  paralysis  is  limited  to  the  muscles 
mentioned — the  common  extensor  of  the  fingers,  the  extensor  indicis, 
the  extensors  of  the  phalanges  of  the  thumb,  and  those  of  the  wrist. 
All  these  muscles  are  supplied  by  the  musculo-spiral  nerve.  But  the 
supinator  longus,  also  supplied  by  that  nerve,  almost  always  escapes, 
and  so  also,  as  a  rule,  does  the  extensor  of  the  metacarpal  bone  of  the 
thumb. 

The  affected  muscles  rapidly  waste,  and  the  back  of  the  forearm 
becomes  flattened,  rendering  the  integrity  of  the  supinator  longus  still 
more  striking  by  contrast.  The  electrical  reactions,  as  already  stated, 
are  those  of  nerve-degeneration  (see  vol.  i,  p.  54).  The  irritability  to 
voltaism  is  for  a  time  increased,  and  is  commonly  changed  in 
quality.  Such  a  qualitative  change  may  even  precede  the  onset  of 
the  paralysis  (Erb).  In  an  early  case,  in  which  one  arm  only  was 
affected,  I  found  in  it  the  increased  anodal  contraction;  while  in 
the  other,  which  was  not  paralysed,  a  distinct  change  was  the  occur- 
rence of  tetanic  contraction  with  an  unduly  weak  current.  The  exces- 
sive degree  of  voltaic  irritability  passes  away  in  the  course  of  a  few 
months,  but  some  irritability  remains  for  a  year  or  two,  even  when 
there  is  no  return  of  power,  and  it  can  often  be  quickly  increased 
by  sedulous  electrical  treatment. 

Although  the  atrophic  palsy  is  usually  limited  to  these  muscles,  it 
occasionally  invades  the  upper  arm.  The  deltoid  suffers  most  fre- 
quently, and  sometimes  before  the  forearm  muscles.  Occasionally  the 
biceps,  deltoid,  and  brachialis  anticus  suffer,  the  palsy  then  assuming 
the  "upper-arm  "  type.  Very  rarely  the  supinators  suffer  early.  Occa- 
sionally the  small  muscles  of  the  hand  are  involved,  but  it  is  more 
common  for  their  affection  to  be  of  the  second  variety,  the  primarily 
atrophic.  Different  parts  of  a  muscle  may  be  affected  in  different 
degree  ;  thus  the  several  fingers  may  be  variously  paralysed  by  the 
greater  affection  of  certain  parts  of  the  common  extensor,  and  one  part 
of  the  deltoid  may  suffer  more  than  another. 

In  the  legs,  paralysis  sometimes  occurs,  analogous  to  that  just 
described  iu  the  arm.  The  muscles  chiefly  affected  are  those  homo- 
logous with  the  forearm  muscles,  viz.  the  long  extensor  of  the  toes, 
and  the  peronei  muscles,  supplied  by  the  peroneal  nerve.  The 
tibialis  anticus,  although  supplied  by  the  same  nerve,  usually  escapes, 
*  This  swelling  is  sometimes  termed  "  Gubler's  tumour." 


SYMPTOMS.  951 

like  the  supinator  longus  in  the  arm.  The  affected  muscles  present 
the  degenerative  reactions  already  described.  Slight  deformity  of  the 
foot,  talipes  equino- varus,  may  result. 

Occasionally  muscles  in  which  there  is  no  wasting  may  be  weak, 
especially  the  muscles  of  the  upper  arm  and  thigh  (including  the  ileo- 
psoas).  In  such  muscles  there  is  often  (as  we  have  seen)  a  slight 
indication  of  the  qualitative  change  in  voltaic  irritability. 

The  second  form,  characterised  by  primary  atrophy,  occurs  espe- 
cially in  the  intrinsic  muscles  of  the  hand,  but  is  sometimes  extensive 
and  irregular  in  its  distribution,  affecting  many  muscles  in  all  four 
limbs.  The  wasting  is  slow,  and  accompanies,  instead  of  succeeding, 
loss  of  power.  Fibrillary  twitchings  are  common,  as  in  progressive 
muscular  atrophy.  The  muscles  still  act  to  faradism,  although  the 
irritability  is  lowered  in  proportion  to  the  wasting;  the  voltaic 
irritability  is  usually  lowered  in  a  similar  manner,  but  it  is  sometimes 
a  little  greater  than  the  faradic,  and  there  is  often  a  qualitative  change. 
This  form  usually  accompanies  the  degenerative  extensor  paralysis, 
but  it  may  occur  alone.  It  is  much  more  obstinate  than  the  degene- 
rative form,  and  often  persists  long  after  the  latter  has  recovered;  it 
may,  indeed,  be  permanent.  For  instance,  a  gentleman,  poisoned  by 
drinking-water,  suffered  complete  wrist-drop  on  both  sides,  with 
wasting  and  loss  of  faradic  irritability  in  the  muscles,  the  voltaic 
irritability  being  preserved.  There  was  transient  weakness,  without 
wasting,  in  the  deltoids.  The  abductor  indicis  had  slowly  wasted  with 
merely  diminution  of  both  faradic  and  voltaic  irritability,  and  it 
remained  in  nearly  the  same  state  four  years  later,  although  the  para- 
lysis of  the  forearm  muscles  recovered  in  twelve  months.  An  instance 
of  extensive  atrophic  paralysis  was  afforded  by  a  painter,  aged  thirty- 
two,  with  a  well-marked  line  on  the  gums,  and  a  history  of  three 
attacks  of  colic.  First  the  right  wrist  "dropped,"  and  then  the 
whole  arm  became  weak  from  the  shoulder  downwards.  Four  months 
later  the  left  arm  became  paralysed  in  a  similar  manner,  and  soon 
afterwards  both  legs  became  weak.  He  came  under  treatment  six 
months  later;  there  was  general  wasting  of  the  limbs,  including  in 
the  arms  the  flexor  muscles  and  supinator,  the  hand  muscles  being 
almost  entirely  gone.  The  muscles  of  the  legs  below  the  knees  were 
much  wasted.  Everywhere  faradic  and  voltaic  irritability  was 
lessened  in  proportion  to  the  wasting,  and  even  in  the  most  wasted 
muscles,  faradic  irritability  was  not  entirely  extinct.  The  patient  was 
treated  with  electricity,  iodide,  &c,  for  six  months,  but  there  was  no 
discoverable  improvement  in  the  state  of  the  limbs. 

As  the  cases  just  mentioned  show,  the  course  of  the  primary  atrophy 
is  extremely  chronic,  and  it  has  little  tendency  to  recover.  On  the 
other  hand,  the  degenerative  paralysis,  of  which  the  wrist-drop  is  the 
type,  usually  recovers  perfectly,  although  its  duration  is  prolonged  in 
proportion  to  the  amount  of  wasting  that  has  occurred.  When  this 
is  great,  the  paralysis  continues  for  six  or  eight,  or  even  twelve  months 


952  LEAD-POISONING. 

Voluntary  power  may  return  before  faradic  irritability.  If  the 
wasting  is  moderate,  and  faradic  irritability  is  not  entirely  lost, 
recovery  may  occur  in  three  or  four  months.  Simple  weakness  with- 
out loss  of  faradic  irritability  usually  passes  away  in  the  course  of 
six  or  eight  weeks.  Wrist-drop  readily  recurs  if  the  patient  is  again 
exposed  to  the  influence  of  lead,  and  a  very  slight  exposure  is  suffi- 
cient to  bring  it  back.  A  painter  had  wrist-drop,  and  on  his  recovery 
became  a  college  porter,  spending  his  time  in  a  small  "  porter's  box." 
Some  time  afterwards  a  relapse  occurred,  and  the  only  cause  that 
could  be  ascertained  was  that  the  box  had  been  repainted.  Occasion- 
ally, a  severe  relapse  is  permanent. 

There  is  usually  little  or  no  pain  in  the  affected  limbs,  even  at  the 
time  of  the  onset  of  the  palsy.  Rarely  some  sharp  darting  pains 
occur  before  the  palsy  develops,  more  often  in  the  legs  than  in  the 
arms.  Sensation  on  the  limbs  is  usually  normal,  but  besides  the 
limited  impairment  already  mentioned,  there  is  occasionally,  with 
wrist-drop,  a  little  defect  of  tactile  sensibility  in  the  area  supplied 
by  the  radial  nerve ;  in  one  case  there  were  irregular  areas  of  anses- 
thesia  on  the  front  and  back  of  the  hand  and  wrist,  and  on  the  tips 
of  the  fingers.* 

Spinal  symptoms  have  been  observed  in  rare  cases,  especially  general 
weakness  of  the  legs,  with  a  tendency  to  spasm,  and  ataxy  with  and 
without  loss  of  the  knee-jerk,  similar  to  that  which  occurs  in  arsenical 
poisoning.f 

Local  Spasm. — Cramps  in  the  legs  are  not  uncommon  in  the  early 
stage  of  the  affection,  but  more  definite  local  spasm  is  very  rare.  I 
have  once  known  flexor  spasm  in  the  forearms  to  precede  the  onset  of 
wrist-drop.  J  Another  patient,  with  lead-poisoning  and  colic,  but  no 
paralysis,  suffered  from  a  brief  but  well-marked  attack  of  tetany,  for 
which  no  other  cause  than  the  lead-poisoning  could  be  discovered ; 
the  paroxysms  were  confined  to  the  arms,  and  recurred  several  times 
daily  for  about  a  week. 

Tremor  is  less  common  in  chronic  poisoning  by  lead  than  in  that  by 
some  other  metals,  but  it  is  occasionally  present  in  the  hands  in  cases 
of  long  duration.  It  may  be  fine  tremor  like  that  of  old  age  ;  occa- 
sionally it  resembles  closely  paralysis  agitans,  more  frequently  it  is 

*  Oliver,  '  Brit.  Med.  Journ.,'  1885. 

f  It  lias  been  suggested  by  Putnam  ('Boston  Med.  and  Surg.  Journ.,'  Aug.,  1887; 
that  slight  weakness  in  the  legs,  with  excessive  knee-jerk,  and  also  other  symptoms 
of  impaired  nutrition  of  the  nervous  system,  may  be  due  to  slight  chronic  lead- 
poisoning.  He  has  found  minute  traces  of  lead  in  the  urine  of  many  patients  thus 
affected.  It  is  at  present  doubtful  whether  the  detection  of  a  trace  of  lead  in  the 
urine  justifies  us  in  ascribing  any  symptoms  to  lead-poisoning  when  there  is  no  line 
on  the  gums.  Of  course,  the  condition  of  the  gums  must  be  taken  into  considera- 
tion in  estimating  the  significance  of  the  absence  of  a  lead-line  (see  remarks  in 
"  Diagnosis"). 

J  Similar  transient  spasm  has  been  observed  by  Eiseiilohr,  '  Deut.  Arch.  kl.  Med.,' 
xxxvi. 


SYMPTOMS.  953 

increased  by  movement  more  than  that  of  paralysis  agitans,  and  is  wider 
in  range  and  more  irregular  in  its  distribution.  I  have  known  it  to 
affect  chiefly  the  flexors  of  the  elbow  and  wrist  and  the  supinator 
longus — the  muscles  which  escape  in  paralysis.  The  lips  and  tongue 
may  also  be  involved,  and  if  there  is  no  palsy  the  case  then  closely 
resembles  one  of  mercurial  poisoning.* 

Local  Saturnism. — Under  this  name,  Manouvriez  describedf  sup- 
posed local  effects  of  lead  on  the  parts  to  which  it  was  applied.  Such 
a  local  influence,  except  as  regards  the  cutaneous  nerves,  is  very  diffi- 
cult to  understand,  and  the  facts  that  have  been  supposed  to  demon- 
strate it  have  received  very  little  confirmation.  Manouvriez  collected 
thirty  cases  in  which  local  symptoms  coincided  with  the  local  applica- 
tion of  lead  to  the  skin.  In  some  there  was  a  lead-line,  in  others 
there  was  not.  In  most  cases  there  was  loss  of  motor  power ;  nine 
employed  their  feet  to  stamp  on  lead,  and  had  weakness  of  the  muscles 
of  the  legs.  He  ascribed  the  fact  that  wrist-drop  occurs  first  in  the 
right  hand  (or  in  the  left  in  left-handed  persons)  to  the  chief  use  of 
the  hand  affected,  and  described  two  right-handed  men,  who  manipu- 
lated lead  with  the  left  hand,  in  whom  this  hand  suffered  first. 
Among  a  large  number  of  sufferers  it  would  not  be  difficult  to  find 
some  examples  of  such  coincidence,  even  if  there  wei-e  no  causal  rela- 
tion between  the  phenomena.  Nevertheless  some  analogous  facts 
have  been  also  published  by  others.  MonnereauJ  observed  in 
himself  distinct  loss  of  sensibility  at  the  place  where  lead  had  been 
rubbed  in.  A  smith,  with  colic  and  wrist-drop,  who  had  worked  with 
his  left  hand  in  lead,  presented  extensive  anaesthesia  in  the  left  arm 
and  none  in  the  right.  Again,  a  man,  whose  boots  were  stronglv 
impregnated  with  white-lead,  had  anaesthesia  of  both  feet,  and 
weakness  of  some  muscles  of  the  legs.  These  facts  suggest  that  lead 
may  cause  some  local  anaesthesia,  but  it  is  probable  that  the  coincidence 
of  muscular  weakness  has  been  accidental.§ 

Cerebral  Disturbance;  EncepTialopathia  saturnina  (Tanquerel). 
— Symptoms  of  disturbance  of  the  functions  of  the  brain  occasionally 
occur  in  severe  lead-poisoning,  and  sometimes  in  cases  of  moderate 
severity.  They  vary  much  in  character,  and  may  be  acute,  subacute, 
or  chronic.  The  disturbance  is  usually  general,  but  in  rare  cases 
hemiplegic  symptoms  have  been  observed.  The  loss  of  motor  power 
is  slight,  but  that  of  sensation  is  considerable,  and  sometimes  exists 
alone  as  partial  or  complete  hemianaesthesia,  involving  general  and 

*  Suckling,  Tressillian,  Stewart. 

f  '  Gaz.  des  Hop.,'  1874,  p.  290. 

X  Monnereau,  'These  de  Paris,'  1883;  Capelle,  ibid. 

§  Fremont  ('La  Fr.mce  med.,'  1882,  p.  892)  has  recorded  a  case  of  a  man  who 
one  day  worked  with  his  left  hand  only  in  contact  with  lend,  and  did  not  wash  it  for 
three  hours.  Next  morning  there  was  tingling  in  the  hand  and  weakness  of  the 
extensor  of  the  fingers.  The  possibility  of  a  slight  injury  to  the  musculo-spiral 
nerve  renders  this  case  of  little  significance. 


954  LEAD-POISONING. 

special  sensation.  These  symptoms  are  usually  transient,  and  are 
apparently  due  to  functional  disturbance,  such  as  occurs  in  hysteria. 
Such  hemiplegia  must  not  be  confounded  with  that  which  results 
from  cerebral  haemorrhage  or  softening,  also  common  in  the  subjects 
of  prolonged  lead -poisoning.  Transient  hemianopia  or  amaurosis 
has  also  been  met  with. 

Much  more  frequent  is  general  cerebral  disturbance,  manifested  by 
convulsions,  delirium,  and  coma.  Its  onset  is  often  acute,  but  may 
be  preceded  by  certain  slighter  symptoms,  giddiness,  noises  in  the 
ears,  tremor,  restlessness,  and  insomnia.  The  convulsions  may  occur 
at  the  onset,  or  during  the  course  of  the  delirium  ;  they  are  epilepti- 
form in  character,  consisting  of  tonic  and  clonic  spasm.  They  are 
usually  general,  but  occasionally  one  side  is  affected  before,  or  more 
than,  the  other.  Very  rarely  they  may  be  hysteroid.  The  acute 
delirium  often  sets  in  suddenly,  and  is  usually  active,  with  consider- 
able excitement,  and  sometimes  attended  with  hallucinations  of  sight 
and  hearing.  When  it  is  accompanied  by  muscular  tremor,  the  con- 
dition may  closely  resemble  delirium  ti'emens.  Somnolence  and  coma 
usually  succeed  delirium  and  convulsions.  The  coma  is  not  often 
absolute ;  the  patient  can  be  roused  for  a  few  moments,  but  quickly 
relapses  into  unconsciousness.  This  acute  cerebral  disturbance  is 
often  accompanied  by  optic  neuritis,  and  is  frequently  fatal,  especially 
when  there  are  repeated  convulsions  or  deep  coma.  Slight  fever 
(100° — 101°)  may  attend  these  cerebral  symptoms.  Death  may  occur 
in  the  coma  from  respiratory  failure,  the  heart  continuing  to  act 
after  the  respiration  has  stopped.  Occasionally  such  cerebral  dis- 
turbance, especially  convulsions,  or  coma-like  unconsciousness,  occurs 
as  a  transient  symptom,  and,  like  the  amaurosis  above  mentioned, 
seems  to  be  due  to  an  effect  of  the  poison  on  the  brain  much  slighter 
than  that  which  gives  rise  to  the  severe  symptoms. 

Chronic  general  cerebral  disturbance  also  occurs.  It  may  succeed 
the  acute  stage,  or  may  commence  gradually.  I  have  seen  several 
cases  in  which  convulsions,  similar,  in  character  and  course,  to  those 
of  ordinary  epilepsy,  occurred  in  the  subjects  of  lead-poisoning,  with- 
out other  symptoms,  and  continued  for  years  after  the  toxic  influence 
had  ceased.  Hysteria  is  often  evoked  by  lead-poisoning  in  young 
girls,  who  are  so  often  the  subjects  of  its  acute  form. 

More  frequent,  however,  is  mental  disturbance,  which  may  neces- 
sitate confinement.  The  most  common  form  is  melancholia  with 
delusions,  or  mental  derangement  with  hallucinations,  somewhat 
resembling  alcoholic  insanity.  Sometimes  theie  are  symptoms  of 
mental  failure  and  muscular  weakness,  resembling  those  of  general 
paralysis  of  the  insane,  but  coming  on  more  rapidly.  True  general 
paralysis  of  the  insane,  with  exalted  delusions,  typical  course  and 
post-mortem  appearances,  has  occurred  in  the  subjects  of  lead- 
poisoning,  and  may  have  been  due  to  it  (Monakow,  Ullrich). 

Laryngeal  Palsy  is  a  very  rare  effect  of  lead-poisoning.     One  or 


PATHOLOGICAL   ANATOMY.  955 

both  vocal  cords  may  be  paralysed,  and  their  muscles  may  be  found 
pale  and  atrophied.  The  muscles  affected  have  been  the  arytsenoideus, 
all  tbe  intrinsic  muscles  of  one  side,  and  the  posterior  crico-arytse- 
noids.* 

Ocular  symptoms  are  sometimes  met  with.  The  ocular  muscles 
seldom  suffer,  but  paralysis  of  the  third  nerve  has  been  described  by 
Buzzard.  Inequality  of  the  pupils  has  also  been  observed,  "Vision 
may  be  affected  without  any  ophthalmoscopic  change ;  there  may  be 
complete  bilateral  loss  of  sight,  lasting  many  hours  and  resembling 
ursemic  amaurosis,  but  occurring  when  there  is  no  renal  affection. 
When  unilateral,  or  greater  on  one  side,  it  may  be  associated  with 
hemiansesthesia  and  affection  of  the  other  special  senses  on  that  side, 
and  sometimes  there  is  a  concentric  limitation  of  the  field  and  loss  of 
colour  vision  as  in  hysterical  amblyopia.  I  have  once  met  with 
transient  green  vision. 

In  cases  of  acute  lead-poisoning,  especially  with  cerebral  symptoms, 
optic  neuritis  is  frequent.  The  swelling  of  the  papilla  is  considerable 
in  degree,  and  accompanied  by  haemorrhages  ('  Medical  Ophthalmo- 
scopy,' plate  vii,  fig.  6).  In  less  severe  cases  I  have  occasionally  seen 
slight  chronic  optic  neuritis.  The  inflammation,  both  slight  and 
severe,  may  pass  off  under  treatment,  without  impairment  of  sight, 
but  severe  neuritis  may  cause  "consecutive  atrophy."  Atrophy  has 
also  been  described,  without  preceding  neuritis,  or  with  only  transient 
congestion  of  the  discs  at  the  onset  (Hornei%  Hutchinson).  One  eye 
may  be  affected  before,  and  more  than,  the  other.  The  ultimate  con- 
dition is  usually  a  greyish  atrophy,  often  with  white  lines  along  the 
vessels.     It  may  slowly  progress  to  complete  loss  of  sight.f 

The  several  acute  and  chronic  symptoms  of  lead-poisoning  are 
often  combined,  and  thus  different  cases  vary  much  in  character. 
Even  in  chronic  cases  there  is  often  deviation  from  the  common  type. 
Colic,  although  the  most  frequent,  is  not  constaut ;  palsy  or  cerebral 
disturbance  may  come  on  without  any  preceding  symptoms,  especially 
in  acute  poisoning,  and  tremor  or  pains  sometimes  exist  for  a  long 
time  without  paralysis.  It  is  not  practicable  to  draw  any  sharp  line 
of  demarcation  between  the  symptoms  of  acute  and  chronic  poisoning, 
or  between  the  general  classes  into  which  we  may  roughly  divide  the 
symptoms. 

Pathological  Anatomy. — Lead  may  be  found  in  various  organs 
by  chemical  analysis,  but  its  presence  only  causes  visible  signs  where 
it  has  been  exposed  to  the  influence  of  sulphur  in  a  form  that  can 
enter  into  combination  with  the  lead.  The  intestine  may  be  dotted 
with  minute  black  specks,  as  Fagge  has  pointed  ont.      The  chief 

*  Morell  Mackenzie ;  Seifert  (three  cases),  '  Berl.  kl.  Wochensch.,'  1884.  Horses 
working  in  lead  mines  are  said  to  get  laryngeal  palsy. 

t  Retinitis,  like  that  of  kidney  disease,  but  without  albuminuria,  has  been 
described  by  Lehmann. 


956  LEAD -POISONING. 

lesions  in  lead-poisoning  have  been  found  in  cases  of  local  paralysis 
and  -wasting. 

The  wasted  muscles  are  small  and  pale,  sometimes  even  yellowish 
in  tint,  and  are  brittle.  In  cases  of  short  duration,  many  of  the 
muscular  fibres  are  narrower  than  normal,  but  the  striae  are  preserved, 
although  a  tendency  to  longitudinal  or  transverse  Assuring  is  some- 
times seen.  The  nuclei  of  the  sheath  are  increased  in  number. 
When  the  wasting  has  lasted  for  a  considerable  time,  the  fibres  pre- 
sent still  greater  narrowing,  a  colloid  or  vitreous  aspect,  and  there  is 
often  granular  or  fatty  degeneration,  although  in  some  cases  this  is 
absent.  The  nuclei  are  still  more  increased  in  number,  and  there  is 
also  an  increase  of  the  connective  tissue,  in  which  fat  may  be  found. 
The  process  of  destruction  goes  on,  until  many  of  the  sarco- 
lemma  sheaths  become  empty,  and  in  the  end,  almost  all  trace  of 
muscular  tissue  may  disappear,  connective  tissue,  nuclei,  and  masses 
of  fat  taking  its  place.  The  walls  of  the  vessels  often  become 
thickened. 

In  the  nerves,  morbid  changes  are  constantly  found.  They  are 
always  intense  in  the  intra-muscular  twigs,  and  in  the  branches  from 
which  these  twigs  proceed.  They  are  usually  considerable  in  the 
larger  trunks,  but  commonly  become  slighter  the  further  from  the 
periphery  the  nerve  is  examined.  Sometimes  a  few  degenerated  fibres 
can  be  traced  throughout  the  nerves.  The  affection  of  the  nerve  seems 
to  begin  by  a  change  in  the  medullary  sheath,  which  becomes  narrower, 
cloudy,  aud  granular,  the  axis-cylinder  being  intact,  and  the  outer 
sheath  and  nuclei  presenting  little  alteration.  With  this,  however,  is 
combined  a  more  considerable  change,  resembling  the  "  Wallerian  " 
degeneration  that  is  secondary  to  a  lesion  of  a  nerve  (see  vol.  i, 
p.  49).  The  myelin  undergoes  segmentation,  the  axis- cylinder  also 
breaks  up,  the  nuclei  and  protoplasm  of  the  sheath  become  increased, 
and  the  products  of  this  degeneration  accumulate  in  masses  of  myelin 
and  granule  corpuscles.  The  slighter  change  (which  G-ombault,*  who 
first  described  it,  termed  "  periaxial  neuritis ")  is  sometimes  seg- 
mental, affecting  short  tracts  of  the  nerve  that  are  separated  by 
normal  portions ;  or  the  upper  part  of  the  degenerated  region  may 
present  only  the  change  in  the  medullary  sheath,  while  in  the  lower 
part  there  are  the  more  extensive  alterations.  These  changes  are 
always  most  intense  in  the  radial  nerve  and  its  branches  ;  but  it  is 
only  in  extreme  cases  that  all  the  fibres  of  the  nerve  are  involved ; 
generally,  normal  fibres  are  mingled  with  those  that  are  degenerated, 
and  become  more  numerous  the  higher  up  the  nerve  is  examined. 
In  a  case  in  which  the  loss  of  power  was  limited  to  the  parts  of  the 
extensor  for  the  third  and  fourth  fingers,  Eichhorst  found  degene- 
ration only  in  the  corresponding  branches  of  the  radial  nerve. f  In 
some  cases  of  long  duration,  appearances  have  been  seen  suggestive 

*  '  Arch,  de  Phys.,'  vol.  v,  p.  592. 
t  'Virchow's  Archiv,'  1890. 


PATHOLOGICAL    ANATOMY.  957 

of  a  process  of  regeneration ;  these  are  very  narrow  but  otherwise 
perfect  neiwe-fibres,  or  an  axis-cylinder  seems  to  end  suddenly,  and 
to  be  continued  by  two  smaller  ones  (Westphal,  G-ombault). 

In  most  cases  the  degeneration  ceases  long  before  the  anterior  roots 
are  reached,  and  these  are  normal.  In  a  few  cases,  however,  marked 
changes  have  been  found  in  the  anterior  roots,  similar  to  those  in  the 
peripheral  nerves.  Normal  fibres  were  mingled  with  those  that  were 
affected.  In  one  case  of  unilateral  palsy,  only  the  roots  on  the  side 
corresponding  to  the  paralysis  were  affected.  The  posterior  roots 
have  always  been  found  unchanged. 

In  the  spinal  cord,  in  most  cases,  no  morbid  appearances  have  been 
found,  even  when  wrist-drop  has  been  of  long  duration  and  the 
neuritis  well-marked.  In  cases  with  advanced  kidney  disease  the 
walls  of  the  vessel  have  been  thickened,  and  sometimes  there  has 
been  a  general  increase  in  the  connective  tissue  throughout  the  cord. 
In  a  few  cases,  however,  distinct  alterations  have  been  seen  in  the  grey 
substance,  especially  in  association  with  the  slower  form  of  muscular 
atrophy.  In  one  case  the  consistence  of  the  cervical  enlargement 
was  reduced.  Atrophy  of  the  ganglion-cells  of  the  anterior  cornua 
has  been  several  times  noted,*  slight  in  some  instances,  in  others 
considerable,  especially  in  the  inner  anterior  group  of  cells.  This 
was  especially  conspicuous  in  a  case  described  by  Monakow  in 
which  there  was  slow  wasting  of  the  deltoid,  thenar,  and  hypothenar 
muscles,  in  addition  to  the  common  wrist-drop.  Spots  of  softening 
in  the  anterior  cornua  and  intermediate  grey  matter  were  found 
in  one  case  by  Oeller,  in  addition  to  wasting  of  some  of  the 
nerve-cells. 

The  brain  has  presented  no  marked  changes  even  in  cases  in  which 
the  cerebral  symptoms  have  been  considerable.  Slight  traces  of 
inflammation  have  been  found  in  the  membranes  in  a  few  instances, 
and  in  the  case  in  which  there  were  the  characteristic  symptoms  of 
general  paralysis  of  the  insane,  there  was  evidence  of  considerable 
inflammation  both  of  the  pia  mater  and  of  the  external  surface  of  the 
dura  mater.  In  the  optic  papilla  the  usual  signs  of  inflammation 
have  been  found,  and  in  Oeller's  case  there  was  also  "  hyaline  degene- 
ration "  of  the  walls  of  the  vessels,  extending  back  into  the  trunk  of 
the  optic  nerve.  Degeneration  of  the  larger  arteries  is  common  in 
cases  of  long  duration,  in  which  the  kidneys  are  diseased,  and 
resulting  softening  is  often  found. 

Of  the  other  organs,  changes  in  the  liver  and  kidneys  are  constant. 
In  acute  poisoning  there  is  granular  degeneration  of  the  cells  of  each 
organ,  and  an  accumulation  of  lymphoid  cells  between  the  rows  of 
hepatic  cells,  and  around  the  glomeruli  of  the  kidney  ;  increase  of  the 
interstitial  tissues,  and  often  contraction,  are  met  with  in  older  cases. 

*  By  Vulpian,  Monckton,  Zunker,  Monakow,  Carriew,  Oeller,  and  others.  Pig- 
mentation of  the  cells  has  often  been  seen,  but  its  significance  is  doubtful.  I  have 
seen  it  in  one  young  subject. 


958  LEAD-POISONING. 

Pathology. — The  changes  that  have  been  found  in  lead-poisoniug 
clearly  point  to  a  primary  influence  on  the  peripheral  nerves,  and  the 
knowledge  we  now  possess  of  the  occurrence  of  a  primary  degenera- 
tive neuritis,  as  an  effect  of  many  metallic  and  other  poisons,  renders 
the  pathology  of  lead-poisoning  less  mysterious  than  it  was  a  few 
years  ago.  The  wrist-drop  and  other  acute  atrophic  palsies  can  be 
referred  most  surely  to  this  mechanism.  The  peculiar  limitation  of 
the  paralysis  to  the  muscles  supplied  by  a  single  nerve  has  always 
suggested  its  neuritic  origin,  although  the  escape  of  the  supinator 
longus  constituted  a  difficulty  in  accepting  this  explanation,  and  the 
significance  of  the  limitation  is  lessened  by  the  fact,  on  which  Eemak 
has  insisted,  that  palsy  of  a  precisely  similar  distribution  may  result 
from  a  primary  affection  of  the  spinal  cord.  But  it  is  in  the  cases  of 
simple  wrist-drop  that  the  integrity  of  the  cord  has  most  frequently 
been  demonstrated  ;  the  escape  of  the  supinator  longus  (which  is  not 
invariable)  may  be  perhaps  explained  by  the  tendency  in  parts  of  the 
nerve  most  distant  from  the  cord  to  undergo  degeneration,  while  the 
correspondence  of  saturnine  wrist-drop  with  that  which  is  due  to 
alcoholic  and  arsenical  neuritis,  completes  a  very  strong  chain  of 
evidence  regarding  its  nature.  It  is  probable  that  the  same  conclu- 
sion holds  good  regarding  acute  atrophic  palsy  in  other  muscles,  as 
those  of  "the  upper  arm,  and  also  those  of  the  leg  that  correspond  to 
the  extensors  in  the  arm  and  are  supplied  by  the  peroneal  nerve.  The 
neuritis  appears  to  be  essentially  of  the  degenerative  variety,  and  it 
must  be  ascribed  to  a  primary  influence  of  the  toxic  agent  on  the 
nerve-elements.  It  appears,  moreover,  that  the  motor  fibres  suffer  far 
more  than  the  sensory  fibres,  and  probably  they  suffer  alone  in  cases 
of  slight  or  moderate  severity.  This  feature  is  more  conspicuous  than 
in  the  case  of  alcoholic  neuritis.  The  special  tendency  of  the  radial 
nerve  to  suffer,  exhibited  in  many  forms  of  peripheral  neuritis,  is  at 
present  unexplained,  but  should  be  considered  in  connection  with  the 
tact  that  the  grey  substance  of  the  cord,  from  which  the  affected 
fibres  proceed,  is  sometimes  the  seat  of  an  acute  process,  limited  in  its 
effects  to  the  same  muscles.*  For  some  unknown  reason,  these  cells 
and  fibres  seem  to  have  a  low  power  of  resistance  to  morbid  in- 
fluences. Other  nerves  suffer  also  in  severe  cases,  although  le»s 
readily  than  the  radial. 

It  is  doubtful  whether  lead  has  any  primary  action  on  the  muscles. 
The  changes  in  their  nutrition,  and  in  their  reactions  to  electricity, 
are  those  that  are  met  with  after  primary  lesions  of  nerves,  and  are 
sufficiently  explained  by  the  invariable  neuritis. 

But  the  action  of  lead  is  certainly  not  confined  to  the  peripheral 
nerves.  In  severe  cases  the  motor  cells  of  the  cord  and  the  anterior 
roots  may  also  undergo  degeneration,  usually  slow;  this  is  the  cause 
of  the  chronic  atrophy,  which  resembles  closely  that  of  the  primary 

*  See  p.  896,  and  "  Muscular  Atrophy,"  vol.  i,  p.  492. 


DIAGNOSIS.  959 

spinal  form.  Barely  tbere  seems  to  be  a  subacute  process  in  the 
grey  matter,  extensive  in  distribution.* 

The  cerebral  symptoms  of  lead-poisoning  may  be  independent 
of  any  visible  change.  Although  tbey  have  been  ascribed  to  some 
vascular  distui'bance,  it  seems  more  probable  that  they  are  due  to 
the  direct  action,  on  the  nerve-elements,  of  the  lead  or  of  organic 
poisons  which  result  from  the  imperfect  action  of  the  liver  and 
kidneys.  Headache,  for  instance,  has  been  observed  to  coincide 
strictly  with  diminished  elimination  of  urea  (Oliver).  At  the  same 
time,  acute  disturbance,  although  it  begins  in  the  nerve-elements,  is 
apt  to  involve  also  the  interstitial  tissue,  and  even  the  vessels,  and  may 
assume  the  character  of  general  inflammation  in  tissues  disposed  to 
this  process.  The  optic  neuritis  may  be  such  a  direct  effect  of  the 
poison,  but  it  is  possible  that  au  irritative  process  descending  from 
the  brain  aids  in  its  production.  The  certain  effect  of  lead  on  the 
peripheral  nerves  of  the  limbs  makes  the  occurrence  of  this  inflam- 
mation more  intelligible,  and  also  the  paralysis  of  other  cranial 
nerves  occasionally  met  with. 

The  connection  between  lead-poisoning  and  gout  was  formerly 
thought  to  be  simple.  The  poison  lessens  the  elimination  of  uric 
acid,  and  the  excess  of  uric  acid  in  the  system  was  regarded  as  the 
sole  element  in  gout.  But  many  facts  (including  the  infrequency  of 
gout  among  the  subjects  of  lead-poisoning  in  the  North,  noted  by 
Oliver)  have  led  some  authorities  on  the  subject  to  regard  the 
excess  of  uric  acid  as  only  one  element  in  gout,,  and  to  consider 
that  there  must  be  other  organic  poisons  in  the  blood  in  this 
disease,  due  to  imperfect  change  in  the  substances  that  enter  the 
blood,  and  should  be  excreted.  An  altered  state  of  nutrition  of  the 
tissues  may  co-exist.  This  opinion  is  certainly  supported  by  the 
wide  diversity  in  the  manifestations  of  gout,  its  remarkable  effects 
as  an  inherited  diathesis,  and  its  distinct  connection  with  several 
forms  of  rheumatism. 

Diagnosis. — The  recognition  of  lead-poisoning  depends,  first,  on 
the  character  of  the  symptoms  of  nerve  disturbance;  secondly,  on  the 
existence  of  other  indications  of  the  presence  of  lead  in  the  system  ; 
thirdly,  on  the  discovery  of  the  fact  that  lead  is  entering  the  system ; 
fourthly,  on  the  fact  that  lead  is  leaving  the  system  by  the  urine. 

*  Whether  lead  has  also  an  action  on  the  upper  segment  of  the  motor  path  (see 
vol.  i,  p.  176)  so  as  to  cause  weakness  without  wasting1  and  with  an  increase  in 
myotatic  irritability,  we  do  not  know.  The  facts  collected  by  Putnam  (p.  952,  note) 
suggest  that  it  may  be  so,  but  no  distinct  sclerosis  of  the  pyramidal  tracts  has  yet 
been  observed,  even  in  cases  of  long  duration.  It  is,  however,  probable  from 
analogy  that  the  extremities  of  these  fibres  would  be  the  first  to  suffer,  nnd  the 
fibres  themselves  might  undergo  as  little  change  as  do  those  of  the  upper  parts  of 
the  peripheral  nerves.  It  is  evident  that  the  excess  of  myotatic  irritability  can 
only  be  revealed  where  there  is  integrity  of  the  lower  segment.  (Compare  remarks 
on  lateral  sclerosis  in  "  Progressive  Muscular  Atrophy,"  vol.  i,  p.  492.) 


960  LEAD-POISONING. 

The  diagnosis  can  only  i-each  a  high  degree  of  probability  when  two 
or  more  of  these  indications  are  combined.  It  is  especially  important 
that  too  much  weight  should  not  be  placed  on  the  character  of  the 
symptoms  alone ;  many  errors  in  diagnosis  are  due  to  this. 

When  the  symptoms  are  such  as  to  suggest  that  lead  may  be  their 
cause,  the  next  step  in  diagnosis  is  to  ascertain  if  there  is  any  other 
evidence  of  the  presence  of  this  poison  in  the  system.  The  variations 
in  the  lead-line  have  b<jen  already  mentioned.  If  no  line  is  con- 
spicuous, and  the  gums  are  in  general  good,  a  search  should  be  made 
for  any  place  where  the  gum  is  not  closely  attached  to  the  tooth,  and 
the  projections  between  the  teeth  must  be  carefully  examined,  since 
the  line  may  be  found  only  at  these  places.  A  fragment  of  distinct 
line  is  quite  conclusive,  and  the  absence  of  any  line  does  not  exclude 
lead-poisoning  if  the  gums  are  everywhere  in  perfect  contact  with  the 
teeth.  On  the  other  hand,  if  the  gums  are  separated  from  the  teeth 
in  many  places,  and  there  is  tai'tar  on  the  teeth,  the  absence  of  a  line, 
according  to  present  facts,  makes  it  in  the  highest  degree  improbable 
that  the  symptoms  are  due  to  lead.  The  only  condition  in  which  I 
have  seen  a  line  quite  like  that  of  lead,  is  silver-poisoning,  but  this 
is  sufficiently  distinguished  by  the  tint  of  the  skin. 

The  presence  of  a  lead-line  cannot  be  taken  as  absolute  proof  that 
the  symptoms  are  due  to  lead.  The  line  may  last  long  after  the 
poison  has  ceased  to  be  active.  Iodide  of  potassium  removes  lead 
from  its  organic  combination  in  the  tissues,  but  has  no  action  on  the 
deposit  of  sulphide  of  lead  in  the  gums.  Indeed,  a  solution  of  iodide 
of  potassium  is  absolutely  incapable  of  dissolving  sulphide  of  lead, 
even  if  the  two  are  boiled  together.  The  lead-line  does  slowly  dis- 
appear in  the  course  of  years,  but  I  have  known  it  to  present  little 
change  in  aspect,  two  years  after  the  entrance  of  lead  into  the  system 
had  been  stopped.  Yet  it  has  been  observed  to  pass  away  in  three 
months,  and  hence  the  precise  state  in  which  the  pigment  exists  in  the 
tissue  of  the  gum  probably  varies.  The  persistence  of  the  line  is 
perhaps  related  to  its  previous  duration. 

Other  effects  of  lead-poisoning,  colic,  gout,  ansemia,  seldom  do  more 
than  corroborate  the  diagnosis  ;  although,  in  the  absence  of  a  lead-line, 
owing  to  the  intact  state  of  the  gums,  frequent  attacks  of  colic  are  of 
significance,  and  even  the  fact  that  gout  has  developed,  without 
its  usual  causes,  may  be  allowed  some  weight.  In  these  cases,  how- 
ever, the  diagnosis  depends  on  the  discovery  of  a  source  of  lead- 
poisoning,  or  of  the  fact  of  the  excretion  of  lead.  If  there  is  no 
obvious  source  of  poisoning,  the  water  and  its  receptacles  should  be 
examined.  Most  cases  of  lead-poisoning  that  are  not  due  to  occupa- 
tion are  due  to  the  contamination  of  water,  although  the  other 
occasional  sources  should  always  be  borne  in  mind.  The  examination 
of  the  urine  is  often  of  much  help  of  the  investigator ;  it  should  be 
analysed  after  iodide  of  potassium  has  been  taken  for  a  week.  It  is 
doubtful  whether  the  presence  of  a  very   faint  trace  of  lead  is  of 


PEOGNOSIS.  961 

significance.  On  the  other  hand,  after  iodide  of  potassium  has  been 
taken  for  several  weeks,  the  absence  of  lead  probably  does  not  exclude 
lead-poisoning.* 

It  is  on  the  above  points  that  the  differential  diagnosis  from 
maladies  that  resemble  those  produced  by  lead,  chiefly  turns.  The 
wrist-drop  has  been  confounded  with  paralysis  of  the  musculo- spiral 
nerve,  but  this  is  always  unilateral  and  usually  comes  on  suddenly. 
In  alcoholic  neuritis  the  palsy  may  closely  resemble  that  from  lead, 
but  the  diagnosis  is  seldom  difficult;  the  other  signs  of  lead- 
poisoning  are  absent ;  pains  are  generally  obtrusive ;  the  legs  suffer 
earlier,  and  there  is  almost  always  a  clear  history  of  alcoholic  excess. 
Wrist-drop  may  be  produced  by  arsenical  poisoning,  but  in  this 
also,  the  legs  suffer  before  the  arms,  and  sensory  symptoms  are  more 
prominent.  The  greatest  difficulty  is  presented  by  some  cases  of 
central  disease.  Progressive  muscular  atrophy  (ultimately  exten- 
sive) may  commence  by  a  subacute  palsy  of  the  extensors  of  the  wrists 
exactly  like  that  produced  by  lead,  and  atrophic  palsy  due  to  polio- 
myelitis may  have  the  same  distribution.f  If  the  gums  are  perfect, 
an  examination  of  the  drinking-water  or  urine  may  be  indispensable 
for  the  diagnosis.  The  cases  of  general  muscular  atrophy  of  saturnine 
origin  scarcely  ever  present  any  difficulty,  because  they  usually 
supervene  on  severe  lead-poisoning  that  has  caused  characteristic 
symptoms. 

Most  errors  in  diagnosis  occur  in  cases  in  which  the  nervous  sym- 
ptoms are  anomalous  and  slight,  and  are  not  such  as  to  suggest  their 
cause.  In  the  case  of  a  lady  with  saturnine  neuralgia,  the  cause  of 
the  symptoms  might  never  have  been  discovered  (for  the  perfect  gums 
told  no  tale)  had  not  her  husband  suffered  from  wrist-drop.  A 
gentleman  had  some  obscure  cerebral  symptoms  with  inequality  of 
pupils ;  a  fragment  of  lead-line  opposite  one  tooth  suggested  lead- 
poisoning,  and  it  was  found  that  his  water  was  stored  in  a  leaden 
cistern.  It  is  not  possible  to  avoid  error  in  such  cases  except  by  the 
habit  of  remembering  lead  as  a  possible  cause  in  obscure  cases. 
The  severe  cerebral  disturbance  is  practically  confined  to  workers  in 
lead,  and  although  the  subjects  have  often  not  been  long  engaged  in 
the  occupation,  the  effect  is  usually  due  to  a  quantity  so  large  as  to 
cause  other  symptoms  that  cannot  be  mistaken. 

Prognosis. — It  may  be  said,  generally,  that  the  more  acute  the 
onset  of  paralysis,  the  better  is  the  prospect  of  complete  recovery. 
The  acute  cerebral  symptoms  are  alone  attended  with  immediate 
danger  to  life,  and  the  prognosis  is  worse  when  there  are  convulsions, 
and  especially  when  there  is  coma,  than  in  simple  delirium.  Con- 
vulsions are  of  graver  significance  when  they  succeed  delirium  than 

*  See  note  on  next  page.     On  the  danger  of  mistaking  bismuth  for  lead  in  the 
urine  gee  Putnam,  '  Bost.  Med.  and  Surg.  Journ.,'  1883,  Oct.  14th,  p.  315. 
t  As  in  the  conclusive  case  mentioned  on  p.  896. 
VOL.   II.  61 


962  LEAD-POISONING. 

when  they  occur  first.  Alcoholism  increases  much  the  gravity  of  the 
prognosis,  and  so  do  a  considerable  diminution  in  the  amount  of  urine, 
marked,  and  especially  acute,  anaemia,  and  the  evidence  of  organic 
changes  in  the  kidneys.  If  death  does  not  take  place,  the  patient 
usually  recovers  completely.  The  prognosis  in  the  chronic  cerebral 
symptoms  is  unfavorable  to  recovery  when  these  take  the  form  of 
pronounced  mental  derangement  or  of  epilepsy.  Of  the  paralytic 
affections,  those  with  the  wasting  and  the  degenerative  reaction  in 
the  muscles,  of  which  the  wrist-drop  is  the  type,  almost  always 
ultimately  pass  away,  but  their  course  is  very  slow,  and  the  chief 
prognostic  indications  have  been  mentioned  in  the  account  of  the 
course  of  the  disease.  In  relapses,  if  these  are  due  to  a  considerable 
dose  of  lead,  the  prognosis  is  less  favorable,  although  two  or  three 
successive  attacks  may  be  recovered  from.  In  all  cases  the  ultimate 
prognosis  must  be  influenced  by  the  extent  to  which  the  patient  can 
be  withdrawn  from  the  deleterious  influence,  but  it  must  be  remem- 
bered that,  in  chronic  cases,  the  chief  danger  to  life  is  often  from 
the  associated  disease  of  the  kidneys,  with  or  without  gout,  and  from 
arterial  degeneration  These  may  slowly  increase,  and  even  first 
manifest  their  presence,  long  after  the  lead -poisoning  has  ceased. 

Treatment. — The  first  step  is  to  ari'est  the  entrance  of  lead  into 
the  system,  and  the  second  is  to  promote  the  elimination  of  the. lead 
that  has  been  already  taken  in.  The  chief  agent  for  securing  the 
latter  is  iodide  of  potassium,  given  in  doses  of  three  or  five  grains. 
Although  iodide  of  lead  is  an  insoluble  salt,  it  has  been  abundantly 
demonstrated  that  the  administration  of  iodide  of  potassium  increases 
the  excretion  of  lead  by  the  urine,  apparently  in  some  complex  com- 
bination. The  amount  of  lead  in  the  urine  increases  for  a  few  weeks 
and  then  gradually  subsides.*  The  quantity  of  lead  excreted  is  much 
less  than  might  be  expected  ;  this  may  be  due  in  part  to  the  fact  that 
much  passes  away  by  the  liver,  but  probably  its  chief  cause  is 
that  the  amount  retained  in  the  tissues,  which  the  iodide  liberates, 
is  never  actually  great.  When  there  are  acute  symptoms,  and  lead 
is  circulating  in  the  blood,  iodide  should  not  be  given  at  once,  since 
the  toxic  effects  may  be  intensified  by  the  sudden  increase  of  the 
amount  that  is  in  the  blood.  Such  a  result  has  been  noted  by  many 
observers.  By  saline  aperients  (especially  the  sulphates  of  soda  and 
magnesia  with  some  free  sulphuric  acid)  the  alimentary  canal  should 
be  first  cleared  of  any  lead  it  may  contain,  or  which  may  be  excreted 
from  its  mucous  membrane.  If  colic  exists,  it  may  be  necessary  to 
give  a  full  dose  of  opium,  to  relax  the  spasm,  before  aperients  can  be 

*  Thus,  in  one  case  in  which  no  lead  could  be  found  in  the  urine  before  the  treat- 
ment, five  grains  of  iodide  were  given  four  times  daily,  and  on  the  first  day  five 
milligrammes  of  lead  were  found  in  the  urine,  on  the  fourth  12,  on  the  fourteenth. 
22,  and  then  the  quantity  gradually  lessened,  and  after  two  weeks  more,  only  traces 
were  found.     (Swete,  'Brit.  Med.  Journ.,'  1882.) 


AESENICAL   POISONING.  963 

effective.  The  "bowels  sometimes  act  spontaneously  after  a  few  hypo- 
dermic injections  of:  morphia.  Subcutaneous  injections  of  atropine 
have  "been  recommended  for  the  same  purpose.  In  two  or  three  days, 
the  administration  of  the  iodide  may  be  commenced.  Sulphur  baths 
have  also  been  extensively  employed  to  promote  the  elimination  of 
lead,  but  their  utility  is  doubtful.  It  seems  that  lead  passes  off  by 
the  skin  only  when  the  amount  in  the  blood  is  very  great,  since, 
in  chronic  cases,  even  the  copious  diaphoresis  produced  by  pilo- 
carpine, does  not  eliminate  the  metal.  If  there  is  anaemia,  iodide  of 
iron  may  be  advantageously  combined  with  the  iodide  of  potassium. 

Fof  the  local  paralysis,  strychnine  has  been  given  internally.  Its 
mode  of  action  suggests  that  it  may  do  good,  although  its  actual 
effect  is  difficult  to  appraise.  There  is  no  evidence  that  its  local 
injection  has  special  advantages.  The  most  important  agent  in  the 
treatment  of  the  paralysis  is  electricity.  The  nerves  have  lost  irrita- 
bility, but  the  muscles  still  respond  to  the  voltaic  current,  slowly 
interrupted,  which  certainly  keeps  up  their  irritability,  and  must 
therefore  influence  the  nutrition  of  the  muscles  while  the  nerves  are 
recovering.  Thus  the  amount  of  muscular  change  is  lessened,  and 
the  ultimate  recovery  is  rendered  more  perfect.  In  a  severe  case,  if 
the  muscles  are  left  alone  for  a  few  months,  or  are  merely  treated 
with  faradism,  there  may  be  only  the  feeblest  response  to  the  voltaic 
current,  but  (as  I  have  seen)  this  increases  notably  after  two  or  three 
applications,  and  the  paralysis,  before  stationary,  may  in  a  fortnight 
be  distinctly  less,  and  the  improvement  may  steadily  go  on  to  complete 
recovery.  In  such  a  case  the  value  of  electricity  scarcely  admits  of 
question.  Only  the  voltaic  current,  to  which  the  muscles  respond,  is 
of  service.  Faradism  should  not  be  used  unless  it  excites  contraction, 
as,  for  instance,  in  the  primary  atrophic  form.  But  in  this  it  is 
difficult  to  get  evidence  of  the  value  of  the  application.  Massage  of 
the  limbs  is  also  of  service.  Cerebral  symptoms,  especially  convul- 
sions, are  often  associated  with  increased  tension  of  the  pulse,  and  it 
is  said  that  nitrite  of  amyl  has  a  marked  effect  upon  them  (Oliver). 
Nitro-glycerine,  by  the  mouth,  would  probably  be  useful  in  such  cases, 
and  might  be  combined  (in  alcoholic  solution)  with  the  acidulated 
saline  aperient. 


AESENICAL  POISONING. 

Arsenical  poisoning  differs  from  lead-poisoning  in  being  seldom  the 
result  of  occupation.  Disturbance  of  the  nervous  system  has  generally 
been  due  either  to  a  single  large  dose,  taken  by  accident  or  design,  or 
else  to  slow  poisoning  from  the  use  of  pigments  containing  arsenic  ; 


964'  ARSENICAL    POISONING. 

it  has  thus  been  produced  through  the  agency  of  paints,  wall-papers, 
book-covers,  &c.  The  poison  differs  from  lead  in  being  moi-e  readily- 
diffused  through  the  air,  and  taken  iu  by  the  lungs.  Some  interesting 
facts  regarding  these  accidental  causes  have  been  collected  by  the 
Medical  Society  of  London.*  Putnam  has  shown  how  often  arsenic 
can  be  detected  in  the  urine  of  those  who  live  in  rooms  the  walls  of 
which  are  hnng  with  paper,  or  the  floor  covered  with  carpet,  coloured 
with  arsenical  pigments.  Slight  symptoms  had  been  produced  in  some 
persons,  in  others  none.  This  cause  has  become  rare  in  England, 
but  several  cases  of  poisoning  occurred  not  long  ago  among  those 
who  used  muslin  of  certain  tints,  obtained  from  the  same  firm. 
The  muslin  was  ultimately  found  to  contain  a  considerable  quantity 
of  arsenic.  One  of  the  sufferers  crime  under  my  notice  with  symptoms 
of  extreme  severity,  which  had  been  slowly  increasing  for  two  years, 
with  exacerbations  traced  to  specially  close  work  at  the  muslin, 
on  which  she  often  slept.  The  symptoms  at  last  became  so  pro- 
nounced that  an  acute  practitioner  suspected  and  proved  the  cause. 
Extensively  as  arsenic  is  used  in  medicine,  toxic  effects  (beyond  a 
little  conjunctivitis  and  gastric  irritation)  are  not  common  when 
it  is  administered  in  ordinary  doses.  In  one  case,  severe  sym- 
ptoms were  produced  by  the  medicinal  administration  of  arsenious 
acid,t  and  in  another  they  resulted  from  Eowler's  solution  in  large 
doses.J 

Arsenic,  like  lead,  is  eliminated  by  the  urine,  in  which  its  presence 
may  confirm  the  diagnosis.  After  acute  poisoning  it  is  to  be  found 
for  a  month  or  six  weeks,  but  after  chronic  poisoning  it  may  be 
detected  for  six  or  nine  months  after  the  entrance  of  arsenic  into  the 
system  has  ceased  (Putnam). 

The  nervous  symptoms  produced  by  arsenic  vary  much  in  character, 
but  as  a  rule  present  a  combination  of  those  caused  by  alcohol  and 
those  due  to  lead,  aud  the  mechanism  by  which  they  are  produced  is, 
in  general,  an  affection  of  the  peripheral  nerves.  They  are  of  three 
classes :  first,  a  palsy  of  the  muscles  of  the  limbs,  especially  of  the 
extensors  of  the  hands  and  feet ;  secondly,  "  a  pseudo-tabes  " — 
ataxy,  with  defective  sensibility,  especially  in  the  muscles ;  thirdly, 
sensory  symptoms,  pain,  loss  of  sensation,  and  disordered  sensibility. 
These  symptoms  occur  as  a  result  of  chronic  poisoning  by  small  doses, 
or  as  an  after-effect  of  acute  poisoning,  and  they  may  also  be  a  sequel 
to  acute  symptoms  produced  by  the  cumulative  influence  of  small 
doses.  The  interval  between  the  cessation  of  the  symptoms  of  acute 
poisoning  and  the  onset  of  the  nerve  disturbance,  has  varied  from  a 

*  '  Proc.  Med.  Soc.  Lond.,'  1880.  See  also  an  instructive  series  of  cases  described 
by  Putnam,  '  Boston  Journal,'  1889. 

t  Da  Costa,  '  Phil.  Med.  Times,'  1881,  pp.  381  and  614. 

%  A  series  of  cases  of  poisoning  from  the  medicinal  use  lias  been  collected  l>y 
Putnam,  '  Boston  Journal,'  18S8.  Other  instructive  facts  are  recorded  by  Hutchin- 
son, '  British  Med.  Journ.,'  1891. 


AESENICAL   POISONING.  965 

few  days  to  a  few  weeks ;  among  recorded  cases  are  intervals  of  six 
days,  two,  three,  and  four  weeks.* 

The  paralysis  in  the  legs  and  arms  has  the  same  distribution  as  that 
commonly  pi'oduced  by  lead-poisoning,  but  sensory  symptoms  are 
much  more  pronounced.  Atrophy  of  the  muscles  occurs  very  rapidly. 
The  electrical  irritability  presents  the  same  degenerative  changes  as 
in  other  toxic  palsies,  but  in  very  severe  cases  the  voltaic  irritability 
may  quietly  fall  below  the  normal.  The  knee-jerk  is  often  lost. 
Sometimes  other  muscles  are  involved,  those  of  the  upper  arm  and 
thigh  may  lose  power,  but  not  to  the  same  degree  as  those  of  the 
extremities.  Yery  rarely  the  trunk  muscles  have  also  suffered. 
Paralysis  of  accommodation  has  been  observed. f  Muscular  tremor 
has  been  an  occasional  symptom,  and  acute  palsy  has  been  preceded 
by  cramp-like  contraction  in  the  limbs. 

Arsenical  ataxy,  although  less  frequent  than  the  muscular  paralysis, 
is  not  rare.  It  is  usually  met  with  in  the  legs,  but  has  been  observed 
also  in  the  arms.  It  resembles  closely  the  inco-ordination  of  tabes, 
but  develops  in  a  much  more  acute  manner,  and  is  accompanied  by 
considerable  muscular  weakness,  and  sometimes  by  the  characteristic 
atrophic  palsy  in  the  muscles  in  front  of  the  lower  leg.  It  has,  how- 
ever, been  known  to  come  on  (or  become  evident)  as  the  palsy  was 
passing  away.  Severe  pains  attend  the  onset,  and  there  are  also 
subjective  sensations,  formication,  tingling,  &c.  The  sensibility  of  the 
muscles  is  lessened  or  lost,  and  so,  as  a  rule,  is  the  knee-jerk  ;  some- 
times it  is  preserved,  and  in  the  case  of  poisoning  from  muslin  it  was 
excessive,  in  spite  of  atrophy  below  the  knee.  The  loss  may  last  longer 
than  the  other  symptoms,  and  has  been  known  to  continue  for  a  year. 

The  other  sensory  symptoms  are  like  those  met  with  in  alcoholic 
neuritis.  They  occur  first  in  the  legs  and  then  in  the  arms.  Yarious 
subjective  sensations  may  be  experienced  at  the  onset.  Pains  are 
constant,  in  chronic  cases  they  are  at  first  slight,  but  in  all  they 
become,  sooner  or  later,  sharp,  darting  or  burning  in  character,  some- 
times momentary.  They  are  felt  in  various  parts  of  the  extremities, 
and  often  take  the  course  of  the  nerves,  in  which  there  may  be 
marked  tenderness.  At  first  there  is  hyperesthesia  of  the  skin,  sub- 
sequently, in  many  cases,  loss  of  sensation  to  touch  or  to  all  forms  of 
sensation.  Painful  impulses,  when  not  lost,  may  be  delayed.  Hyper- 
algesia may  coexist  with  loss  of  tactile  sensibility — the  "anaesthesia 
dolorosa."  The  loss  usually  begins  in  the  foot,  and  may  first  involve 
the  sole,  spreading  gradually  over  the  foot  and  lower  part  of  the  leg, 
above  the  ankle.  In  the  hand  similar  symptoms  occur  later  and  in 
slighter  form.  The  tactile  loss  may  first  occur  on  the  fingers  and  palm, 
and  be  greater  in  one  nerve  ai*ea  than  in  another.  "When  sensation  is 
impaired  on  the  sole  the  plantar  reflex  is  lost.     The  knee-jerk  may 

*  See   Dana,   'Brain,5   vol.    ix;    Gubler,  'Gours   de   Them  p./  1880;    Gerhardt, 
*  Virchow's  Jahresb.,'  1882;  Seeligumller,  'Deut.  med.  Wochensch.,'  1881. 
t  Murik,  'Virchow's  Jahresb.,'  1891. 


966  ARSENICAL  POISONING. 

persist,  but  is  often  lessened  or  lost,  always  when  there  is  any  atrophy 
of  the  extensors  of  the  knee. 

Cutaneous  eruptions  are  sometimes  observed,  and  seem  to  be  the 
direct  effect  of  the  poison  on  the  nutrition  of  the  skin,  often  doubtless 
produced  through  the  nerves,  but  they  may  be  disconnected  with  the 
other  neuritic  symptoms.  The  hair  may  fall  off  or  become  grey,  the 
nails  may  present  changes  and  even  separate,  bullous  and  erythematous 
eruptions  may  occur,  and  herpes  zoster  is  especially  common,  gene- 
rally on  the  chest.  It  often  follows  the  medicinal  use  of  arsenic, 
when  there  are  no  toxic  symptoms,  as  Hutchinson  first  pointed  out. 
Brownish  pigmentation  of  the  skin  is  also  both  common  and  charac- 
teristic. In  severe  poisoning  it  occurs  in  roundish  spots,  which 
sometimes  first  lead  to  a  suspicion  of  the  cause  of  other  symptoms. 
The  prolonged  medicinal  use  of  arsenic  usually  causes  a  finely  punctate 
pigmentation.  Optic  neuritis  has  been  once  observed  (Dana).  The 
pulse  is  often  frequent,  and  sometimes  the  temperature  is  raised. 

Pathology. — The  dependence  of  the  symptoms  on  changes  in  the 
nerves,  suggested  by  Jaschke  in  1882,  was  rendered  practically  certain 
by  the  discovery  of  the  cause  of  the  similar  symptoms  that  are  produced 
by  alcoholism,  and  has  since  been  proved.  Characteristic  degeneration 
was  found  by  Erlicki  in  the  radial  and  peroneal  nerves.  The  cells  of 
the  anterior  cornua  in  the  cervical  and  lumbar  regions  of  the  spinal 
cord  also  presented  slight  changes.  The  chief  effect  of  arsenic  is 
doubtless  always  to  cause  a  degenerative  parenchymatous  peripheral 
neuritis.  In  some  cases  the  chief  action  is  on  the  motor  nerves, 
giving  rise  to  the  atrophic  palsy,  in  others  on  the  sensory  nerves  of 
the  skin,  producing  the  subjective  sensations  and  sensory  impairment, 
or  of  the  muscles  and  joints,  causing  the  ataxy.  Paralytic  symptoms, 
or  sensory  and  ataxic  symptoms,  may  pi-edominate  in  different  cases, 
but  are  not  met  with  exclusively  in  any,  and  in  severe  cases  both 
classes  are  met  with  in  considerable  degree. 

Diagnosis. — The  distinction  from  lead-poisoning  rests  on  the 
common  onset  after  acute  symptoms,  on  the  more  pronounced  disturb- 
ance of  sensibility,  the  early  affection  of  the  muscles  of  the  lower  leg, 
and  on  the  absence  of  other  indications  of  the  effect  of  lead  on  the 
system.  In  chronic  cases  the  discovery  of  a  source  from  which  arsenic 
may  have  entered  the  system  is,  as  a  rule,  possible,  and  its  presence 
may  be  confirmed  by  an  examination  of  the  urine.  The  absence  of  a 
history  of  intemperance  is  the  most  important  general  distinction  from 
alcoholic  palsy,  which  that  produced  by  arsenic  closely  resembles  ; 
but  the  most  marked  peculiarities  are  the  deferred  onset  after  acute 
poisoning,  the  manner  in  which  ataxy  may  follow  paralysis,  and  the 
long  duration  of  the  effects  of  a  single  ingestion  of  the  poison.  In 
chronic  poisoning  the  early  pains  are  sometimes  ascribed  to  gout  or 
rheumatism  ;  in  all  cases  in  which  there  are  persistent  pains  in  the 


SILVEB-POISONING.  967 

limbs,  a  careful  search  should  be  made  for  tenderness  of  the  nerve- 
trunks,  which  points  to  the  probability  of  toxic  irritation. 

The  course  of  arsenical  palsy  is  similar  to  that  which  is  due  to  lead, 
and  the  treatment  necessary  is  essentially  the  same.  Iodide  of 
potassium  appears  to  have  a  similar  influence  in  removing  the  arsenic 
from  the  system.* 

Silver-poisoning  ;  Argyria. 

Chronic  silver-poisoning  is  due  almost  exclusively  to  the  medicinal 
use  of  the  metal.  It  is  less  frequent  now  than  when  a  long  course  of 
silver  was  the  fashionable  treatment  for  epilepsy  and  spinal-cord 
disease.  Most  cases  are  due  to  internal  administration,  but  argyria 
has  been  known  to  result  from  applications  to  the  palate  or  tongue, 
continued  during  many  years.  Working  in  silver  involves  no  liability. 
Of  the  cases  that  have  come  under  my  own  notice,  two  were  epileptics 
(in  whom  the  fits  continued  in  spite  of  the  influence  of  the  silver), 
a  third  had  been  treated  with  silver  for  a  syphilitic  gumma  pressing 
on  the  spinal  cord,  and  a  fourth  had  taken  a  salt  of  silver  in  a  "dinner 
pill."  The  discoloration  of  the  skin,  which  is  the  characteristic  of 
'  argyria,'  depends  on  a  deposit  of  silver  beneath  the  Malpighian 
layer, f  and  commences  when  about  an  ounce  of  a  salt  of  silver  has 
been  taken,  during  any  period  of  time.  It  is  accompanied  by  a  black 
line  on  the  gums  close  to  the  tooth,  closely  resembling  the  lead-line. 
This  appears  before  the  darkening  of  the  skin,  and  is  therefore  im- 
portant as  a  warning.J  Among  other  internal  organs, §  silver  is 
deposited ||  in  the  kidneys — in  the  Malpighian  bodies,  and  around  the 
tubules;  albuminuria  has  been  observed  both  in  animals  and  in  man. 
In  these  two  points  the  effect  of  silver  resembles  that  of  lead.  In 
animals,  moreover,  paralysis  is  produced.  I  have  been  unable  to  find 
any  recorded  instance  of  paralysis  in  man,  but  one  remarkable  case  has 
come  under  my  own  observation,  which  shows  that  the  effect  of  silver 
may  be  almost  the  same  as  that  of  lead.  The  case  was  that  of  a 
gentleman,  aged  forty-four,  who  had  been  ordered,  twelve  years  before, 
a  "  dinner  pill,"  without  any  caution  or  other  direction  than  that  one 
pill  was  to  be  taken  three  times  a  day.  He  did  not  follow  the  direc- 
tions literally,  but  took  sometimes  one,  sometimes  three,  a  day,  for  a 
few  days  at  a  time.  He  estimated  that  he  had  taken  about  six  pills 
a  month  during  the  twelve  years.  After  he  had  taken  the  pills  for 
about  eleven  years,  a  dusky  tint  of  the  face  attracted  notice,  but  its 
nature  was  not  suspected  until  the  tint  had  become  well  marked,  when 

*  A  full  bibliography  is  given  by  Dana,  loc.  cit. 

f  See  Neumann,  '  Wien.  med.  Zeitung.,'  1878,  No.  10. 

J  Respecting  its  constancy,  see  Chaillon,  'These  de  Paris,'  1878. 

§  The  distribution  and  precise  seat  in  the  internal  organs  were  carefully  investi- 
gated in  one  case  by  Weichselbaum,  'Allg.  Wien.  med.  Zeit.,'  1878. 

||  It  is  said  as  an  organic  compound  (Krysinski,  'Gaz.  lekarska,'  1886,  and 
'  Virchow's  Jahresb.,'  ib.,  i,.  372). 


968  MERCURIAL   POISONING. 

it  was  found  that  the  pills  contained  silver  (the  exact  form  could  not 
be  ascertained).  Two  months  before  I  saw  him,  the  extensors  of  the 
right  hand  became  weak  ;  shortly  afterwards,  those  of  the  left.  When 
he  came  under  observation  the  tint  of  the  skin  was  very  characteristic  ; 
his  gums  presented  a  well-marked  black  line,  which  resembled  that 
of  lead  in  being  present  where  there  was  tartar,  and  absent  where 
the  gum  was  in  perfect  apposition  to  the  teeth.  In  both  arms 
there  was  paralysis  of  the  long  extensor  of  the  fingers  and  of  the 
extensors  of  the  phalanges  of  the  thumb,  not  of  the  extensor  of  the 
metacarpal  bone  of  the  thumb.  On  the  right  side  there  was  also 
paralysis  of  the  radial  extensors  of  the  wrist.  The  affected  muscles 
were  wasted,  and  their  irritability  to  faradism  was  lost;  that  to 
voltaism  was  preserved  and  increased.  There  was  no  affection  of  the 
legs.  The  urine  contained  some  albumen  and  casts,  and  the  patient 
had  had  several  attacks  of  gout.  During  three  months  in  which  he 
remained  under  treatment  (electricity,  iodide  of  potassium,  &c.)  there 
was  slight  improvement  in  the  arms,  but  no  considerable  change.  He 
soon  afterwards  showed  symptoms  of  cancer  of  the  liver,  of  which  he 
subsequently  died,  but  no  post-mortem  examination  was  obtained. 

Mercurial  Poisoning:  Hydrargyria. 

Chronic  poisoning  by  mercury  causes  symptoms  of  which  some  are 
due  to  an  action  of  the  poison  on  the  nervous  system.  These  sym- 
ptoms rarely  follow  the  medicinal  use  of  mercury,  but  occur  chiefly  in 
those  who  work  in  the  metal.  Mercury  will  volatilise  at  all  ordinary 
temperatures,  and  it  is  probable  that  it  enters  the  system  mainly 
through  the  lungs,  but  it  may  sometimes  pass  in  through  the  skin 
when  certain  forms  of  mercury  are  much  handled,  and  want  of  clean- 
liness may  increase  the  amount  of  mercury  that  gets  into  the  system 
by  causing  contamination  of  the  food.  Sufferers  are  met  with  espe- 
cially among  those  who  work  in  quicksilver  mines,  at  silvering  mirrors, 
and  in  making  barometers  and  thermometers,  and  also  occasionally 
among  bronzers,  furriers,  and  hat-makers,  mercurial  salts  being  used 
for  preparing  the  skins.  The  weakly  suffer  more  readily  than  the 
strong,  and  the  individual  differences  in  susceptibility  are  very  great. 
The  symptoms  occasionally  develop  after  the  exposure  to  the  cause 
has  ceased. 

The  nervous  symptoms  may  exist  alone,  but  sometimes  they  are 
preceded  by  others  outside  the  nervous  system,  which  resemble  those 
of  acute  mercurial  poisoning.  These  are  stomatitis  and  ulcera- 
tion of  the  mucous  membrane  of  the  mouth,  with  extreme  fcetor, 
necrosis  of  bone,  gastric  and  intestinal  catarrh.  The  remarkable 
removal  of  lime  from  the  bones  and  its  deposit  in  the  kidneys,  dis- 
covered as  a  consequence  of  acute  mercurial  poisoning  by  Prevost  and 
Fruchtiger,  does  not  seem  to  attend  the  chronic  form,  in  which  the 
kidneys  do  not  suffer. 


MEEOURIAL    POISONING.  969 

A  peculiar  tremor,  known  among  the  workmen  as  "the  trembles," 
and  medically  as  "mercurial  tremor,"  is  the  most  common  and 
characteristic  symptom.  It  is  at  first  occasional,  occurring  only 
when  the  patient  is  excited,  and  is  always  increased  by  emotion.  It 
usually  begins  in  the  face  and  tongue,  then  invades  the  arms,  and 
afterwards  the  legs.  At  first  the  tremor  occurs  only  on  movement, 
but  ultimately  it  may  become  constant.  In  the  former  case,  the  con- 
dition of  the  patient  resembles  that  of  one  suffering  from  disseminated 
sclerosis,  except  that  the  tremor  is  less  wide  and  less  irregular 
than  in  characteristic  cases  of  the  latter  disease.  When  constant,  the 
tremor  resembles  that  of  paralysis  agitans.  During  sleep,  the  tremor 
usually  ceases,  but  in  extreme  cases  may  only  lessen.  It  interferes 
much  with  articulation,  rendering  the  speech  stammeriug  and  hesi- 
tating. When  considerable  re  may  render  the  movement  of  the  arms 
so  unsteady  that  the  patient  cannot  feed  himself,  and  his  gait  becomes 
affected.  At  first  the  limbs  are  strong,  but  after  a  time  muscular 
power  is  impaired,  sometimes  more  in  one  limb  than  in  another,  but 
it  seldom  progresses  to  complete  loss.  Rarely  there  is  wide-spread 
weakness  without  tremor.*  Reflex  action  and  power  over  the  sphinc- 
ters are  always  unimpaired,  and  the  electric  irritability  of  the  muscles 
is  normal  throughout. 

Psychical  symptoms  are  also  common,  and  may  precede  the  tremor. 
They  have  been  very  carefully  studied  by  Kussmaul.  Irritability,  and 
a  difficulty  in  giving  attention  to  a  subject,  are  often  the  first  sym- 
ptoms, and  may  be  accompanied  by  considerable  mental  distress  and 
sleeplessness.  Hallucinations  sometimes  occur,  and  there  may  even 
be  outbreaks  of  maniacal  excitement,  but. the  insanity  rarely  corre- 
sponds to  any  distinct  variety.  This  condition  has  been  termed 
"  mercurial  erythism."  It  is  sometimes  accompanied  by  headache  and 
palpitation  of  the  heart. 

Sensory  symptoms  are  present  in  many  cases;  pains,  esj^ecially  in 
the  region  of  the  fifth  nerve  and  in  the  joints ;  formication  in  the 
limbs,  and  sometimes  loss  of  sensibility  to  pain,  with  paroxysms  of  dis- 
tressing sensations  in  the  thorax,  resembling  those  of  asthma.  The 
sensory  disturbance  always  augments  the  mental  instability,  In  rare 
cases  more  grave  cerebral  symptoms  occur — considerable  hemiplegic 
weakness,  aphasia,  and  deafness. 

Although  the  tremor  may  have  been  extreme,  no  alterations  have 
been  discovered  in  either  brain  or  cord,  even  with  the  aid  of  the 
microscope.  The  character  of  the  symptoms  makes  it  probable  that 
they  are  due  to  disturbance  of  the  brain  rather  than  of  the  spinal 
cord.  In  animals  mercurial  poisoning  is  said  to  cause  degeneration 
of  the  medullary  sheaths  of  the  muscle-nerves,  but  not  of  their  axis- 
cylinders,  f 

The   diagnosis   is   rarely    difficult.     From    paralysis    agitans    the 

*  Letulle,  'Arch,  de  Phys.,'  1889. 
f  Ibid. 


970  ALCOHOLISM. 

tremor  is  distinguished  by  its  immediate  increase  on  movement,  and 
by  the  absence  of  the  rigidity  of  the  limbs  and  fixation  of  the 
features.  In  disseminated  sclerosis,  there  is  never  the  peculiar  tremu- 
lous stammering  that  is  met  with  in  mercurial  poisoning,  and  the 
movements  are  wider  in  range  and  wilder  in  their  irregularity.  The 
symptoms  often  resemble  those  of  general  paralysis  of  the  insane  more 
than  those  of  any  other  disease,  but  such  preponderant  tremor  is  rarely 
met  with  in  general  paralysis,  and  the  inequality  of  pupil,  optimism, 
and  indications  of  spinal  degeneration,  present  in  the  latter,  are  absent 
in  mercurial  poisoning.  The  presence  of  stomatitis  should  always 
direct  attention  to  the  probable  nature  of  the  disease,  and  when 
this  is  once  suspected,  the  patient's  occupation  is,  as  a  rule, 
decisive.  The  greatest  diagnostic  difficulty  is  presented  by  some 
cases  of  lead-poisoning  in  which  tremor  is  the  chief  symptom.  These 
are  distinguished  by  the  presence  of  the  lead-line  in  the  gums,  and  if 
there  is  a  suspicion  that  the  patient  is  suffering  from  both  poisons, 
the  question  can  readily  be  set  at  rest  by  an  investigation  into  the 
materials  with  which  he  works.  If  these  are  free  from  mercury,  the 
symptoms  are  certainly  due  to  lead  only. 

The  prognosis  is  in  most  cases  favorable  as  to  the  ultimate  issue, 
but  all  cases  are  prolonged,  and  in  some  the  tremor  never  passes  away. 
For  recovery,  it  is  essential  for  the  patient  to  cease  to  work  in  mer- 
cury. No  precautions  avail  to  prevent  sufficient  absorption  to  main- 
tain symptoms  that  have  once  developed.  Nutritious  food,  fresh  air, 
and  iron  are  important  aids  to  recovery.  To  promote  the  elimination 
of  the  mercury,  iodide  of  potassium  may  be  given,  but  in  small  doses 
— two  or  three  grains  very  gradually  increased.  There  seems  no 
doubt  that  it  does  facilitate  elimination,  and  the  sudden  administra- 
tion of  large  doses  has  been  followed  by  a  considerable  increase  in 
the  symptoms ;  apparently  mercury  released  from  the  tissues  passes 
into  the  blood  and  to  the  nervous  system.  Neither  sweating  nor 
sulphur  baths  seem  to  cause  an  elimination  from  the  skin,  although  it 
is  said  that  the  latter  have  been  found  in  some  way  to  increase  the 
amount  excreted  by  the  kidneys.  The  stomatitis  is  relieved  best  by 
chlorate  of  potash. 


ALCOHOLISM. 


The  nervous  system  is  especially  sensitive  to  the  influence  of  alcohol, 
and  suffers  in  many  cases,  more  than  other  tissues,  from  the  effects 
of  habitual  alcoholic  excess.  The  acute  poisoning  by  alcohol  to  which, 
par  excellence,  the  term  "intoxication"  is  applied,  is  chiefly  of  physio- 
logical and  toxicological  interest.  Only  the  morbid  states  that  are 
distinct  from  simple  drunkenness  come  into  the  province  of  medicine. 
These  are  exceedingly  numerous  ;  many  of  the  organic  and  functional 


ACUTE    ALCOHOLISM.  971 

diseases  already  described  may  be  produced,  or  predisposed  to,  by  in- 
teinperance  ;  some  other  derangements  are  due  chiefly  to  this  cause, 
and  are  seldom  or  never  produced  by  any  other.  To  these  the  term 
"  alcoholism  "  is  generally  applied.  These  disorders  aud  symptoms 
may  be  acute,  subacute,  or  chronic.  The  acute  disturbance  generally 
takes  the  form  of  an  attack  of  delirium,  called,  from  the  tremor  that 
accompanies  it,  "delirium  tremens."*  The  chronic  derangements  are 
exceedingly  varied. 

All  forms  of  alcoholism  have  certain  common  causes.  The  tendency 
to  drink  is  often  inherited ;  less  commonly  it  is  related  to  a  family 
disposition  to  suffer  from  definite  diseases  of  the  nervous  system, 
especially  from  insanity. f  It  is  probably  facilitated  by  peculiarities 
of  nervous  constitution,  in  consequence  of  which  the  sensations  of 
intoxication  are  more  pleasurable  in  some  persons  than  in  others. 
Parental  intemperance,  moreover,  often  involves  facilities  for 
habitual  excess.  Occupation  is  notoriously  influential,  partly  on 
account  of  the  facilities  for  drinking  afforded  to  those  who  are  engaged 
in  the  distribution  or  sale  of  alcoholic  liquors,  partly  on  account  of  the 
social  temptations  to  drink  involved  in  other  callings.  The  temporary 
relief  to  physical  and  mental  depression  afforded  by  alcohol  is  another 
potent  cause  of  intemperance. 

Acute  Alcoholism,  Alcoholic  Delirium,  Delirium  Tremens. 

Alcoholic  delirium  occurs  under  two  forms  :  as  a  primary  affection, 
and  in  association  with  some  local  inflammation  or  injury.  The  latter 
may  be  termed  "  associated  delirium  ;"  it  has  a  double  causation,  the 
influence  of  alcohol  and  the  influence  of  a  local  disease.  The  latter 
may  be  sufficient  by  itself  to  cause  some  delirium,  although  far  less 
in  degree,  and  without  the  peculiar  characteristics  of  the  alcoholic 
form  ;  or  it  may  be  wholly  insufficient  to  derange  the  mind.  The 
simple  primary  delirium  varies  much  in  the  intensity  of  its  symptoms ; 
it  has  been  divided  into  two  classes  according  to  the  presence  or 
absence  of  considerable  fever,  but  the  difference  depends  only  on  the 
degree  of  severity,  and  there  is  no  real  justification  for  the  division. 

Causes. — Delirium  tremens  is  almost  confined  to  drunkards,  in  the 
popular  sense  of  the  word.  In  this  respect  it  differs  from  the  "  asso- 
ciated delirium,"  which  is  not  uncommon  among  those  who  have 
habitually  taken  an  excessive  quantity  of  alcohol  to  keep  up  their 
energy  against  the  depressing  influence  of  debility  or  the  prostration 
of  some  chronic  disease.     Thus  a  man  who  had  never  been  known  to 

*  By  Thomas  Sutton  ('  On  Delirium  Tremens,'  a  tract  published  in  1813). 

f  Of  600  drunkards  admitted  into  the  Institution  at  Port  Hamilton,  New  York, 
intemperance  could  be  traced  in  relations  in  265,  and  the  father  was  intemperate 
in  168.  Insanity  could  be  traced  in  only  38  cases.  In  one  half,  the  habit  was 
established  before  twenty-five  years  of  age. 


972  ALCOHOLISM. 

be  intoxicated,  and  was  believed  to  be  temperate,  died  with  symptoms 
of  acute  delirium  tremens  ;  but  it  was  found  that  his  lungs  were 
extensively  diseased,  and  that  he  had  been  keeping  up  his  working 
power  by  large  doses  of  alcohol  during  the  acute  development  of  the 
pulmonary  disease. 

Delirium  tremens  is  far  more  common  in  men  than  in  women,  the 
proportion  being  about  six  to  one.*  There  are  no  facts  to  show  whether 
there  is  any  sexual  tendency  to  the  disease,  such  as  certainly  exists 
in  the  case  of  another  effect  of  alcohol,  multiple  neuritis,  to  which 
women  possess  a  greater  liability.  As  far  as  the  figures  given  below 
suggest  any  conclusion,  it  is  that  drinkers  in  the  two  sexes  are  equally 
prone  to  suffer  from  delirium  tremens.  The  disease  is  most  frequent  in 
the  middle  period  of  life,  thirty  to  forty  years.  In  both  sexes  the  maxi- 
mum mortality  is  at  the  same  age,  a  little  later  than  the  maximum  fre- 
quency, because  second  and  third  attacks  are  the  most  fatal ;  one  third 
of  the  total  number  of  deaths  occur  between  thirty-five  and  forty  five 
years  of  age,  and  about  four  fifths  during  the  twenty  years — thirty  to 
fifty.  It  rapidly  lessens  in  later  life,  no  doubt  because  the  worst 
drinkers  acquire  the  habit  early,  and  die  off  from  some  effect  of  intem- 
perance, but  cases  of  delirium  tremens  occur  even  up  to  advanced 
senility.  Moreover,  females  bear  a  proportion  to  males  that  steadily 
increases  as  life  goes  on,  probably  because  drinking  habits  are  acquired 
relatively  later,  under  the  influence  of  individual  causes  rather  than 
as  an  effect  of  occupation  or  of  social  life.f  Under  twenty-five, 
the  affection  is  chiefly  met  with  as  a  complication — especially  of  pneu- 
monia. J  It  is  probable  that  an  hereditary  tendency  to  neuroses 
facilitates  the  occurrence  of  this  disease,  especially  a  tendency 
to  intemperance, §  and  insane  heredity  unquestionably  modifies  its 
course.  The  disease  is  less  frequent  in  beer-drinkers  than  in  those 
who  drink  wine,  and  most  frequent  in  spirit-drinkers,  but  it  is  proba- 

*  During  the  twenty-five  years  ending  1872,  there  died  from  this  cause  in  England 
and  Wales  10,448  males  and  1398  females.  It  is  probable  that  this  disease  is  one  on 
which  the  Registrar-General's  returns  are  fairly  accurate,  since  this  cause  of  death 
is  unlikely  to  be  given  unless  there  is  a  history  of  intemperance.  The  figures  give 
the  proportion  of  deaths  as  7i  males  to  1  female.  But  the  disease  is  not  only  more 
common  in  males,  it  is  also  more  oftin  severe,  and  therefore  it  is  more  often  fatal. 
Hence  the  disproportion  between  the  sexes  is  doubtless  rather  less  in  cases  than  in 
deaths.  Of  54  consecutive  cases  in  University  College  Hospitil,  8  were  in  females, 
giving  the  proportion  of  6  to  1,  which  is  probably  very  near  the  truth. 

f  The  proportion  of  deaths  of  males  to  each  female  is  about  12|  in  the  ten  years — 
fifteen  to  twenty -five,  and  then  steadily  falls,  the  proportion  in  each  successive 
later  decade  being  10 — 1,  7J — 1,  7| — 1,  6 — 1,  4£ — 1,  and  only  3 — 1  in  those  over 
seventy-five. 

X  A  few  cases  have  been  recorded  of  acute  alcoholism  in  childhood.  Thus  a  boy 
of  five,  to  whom  spirits,  and  also  wine,  had  been  given  daily,  had  a  brief  but  typical 
attack  of  delirium  tremens  after  a  fracture  of  the  thigh  (Cohn,  'Berlin,  kl.  Wochen- 
schr.,'  1888). 

§  In  Germany  neuropathic  heredity  was  traced  by  Krukenberg  in  half  the  patients 
(265),  and  in  one  fifth  the  father  was  intemperate  ('Zeitseh.  f.  kl.  Med.,'  xix). 


ACUTE    ALCOHOLISM.  973 

ble  that  the  amount  of  alcohol  taken  has  much  greater  influence  than, 
its  form. 

In  most  cases  the  malady  follows  a  severe  "bout"  of  drinking, 
often  without  any  interval.  Occasionally  there  has  been  a  cessation 
of  drinking  for  a  few  days  before  the  onset  of  the  delirium.  These 
cases  have  led  to  the  idea  that  the  discontinuance  of  the  stimulant 
has  been  the  cause  of  the  attack;  but  it  is  more  probable,  as 
Anstie  and  others  have  suggested,  that  a  sudden  distaste  for  liquor 
was  really  the  first  effect  of  the  commencing  disease.  The  onset  occa- 
sionally follows  some  slight  injury  or  trifling  illness,  which  apparently 
disturbs  the  nervous  system,  and  serves  to  excite  the  disturbance 
that  is  ready  to  break  out.  Such  cases  present  a  gradation  to  the 
"associated  delirium  tremens,"  in  which  there  is  some  real  cause  of 
general  indisposition,  a  severe  accident  or  a  local  inflammation,  espe- 
cially pneumonia.  The  pyrexia  resulting  might  or  might  not  be 
attended  with  delirium  in  the  healthy  ;  in  the  alcoholic,  the  delirium 
is  severe,  and  presents  the  same  characteristics  as  in  the  pure  form  of 
delirium  tremens. 

Symptoms. — The  symptoms  of  delirium  tremens  usually  develop 
gradually  but  rapidly,  attaining  considerable  intensity  in  the  course 
of  two  or  three  days.  Disturbed  sleep,  loss  of  appetite,  and  restless 
irritability  are  commonly  the  first  indications  of  the  impending  dis- 
order. Distressing  or  horrible  dreams  of  peculiar  vividness  attend 
sleep,  and  the  patient  cannot  shake  off  their  effect  when  he  wakes. 
He  is  depressed,  uneasy,  restless  during  the  day,  often  annoyed  with 
floating  specks,  or  flashes  of  light  before  his  eyes,  and  the  next  night 
brings  the  same  distressing  dreams.  As  soon  as  he  closes  his  eyes, 
unpleasant  scenes  present  themselves  before  him,  and  he  tosses  about 
all  night,  half  awake,  or  perhaps  is  unable  to  obtain  any  real  sleep. 
Next  day,  from  time  to  time,  more  definite  hallucinations  of  sight  or 
hearing  occur ;  the  patient  can  shake  them  off,  and  knows  that  they 
are  unreal,  but  they  return  again  and  again,  When  night  comes,  they 
take  possession  of  him,  prevent  all  sleep,  and  the  following  morning 
they  are  no  longer  to  be  shaken  off.  This  insomnia,  first  partial  and 
then  absolute,  with  the  distressing  hallucinations  which  disturb  the 
imperfect  sleep  that  is  obtained,  characterises  the  early  period  of  the 
disease.  The  transition  to  more  considerable  disturbance  is  usually 
attended  with  unnatural  loquacity,  and  by  indications  of  suspicion 
and  of  uneasiness.  The  period  of  definite  delirium  begins  with  the 
persistence  of  the  hallucinations  during  the  day.  They  are  chiefly 
visual,  sometimes  auditory,  and  occasionally  related  to  some  cuta- 
neous sensations ;  they  are  almost  always  unpleasant.  At  first  the 
objects  that  the  patient  actually  sees  are  transformed  into  other 
things  than  they  really  are,  often  into  living  creatures  in  active 
motion;  the  pattern  of  the  wall-paper  becomes  beetles,  spiders, 
snakes  ;  and  then  these  appear  spontaneously,  and  are  crawling  about 


974  ALCOHOLISM. 

the  bedclothes ;  the  sufferer  tries  to  brush  them  away  or  to  escape 
from  them.  At  first  he  can  be  recalled  from  bis  aberration  for  a  few 
moments,  and  will  answer  questions  correctly,  but  soon  relapses  into 
tbe  delirium.  Delusions  of  wider  extent  grow  out  of  the  hallucina- 
tions, or  are  excited  by  some  bodily  discomfort.  Faces  appear  before 
him,  grinning  at  him,  or  he  fancies  that  persons  are  standing  by  his 
bedside,  upbraiding  or  abusing  him.  A  characteristic  of  the  delirium 
is  the  versatility  of  the  false  ideas  ;  they  change  continually.  Gradu- 
ally he  ceases  to  be  able  to  shake  them  off,  even  for  a  moment,  and 
no  longer  recognises  his  friends  or  doctor.  The  attendants  are 
thought  to  be  the  subjects  of  his  delusions,  and  he  may  strike  at 
them  under  the  impression  that  they  are  attempting  to  injure  him. 
Often  the  modified  incidents  of  his  daily  life  seem  to  occur  before 
his  eyes.  He  usually  talks  incessantly,  but  may  wander  incoherently 
from  one  subject  to  another  in  the  course  of  the  same  sentence. 
Auditory  hallucinations  may  occur  early  or  may  be  grafted  on  those 
of  vision,  and  the  patient  thinks  he  hears  reproaches  or  insults  from 
the  fancied  bystanders.  Less  commonly  au  unpleasant  smell  or  a 
disagreeable  taste  annoys  him,  or  he  fancies  that  insects  are  crawling 
on  his  skin.  The  delusions  often  excite  iutense  emotions  of  horror  or 
dread. 

The  characteristic  tremor  is  usually  present  from  the  first.  It 
occurs  only  on  movement,  and  is  irregular,  but  considerable  in 
range;  it  is  most  conspicuous  in  the  arms,  the  face,  and  the  tongue, 
but  is  to  be  seen  also  in  the  legs  when  these  are  put  into  voluntary 
movement,  especially  if  the  patient  attempts  to  stand.  It  is  the  more 
conspicuous,  because  the  patient  is  usually  in  constant  movement, 
picking  at  the  bedclothes,  searching  for  imaginary  objects,  attempt- 
ing to  get  out  of  bed.  This  extreme  restlessness  is  seldom  absent. 
Often,  in  addition  to  the  tremor  on  movement,  there  are  spontaneous, 
slight,  partial,  muscular  twitchings,  and  in  severe  cases  these  may 
amount  to  considerable  shock-like  contractions,  and  may  occur  in  the 
muscles  of  the  trunk  as  well  as  in  the  limbs. 

The  countenance  of  the  patient  is  often  flushed,  and  the  conjunc- 
tiva injected  ;  but  occasionally  the  face  is  pale,  and  sometimes  initial 
flushing  is  replaced  by  pallor  as  the  stage  of  depression  comes  on. 
The  pulse  is  frequent  and  soft ;  the  frequency  is  proportioned  to  the 
severity  of  the  attack  and  to  its  duration.  At  first  the  pulse  is  full  and 
large,  but  as  the  disease  goes  on,  it  usually  becomes  smaller  as  it  gets 
more  frequent.  In  severe  attacks  the  frequency  may  be  140  or  150, 
sometimes  even  more,  and  it  is  then  always  feeble.  The  patient  usually 
perspires  freely.  The  temperature  is  raised  in  all  except  the  slightest 
cases.  When  the  attack  is  of  moderate  severity,  the  elevation  is  slight, 
and  does  not  exceed  two  or  three  degrees,  but  in  severe  attacks  it  may 
reach  103°,  104°.  or  even  105°.  Occasionally,  hyperpyrexia  is  attained, 
108°  or  109°,  a  symptom  of  fatal  significance.  The  tongue  is  thickly 
coated,  and  there  is  usually' complete  anorexia;  the  patient  may  or 


ACUTE    ALCOHOLISM.  975 

may  not  be  thirsty ;  thirst  is  often  a  consequence  of  the  copious 
perspiration.  Tbe  urine  is  scanty  if  there  is  much  sweating,  and  is 
usually  deep  coloured,  of  a  high  specific  gravity,  and  very  often 
contains  a  small  quantity  of  albumen  apart  from  organic  kidney 
disease.  There  is  occasionally  slight  blurring  of  tbe  edges  of  the 
optic  disc,  with,  according  to  Uhthoff,  some  opacity  of  the  retina  ;* 
but,  as  a  rule,  the  fundus  is  normal.  Sometimes  acuity  of  vision  is 
lessened,  or  the  fields,  for  a  time,  are  restricted. 

This  state  usually  continues  for  two,  three,  or  four  days  without 
interruption.  The  patient  gets  no  sleep,  or  only  dozes  for  an  hour  or 
so  at  a  time,  and  wakes  up  unrefreshed.  The  pulse  becomes  softer 
and  more  frequent,  and  the  muscular  strength  becomes  lessened  by 
the  constant  exertion.  In  favorable  cases  the  patient  at  last  falls 
into  a  sound  sleep,  which  continues  for  eight,  ten,  or  twelve  hours,  and 
he  wakes  up  free  from  all  mental  disturbance,  or  with  only  a  trifling 
amount  of  delirium,  which  another  sleep  entirely  removes.  The  tremor 
lessens,  but  often  continues  in  slight  degree,  sometimes  for  some  days 
or  weeks'.  The  pulse  falls  in  frequency  and  improves  in  strength,' 
after  the  cessation  of  the  delirium,  and,  in  the  course  of  a  few  days, 
the  slight  tremor  and  muscular  weakness  are  the  only  relics  of  tbe 
attack  through  which  the  patient  has  passed.  In  other  cases,  however, 
sleep,  when  it  does  come,  is  briefer,  and  is  not  followed  by  the  same 
signs  of  improvement ;  the  delirium  continues,  but  is  less  active  than 
before,  and  the  signs  of  general  prostration  are  greater.  In  such 
cases  there  is  considerable  danger  to  life.  A  second  or  third  period 
of  sleep  may  bring  improvement,  and  slow  convalescence  may  ensue 
at  the  end  of  six  or  seven  days,  but  in  other  cases  the  prostration  in- 
creases, the  pulse  becomes  still  feebler  and  more  frequent,  and  a 
eomatose  state  comes  on,  in  which  the  patient  dies.  This  unfavor- 
able condition  is  sometimes  reached  without  any  sleep  having  occurred, 
in  spite,  it  may  be,  of  strong  narcotics.  Convulsions  or  hyperpyrexia 
may  attend  the  iucreased  prostration  of  the  later  stage,  and  are 
generally  a  fatal  omen.  Convulsions  may  also  occur  at  the  onset,  and 
are  not  then  of  much  significance ;  at  the  later  period  of  an  attack, 
by  the  disturbance  of  the  nervous  system  which  they  reveal,  as  well 
as  by  their  effect  on  the  patient,  they  add  greatly  to  his  peril.  They 
resemble  the  attacks  of  ordinary  epilepsy. 

Complications. — The  most  important  of  these  are  other  diseases 
due  to  alcohol,  or  local  acute  inflammations,  especially  pneumonia. 
Cirrhosis  and  fatty  degeneration  of  the  liver,  and  disease  of  the  kidney, 
are  especially  serious  complications.  TJrsemic  coma  occasionally  comes 
on  in  the  course  of  delirium  tremens.  Pneumonia  is  a  very  common 
accompaniment,  and  its  occurrence  is  facilitated  by  alcoholism  ;  it 
may  lead  the  way,  and  the  nervous  disorder  may  be  secondary  in 
time,  although  ultimately  dominating  the  symptoms,  or  the  lung 
affection  may  be  a  subordinate  complication  of  the  disease,  developing 
*  Uhthoff,  quoted  by  Moeli,  '  Chavite  Annaleu,'  ix,  p.  524. 


976  ALCOHOLISM. 

after  the  onset  of  the  toxic  disorder,  when  the  patient  is  prostrate. 
Its  development  is  then  often  insidious,  and  may  be  unaccompanied 
bv  pain  or  cough,  while  the  effect  on  the  breathing  may  be  masked 
by  the  restlessness  of  the  patient.  Hence,  examination  of  the  chest 
is  of  extreme  importance  in  every  case.  In  many,  undetected  tuber- 
culosis aids  in  causing  the  pneumonia  and  in  determining  an  un- 
favorable course.  A  rare  complication  is  meningeal  haemorrhage, 
which  has  been  met  with  in  a  few  cases.  Chronic  lesions  of  the 
nervous  system  are  also  often  present,  and  are  intensified  by  the 
acute  disturbance.  Those  of  multiple  neuritis — pains,  paresis,  ataxy, 
with  loss  of  the  knee-jerk — are  the  most  frequent. 

Terminations  and  Sequelse. — Delirium  tremens  lasts  from  three  to 
seven  days,  and  commonly  terminates  in  recovery.  Death  occurs  chiefly 
in  those  who  have  had  several  previous  attacks,  or  whose  tissues  are 
gravelv  damaged,  either  by  the  influence  of  long-continued  intem- 
perance or  by  senile  degeneration.  Its  common  causes  are  exhaustion 
and  gradual  failure  of  the  heart's  action.  Sometimes  death  occurs 
suddenly,  from  unexpected  syncope ;  but  it  more  often  results  from 
associated  acute  diseases,  especially  from  pneumonia,  or  from  the 
effects  of  pre-existing  tuberculosis.  The  mortality  has  been  variously 
stated ;  v.  Franque's  estimate  of  18  per  cent,  is  probably  near  the 
truth.* 

Most  patients  who  recover  do  so  perfectly.  Severe  second  or  third 
attacks  not  only  involve  danger  to  life,  but  pass  away  more  slowly 
and  less  perfectly.  But  curious  exceptions  are  met  with,  in  which 
recurrences  seem  to  be  easily  produced  and  are  brief  in  duration.  In 
one  instance  a  patient  had  survived  no  less  than  twenty-seven  distinct 
attacks.f  When  the  mental  state  continues  abnormal  (especially  in 
those  who  inherit  a  tendency  to  insanity),  the  sleep  that  brings  physical 
quietude  only  partially  restores  the  mental  rest.  The  distressing 
hallucinations  may  cease,  but  some  more  stable  delusions  remain,  and 
may  last  for  weeks  or  months.  If  the  patient  has  had  a  previous  attack 
with  this  sequel,  the  duration  of  the  mental  change  is  longer,  and  the 
state  may  even  be  permanent.  In  that  event  there  is  usually  pro- 
gressive failure  of  memory  and  of  mental  power,  so  that  the  patient 
passes  into  a  condition  of  chronic  insanity  or  of  chronic  dementia ; 
the  latter  is  especially  common  in  late  life. 

Pathology. — In  a  case  of  pure  alcoholic  delirium  the  pathological 
changes  are  slight,  and  consist  only  in  signs  of  congestion  of  the  cortex 
of  the  brain  and  sometimes  of  other  parts,  especially  of  the  medulla 
and  spinal  cord.  There  is  often  some  opacity  of  the  arachnoid,  but  it 
is  probable  that  this  is  a  chronic  change,  the  result  of  long  previous 

*  This  estimate  was  calculated  from  2117  cases  (v.  Franque,  'Ueber  Delirium 
Tremens,'  Munich,  1859).  Krukenberg  found  only  10  per  cent,  in  301  attacks  in 
265  patients  (loc.  cit.). 

f  Krukenberg,  loc.  cit. 


ACUTE    ALCOHOLISM.  977 

intemperance.  Signs  of  actnal  acute  meningitis  are  rare,  but  have 
been  occasionally  found  in  both  the  pia  arachnoid  and  the  dui-a  mater. 
Congestion  of  the  bases  of  the  lungs  is  common,  and  sometimes  there 
are  signs  of  congestion  in  the  kidneys,  but  the  alterations  met  with 
outside  the  nervous  system  are  chiefly  the  chronic  changes  that  result 
from  intemperance. 

Alcohol  may  be  found  by  chemical  analysis  in  various  organs  of  the 
body  up  to  the  fifth  day  after  its  ingestion  ;  by  the  seventh  day  it  has 
disappeared.  But  the  presence  of  alcohol  may  be  demonstrated,  in 
like  manner,  in  persons  who  have  been  drinking,  but  have  not  suffered 
from  delirium  tremens.  We  cannot,  therefore,  regard  it  as  affording  a 
full  explanation  of  the  disease.  This  evidently  depends  on  an  acute 
disturbance  of  the  nerve-centres,  probably  involving  all  parts  of  them, 
but  especially  the  cerebral  cortex, — a  disturbance  of  function  produced 
by  the  toxic  agent,  running  a  definite  course,  with  a  tendency  to  sub- 
side, provided  the  continued  action  of  its  cause  is  prevented. 

Diagnosis. — The  disease  is  easily  recognised.  The  preponderance 
of  visual  hallucinations,  and  the  associated  tremor,  distinguish  it  from 
acute  mania  on  the  one  hand  and  from  symptomatic  delirium  on  the 
other,  while  the  absence  of  headache  and  of  paralysis  is  a  distinction 
from  ordinary  acute  meningitis.  Cases  of  general  paralysis  of  the 
insane,  in  which  muscular  tremor  is  conspicuous,  have  been  mistaken 
for  delirium  tremens;  but  if  there  is  much  mental  alteration,  its 
character  is  altogether  different  in  the  two  diseases ;  the  exaggerated 
delusions  of  general  paralysis,  and  the  mental  complacency  that 
commonly  attends  them,  are  very  different  from  the  anxiety  and  horror 
of  the  alcoholic.  When  depression  occurs  in  general  paralysis,  the 
mental  state  has  generally  developed  gradually,  in  a  maime?  rery  un- 
like the  acute  onset  of  delirium  tremens. 

Prognosis. — The  prognosis  is  good  in  first  attacks,  free  from  com- 
plications, and  in  those  whose  tissues  are  not  seriously  damaged. 
The  pulse  and  temperature  afford  the  most  important  indications. 
The  danger  is  great  in  proportion  to  the  frequency,  softness,  and  small 
size  of  the  pulse,  and,  as  Anstie  has  shown,  the  sphygmographic 
tracing  presents  very  clearly  the  serious  characters,  although  the  in- 
strument is  not  actually  needed  to  detect  them.  As  a  rule,  the  occur- 
rence of  sound  sleep  for  six  or  eight  hours  greatly  improves  the  pro- 
gnosis, but  if  an  exceedingly  unfavorable  pulse  presents  no  improve- 
ment after  sleep,  the  danger  is  great,  and  the  patient  is  very  likely 
to  die  in  a  few  hours.  A  temperature  above  103°  is  always  of  serious 
import,'  and  the  danger  is  greater  in  proportion  to  the  degree  of  pyrexia  ; 
a  rise  to  105°  and  over  is  seldom  survived.  Moreover,  a  sudden  con- 
siderable rise  in  the  later  stages  of  the  disease,  is  also  of  very  grave 
significance,  even  although  the  actual  height  attained  is  not  extreme. 
Advanced  years  add  greatly  to  the  gravity  of  delirium  tremens,  espe- 
vol.  n.  62 


978  ALCOHOLISM, 

eially  when  there  is  considerable  pyrexia  ;  in  a  man  of  sixty,  a  rise  to 
103°  is  as  serious  as  would  be  a  temperature  of  105°  in  a  young  person. 
Any  complication  also  lessens  the  chance  of  recovery,  the  most  serious 
being  pneumonia  and  kidney  disease.  If  the  pneumonia  is  double, 
death  is  practically  certain.  The  prognosis  is  also  grave  when  delirium 
tremens  is  associated  with  traumatic  lesions,  both  because  the  ten- 
dency to  depression  and  collapse  is  increased  by  the  shock  of  the 
original  injury  or  operation,  and  also  because  wounds  run  a  very  un- 
favorable course  in  this  condition. 

Treatment. — The  mental  state  of  the  sufferer  from  delirium 
tremens  necessitates  very  careful  management.  It  is  essential  that 
all  undue  excitement  should  be  avoided,  and  only  the  necessary 
attendants  should  be  in  the  room.  It  is  well  to  have  the  light  dim, 
unless  this  distinctly  increases  the  patient's  suspicion  and  uneasiness. 
When  there  is  much  disposition  to  act  according  to  the  false  ideas, 
male  attendants  are  necessary,  and  physical  restraint  is  often  indis- 
pensable, lest  the  patient  injure  himself  or  others.  He  may  even 
attempt  suicide  by  jumping  from  a  window  or  swallowing  some  acces- 
sible poison,  sometimes  deliberately,  sometimes  under  the  influence  of 
a  false  idea.  Hence  windows  should  be  securely  fastened,  and  no 
lotions  or  poisonous  liquid  should  be  within  the  patient's  reach.  In 
many  cases  the  patient  can  be  kept  in  bed  by  judicious  management 
and  persevering  persuasion  on  the  part  of  the  attendants.  In  other 
cases,  however,  force  is  needed.  The  mode  in  which  it  should  be 
applied  is  a  matter  on  which  authorities  differ.  If  there  is  great 
violence,  continued  exertion  on  the  part  of  the  attendant  is  necessary 
to  keep  the  patient  in  bed ;  two  attendants  are  needed  to  cope  with  a 
strong  delirious  man,  and  the  constant  struggles  are  exhausting  to  the 
patient.  The  "  strait  waistcoat  "  offers,  in  such  cases,  an  effectual 
mode  of  restraint ;  the  interference  with  the  movement  of  the  chest 
produced  by  it  has  been  urged  as  an  objection  to  its  use,  but  this 
drawback  has  certainly  been  exaggerated.  Leather  gauntlets  on  the 
wrists  and  ankles  may  be  secured  to  the  sides  and  foot  of  the  bed,  and 
restrain  the  patient  effectually  without  any  interference  with  respira- 
tion. Bandages  are  sometimes  employed  for  this  purpose,  but  may 
cut  into  the  skin  if  the  struggles  are  violent.  Another  effectual  means 
of  restraint  is  a  sheet  across  the  trunk  and  arms,  firmly  secured 
at  the  sides  of  the  bed.  In  most  cases  of  delirium  tremens  this  answers 
as  well  as  the  strait  waistcoat,  and  has  the  advantage  of  being  always 
available,  but  it  also  may  slightly  hamper  the  respiratory  movements. 

Pood  must  be  given  in  licpuid  form;  beef  tea,  milk,  and  beaten-up 
eggs  should  form  its  chief  part.  The  anorexia  often  renders  it  difficult 
to  give  nourishment,  but  the  difficulty  can  generally  be  overcome  by  a 
little  perseverance.  It  is  well,  in  this  as  in  other  acute  diseases, 
to  commence  the  process  of  digestion  of  food  before  it  is  taken. 
Benger's  Liq.  Pancreaticus  andLiq.  Pepticus  offer  the  readiest  means 


ACUTE  ALCOHOLISM.  979 

for  doing  this,  the  former  being  used  for  milk,  the  latter  for  beef  tea. 
Half  a  drachm  of  either  may  be  added,  and  the  food  kept  warm  (not 
hot)  for  twenty  minutes  or  half  an  hour,  and  then  given.  The 
process  of  digestion  thus  commenced  goes  on  within  the  body.*  If 
there  is  vomiting,  peptonised  enemata,  well  digested,  must  be  given. 
The  patient  should  not  be  without  food  for  more  than  three  hours ;  a 
due  supply  of  nourishment  is  by  far  the  most  important  element  in 
treatment.  Whether  alcoholic  stimulants  should  be  given  must  depend 
on  the  state  of  the  pulse.  They  are  better  withheld  unless  the  pulse 
calls  for  them  in  language  that  is  not  only  unequivocal,  but  is  rather 
more  decided  than  would  be  held  a  sufficient  indication  in  an  acute 
disease  of  other  nature.  Some  stimulation  may  be  obtained  from 
ammonia  and  ether.  Coffee  has  been  recommended  for  the  same 
purpose,  and  may  be  used  after  sleep  has  been  obtained,  or  either 
caffeine  or  cocaine  may  be  employed  as  a  substitute.  In  all  cases  an 
aperient  should  be  given  at  the  Qutset,  enough  to  open  the  bowels 
freely,  but  not  so  strong  as  to  cause  prostrating  purgation. 

It  was  formerly  customary  to  administer  sedatives  freely  from  the 
first  in  the  endeavour  to  procure  the  sleep  that  usually  ends  the  acute 
disturbance.  Bromides  are  commonly  inadequate  to  compel  sleep, 
although  often  useful  as  tranquillising  agents ;  opium  or  morphia  and 
chloral  are  the  hypnotics  usual]}'-  given.  In  most  severe  cases  efforts 
to  produce  sleep  fail  until  near  the  time  when  the  terminal  sleep 
naturally  comes.  The  insusceptibility  to  sedatives  in  the  early  stage 
is  extraordinary;  dose  after  dose  may  be  given  until  a  poisonous 
quantity  is  in  the  system,  and  still  the  patient  may  be  sleepless,  with 
increasing  and  perhaps  alarming  exhaustion.  If  the  hypnotics  are 
boldly  pushed,  they  at  last  may  act,  and  the  patient  may  die  from 
their  influence.  Anstie  believed  that  when  opiates  fail  to  influence 
the  brain  and  to  induce  sleep,  they  sometimes  paralyse  the  heart.  He 
mentioned  a  case  in  which,  almost  immediately  after  the  administra- 
tion of  a  second  large  dose  of  opium,  the  patient  became  ghastly  pale, 
the  pulse  fluttered  and  then  stopped,  and  in  a  few  minutes  the  patient 
was  dead.f  Without  doubt  many  cases  have  ended  fatally  in  conse- 
quence of  the  idea  that  it  is  absolutely  necessary  to  procure  sleep  at 
all  risks.  It  is  only  in  a  very  slight  case  that  it  is  right  to  try  to 
force  sleep  in  the  early  stage.  In  all  severe  attacks  it  is  wiser  to 
postpone  the  attempt  until  the  duration  of  the  disease  has  increased 
the  prospect  of  success — that  is,  until  the  third  or  fourth  day  of  the 
attack.  If  a  narcotic  dose  is  given  earlier  (such  as  a  quarter  of  a 
grain  of  morphia  beneath  the  skin,  or  sixty  grains  of  chloral  by  the 
mouth),  it  should  not  be  repeated  until  sufficient  time  has  elapsed  to 
permit  its  action  to  pass  off.  It  is  better,  however,  in  the  early  stage 
to  be  content  with  moderate  doses,  merely  sufficient  to  favour  tran- 

*  This  is  a  much  better  method  than  that  commonly  employed  of  carrying  the 
process  of  artificial  digestion  further,  and  then  stopping  it  by  heat. 

f  Art.  "Alcoholism,"  'Reynolds'  Syst.  of  Med.,'  vol.  ii,  2nd  ed.,  p.  169. 


980  ALCOHOLISM. 

quility.  A  scruple  or  half  a  drachm  of  bromide,  with  fifteen  or 
twenty  grains  of  chloral,  may  be  given  every  six  or  eight  hours,  and 
then,  after  about  forty-eight  hours,  a  stronger  hypnotic  may  be  tried. 
Chloral  generally  acts  better  and  is  attended  by  less  danger  than 
opium  or  morphia.  Of  the  latter,  not  more  than  a  third  of  a  grain 
should  be  iujected,  and  it  is  wiser  to  give  first  a  smaller  dose,  a 
quarter  or  a  sixth.  The  practice  of  repeating  moderate  doses  at  short 
intervals  has  been  recommended,  but  it  is  better  to  wait  for  six  hours 
and  then  to  give  a  second  full  dose.  Opium  has  been  thought  by 
some  to  be  safer  than  chloral  if  there  is  weakness  of  the  heart,  but 
the  fact  is  doubtful.  In  mild  cases,  half  a  grain  of  the  extract  of 
Indian  hemp  sometimes  promotes  sleep.  Chloralamide  and  sulphonal 
are  often  effective  and  also  safe. 

The  treatment  by  large  doses  of  digitalis,  introduced  by  Jones  of 
Jersey,  has  been  universally  relinquished.  The  good  thereby  effected 
was  doubtful,  and  certainly  altogether  disproportionate  to  the  danger 
of  the  treatment.  The  use  of  pilocarpine  to  increase  the  sweating  and 
thus  help  to  eliminate  the  alcohol  has  been  recommended,*  but  the 
agent  is  unneeded  in  slight  cases,  and  in  all  others  the  use  of  a  drug 
that  depresses  should  be  carefully  avoided.  This  remark  applies 
also  to  the  employment  of  tartar  emetic  for  the  same  purpose,  which 
was  at  one  time  in  vogue.  A  drug  that  has  been  strongly  recom- 
mended, and  is  at  least  not  open  to  the  same  objection  of  lowering  the 
strength  of  the  patient,  is  capsicum.  Three  or  four  doses  given  every 
three  hours  are  said  frequently  to  produce  calm,  refreshing  sleep.  Ten 
or  even  twenty  grains  of  cayenne  pepper,  in  the  form  of  an  infusion, 
or  half-drachm  doses  of  the  tincture  may  be  given. f 

If  alcohol  is  necessary  during  the  acute  stage  of  the  disease,  it 
should  be  discontinued  as  soon  as  possible,  and  altogether  withheld 
during  convalescence.  An  attack  of  delirium  tremens  is  sometimes  a 
turning-point  in  a  drunkard's  life,  and  every  means  should  be  taken 
to  enforce  upon  him  the  lesson  of  the  illness,  a  lesson  which  he  is  pro- 
verbially prone  to  forget  with  returning  health. 

Acute  Alcoholic  Insanity. — Delirium  tremens,  although  the 
patient  is  for  the  time  insane,  is  not  classed  as  a  form  of  insanity. 
Acute  attacks  of  mental  derangement  sometimes  result  from  this- 
cause,  and  are  scarcely  to  be  distinguished,  except  in  their  origin, 
from  the  similar  condition  that  comes  on  from  other  causes.  Indeed, 
in  almost  all  cases  of  the  kind  there  is  an  hereditary  tendency  to 
mental  derangement,  and  the  alcoholic  excess  is  merely  the  exciting 

*  Isliam,  'Am.  Med.  News,'  1885,  p.  312. 

t  Cayenne  is  an  old  negro  remedy  in  Jamaica  for  many  acute  ailments.  (See 
Kinnear,  '  Lancet,'  1862,  i,  p.  261,  and  an  anonymous  letter,  ib.,  p.  390.)  It  was  at 
first  given  in  a  glass  of  spirit,  a  vehicle  open  to  objection  in  delirium  tremens.  In 
many  of  the  cases  in  which  its  influence  has  been  supposed  to  be  most  conspicuous 
by  contrast  with  other  drugs,  it  was  given  after  these  had  been  tried  in  vain,  and  at. 
the  period  when  a  spontaneous  subsidence  of  the  disease  might  be  looked  for. 


CHEON10  ALCOHOLISM.  981 

cause.  Acute  mania  may  thus  come  on,  distinguished  from  delirium 
tremens  by  more  persistent  delusions  and  by  the  absence  of  tremor 
and  of  the  restlessness  of  mind  and  body,  Some  of  these  cases 
run  a  shorter  course  than  acute  mania  commonly  does ;  sleep 
has  a  more  pronounced  ameliorating  influence,  and  slight  tremor  may 
be  present.  Thus  there  are  forms  that  seem  to  be  intermediate 
between  simple  acute  mania  and  delirium  tremens.  Chronic  mental 
-alteration  is  apt  to  be  left  behind  for  a  time,  but  this,  as  we  have  seen, 
is  not  uncommon  after  delirium  tremens  in  those  who  inherit  a 
tendency  to  insanity.  Acute  melancholia  also  sometimes  occurs  from 
alcoholic  excess,  but  does  not  present  any  special  peculiarities.  A 
peculiar  form  of  recurring  insanity,  associated  with,  and  excited  by, 
a  drinking  tendency,  has  been  termed  oinomania.  There  is  some- 
times permanent  moral  deficiency,  and  there  are  periods  in  which  the 
subject  loses  all  moral  sense,  falls  into  various  excesses,  and  may 
wander  about  and  act  in  an  absurd  and  often  indecent  manner.  In 
some  cases,  during  the  intervals  between  the  outbreaks,  the  patient 
■exhibits  no  moral  or  intellectual  defect. 


Chronic  Alcoholism. 

Various  morbid  states  of  the  nervous  system  are  slowly  induced  by 
habitual  alcoholic  excess.  These  differ  from  the  acute  disturbance  in 
that  they  are  often  induced  by  habitual  excess  which  never  attains  the 
degree  necessary  to  cause  actual  drunkenness.  The  most  common 
symptom  is  muscular  tremor,  seen  chiefly  in  the  hands,  lips,  and 
tongue.  It  is  inconspicuous  in  the  legs,  although  it  may  often  be 
found  there  if  looked  for.  It  is  a  fine  irregular  tremor,  and  occurs 
only  when  the  muscles  are  put  in  action  by  the  will.  It  results 
from  all  kinds  of  excess,  and  may  be  as  conspicuous  in  those  who 
drink  only  beer  as  in  spirit  drinkers.  It  is  generally  greatest  in  the 
morning,  and  is  less  after  some  alcohol  is  taken.  Sometimes  there 
are  also  sudden  starts  of  the  limbs,  especially  during  sleep.  In- 
somnia is  often  troublesome ;  sleep,  when  it  occurs,  may  be  disturbed 
by  distressing  dreams,  and  visual  hallucinations  may  distress  the 
patient  in  the  state  between  sleeping  and  waking,  and  may  prevent 
sound  sleep.  To  these  symptoms  some  persistent  mental  changes 
are  often  added,  irritability,  restlessness,  failure  of  memory.  Other 
symptoms  of  disease  outside  the  nervous  system  may  co-exist, 
congestion  of  the  face  and  conjunctiva,  fulness  of  the  eyelids,  a 
tendency  to  skin  eruptions  on  the  face,  a  furred  tongue,  anorexia, 
and  morning  vomiting. 

Besides  these  mental  disorders,  other  definite  maladies  occur, 
subacute  or  chronic  in  character.  The  most  important  of  these  is 
multiple  neuritis,  a  description  of  which  was  given  in  the  first  volume. 


982  ALCOHOLISM. 

Alcoholism  is  by  far  the  most  common  cause  of  tbis  disorder,*  and  to 
this  form  of  neuritis  women  are  more  prone  than  men.  The  symptoms 
may  present  either  of  the  three  leading  forms— paralytic  atrophy, 
sensory  loss,  or  ataxy  ;  a  combination  of  the  motor  and  sensory 
symptoms,  or  of  the  latter  with  inco-ordination,  is  the  most  common. 
In  all,  pains  are  usually  distressing,  and  the  muscular  tenderness  is 
often  greater  than  that  of  the  nerves.  Sensory  disturbance  occurs 
first  in  the  legs,  the  atrophic  palsy  in  the  arms.  The  craiiial  nerves 
as  a  rule  escape  in  this  form,  but  the  vagus,  and  the  nerves  of  the 
eyeball  muscles,  have  suffered  when  alcohol  has  been  continued  after 
the  onset  of  the  palsy. 

Chronic  and  subacute  myelitis  certainly  sometimes  results  from 
alcoholism,  as  is  shown  by  a  case  figured  in  vol.  i.  (Fig.  105).  In  this, 
as  in  most  cases  of  the  kind,  the  inflammation  of  the  cord  accom- 
panied peripheral  neuritis,  by  which  its  symptoms  were  masked  to  a 
considerable  extent.  Disease  of  the  spinal  cord  was  formerly  thought 
to  be  the  common  cause  of  alcoholic  palsy  in  the  form  that  we  now 
know  to  be  the  result  of  neuritis.  Most  cases  of  "  alcoholic  paraplegia  " 
formerly  described  were  certainly  examples  of  neuritis.  An  isolated 
affection  of  the  cord  due  to  alcohol  is  rare.  It  would  seem  that  the 
susceptibility  of  the  peripheral  nerves  is  greater  than  that  of  the  cord, 
but  the  two  affections  are  scarcely  comparable,  since  in  the  spinal 
cord  the  inflammation  is  interstitial,  while  in  the  nerve,  the  fibres 
suffer  primarily  from  the  toxic  influence. 

In  France,  functional  hemianesthesia  is  said  to  be  not  uncommon 
in  alcoholics,  and  some  examples  have  been  described  by  Maguan.f 
similar  to  the  unilateral  loss  that  is  met  with  in  hysteria.  But 
the  condition  is  rarely  met  with  in  this  country.  Epilepsy  is  occa- 
sionally an  effect  of  alcoholic  excess,  but  the  attacks  seldom  occur 
periodically,  as  they  do  in  the  ordinary  form  of  the  disease.  Usually 
a  series  of  attacks  are  excited  by  a  bout  of  drinking,  or  even  by  a 
single  intoxication,  and  the  patient  is  free  from  them  until  he  again 
gives  way  to  excess.  In  such  cases  the  fits  are  apt  to  accompany  an 
attack  of  delirium  tremens. 

Neuralgic  pains  in  the  limbs  are  sometimes  troublesome ;  these  ar-e 
doubtless  often  the  result  of  an  influence  of  alcohol  on  the  nerves,  such 
as,  in  greater  degree,  causes  actual  neuritis.  But  some  of  these  nerve- 
pains  are  produced  through  the  agency  of  a  gouty  diathesis,  to  which 
alcoholic  excess  unquestionably  contributes.  It  is  important  to 
recognise  and  remember  the  frequency  of  this  combination,  which 
may  be  seen  in  various  effects  of  the  two  influences,  and  even  in  the 
neuritis.  The  influence  of  gout  perhaps  sometimes  determines  the 
occurrence  of  the  myelitis,  and  renders  the  peripheral  neuritis  in 

*  It  has  been  pointed  out  by  Dr.  Dreschfeld  (in  a  valuable  article  in  'Brain,' 
Jan  ,  1886,  p.  434)  that  an  accurate  sketch  of  the  symptoms  of  alcoholic  neuritis  was 
given  by  Dr  James  Jackson,  of  Boston,  U.S.,  in  1822. 

+  '  On  Alcoholism,'  Greenfield's  trans. 


CHRONIC  ALCOHOLISM.  983 

greater  degree  interstitial,  and  it  may  cause  an  isolated  perineuritis  (as 
of  the  sciatic  nerve)  to  be  combined  with  symmetrical  polyneuritis. 

It  is  an  undecided  question  whether  alcohol  causes  amblyopia  and 
optic  nerve  atrophy,  such  as  result  from  the  use  of  tobacco.  In  many 
cases  of  tobacco  amblyopia,  there  is  a  history  of  alcoholic  excess,  which 
has  been  thought  to  favour  the  occurrence  of  the  affection,  but  ito 
production  by  alcohol  alone  is  not  well  established. 

I  have  occasionally  seen  distinct  slight  optic  neuritis  in  the  subjects 
of  chronic  alcoholism,  generally  in  association  with  headache  and 
trifling  mental  changes.  It  is  probable  that  in  many  of  these 
cases  there  is  chronic  meningitis  Opacity  and  thickening  of  the 
arachroid  and  dura  mater  are  met  with  after  death  in  some  cases, 
chiefly  marked  over  the  convexity  of  the  brain,  and  are  probably  a 
direct  effect  of  the  alcohol.  This,  with  some  slight  shrinking:  of  the 
cortex,  constitutes  the  most  common  post-mortem  change  in  cases  of 
long  duration.  Patty  degeneration  of  the  walls  of  the  small  arteries  is 
apparently  more  common  in  alcoholic  subjects  than  in  others.  Minute 
foci  of  softening  due  to  vascular  disease,  and  called  "  encephalitis," 
have  been  met  with  in  the  cortex  in  rare  cases,  usually  in  association 
with  considerable  and  long-standing  mental  changes. 

Chronic  alcoholism  may  aid  in  the  production  of  many  forms  of 
definite  insanity,  but  the  only  variety  that  can  be  certainly  ascribed 
to  this  cause,  acting  alone,  is  chronic  dementia — failure  of  memory, 
commonly  progressive  for  a  time,  accompanied  by  defective  power  of 
judgment,  and  often  by  want  of  cleanliness  and  other  indications 
of  impaired  moral  sense.  Mental  weakness  may  be  associated  with 
defective  articulation,  and  with  recurring  slight  paralytic  attacks, 
so  as  to  constitute  a  group  of  symptoms  bearing  some  resemblance 
to  general  paralysis  of  the  insane,  but  differing  in  the  non-progressive 
character  of  the  disorder  if  alcohol  is  given  up.  Actual  recovery  is, 
however,  rare,  although  the  sufferers  may  live  for  many  years.  It 
is  probable  that,  in  such  cases,  there  is  chronic  meningitis.  The 
influence  of  alcohol  in  causing  true  general  paralysis  has  been  much 
discussed ;  the  disease  very  seldom  results  from  this  cause  acting 
alone,  although  intemperance  may  aid  other  influences  in  producing  it. 

The  diagnosis  of  the  effects  of  chronic  alcoholism  from  the  maladies 
with  which  they  may  be  confounded  has  been  sufficiently  considered 
in  the  description  of  those  diseases.  The  most  common  question  is 
the  distinction  of  alcoholic  tremor  from  other  forms,  especially  from 
the  very  similar  tremor  that  is  sometimes  congenital,  or,  if  not 
congenital,  has  existed  from  early  life,  and  is  often  inherited.  The 
history  of  the  tremor  sufficiently  distinguishes  the  two  affections. 

The  chief  element  in  the  treatment  of  chronic  alcoholism  is  the 
change  in  the  habits  of  the  patient.  Bitter  tonics,  such  as  bark,  have 
been  sometimes  found  of  service,  as  in  some  measure  satisfying  the 
craving  for  drink.  Tincture  of  capsicum  has  also  been  praised;  ten- 
minim  doses  may  be  given  before  meals  or  when  the  craving  for  drink 


984  HYSTERIA. 

comes  on.*  Hydroehlorate  of  cocaine  (^  to  \  gr.)  is  also  useful,  and 
may  be  given  after  food,  combined  with  half  a  minim  of  the  alcoholic 
solution  of  nitro-glycerine  (2--^  gr.),  four  minims  of  liquor  strychnia^, 
and  some  liquid  preparation  of  pepsin.  The  special  derangements 
will  generally  subside  when  the  cause  ceases  to  act.  The  treatment 
that  may  be  needed  has  been  described  in  the  account  of  these 
disorders.  Strychnine  and  nux  vomica  are  useful  for  the  tremor.  To 
lessen  the  insomnia  and  nervous  restlessness,  Marcet  has  recommended 
oxide  of  zinc,  in  two-grain  doses,  two  or  three  times  a  day. 


HYSTERIA. 

The  term  "hysteria"  is  applied  to  a  morbid  state  of  the  nervous 
system  which  is  far  more  common  in  women  than  in  men.  The 
primary  derangement  is  in  the  higher  cerebral  centres,  but  the  func- 
tions of  the  lower  centres  in  the  brain,  of  the  spinal  cord,  and  of  the 
sympathetic  system,  may  be  secondarily  disoi'dered.  Hence  the  sym- 
ptoms vary  much,  and  the  secondary  manifestations  may  preponderate 
and  obscure  the  primary  disturbance.  The  name  is  derived  from  an 
erroneous  idea  that  there  is  a  special  connection  between  the  disease 
and  disorders  of  the  womb  (bo-repn),  which  was  even  once  thought  to 
move  about  the  body,  and  cause  the  local  symptoms.  The  opinion 
that  the  disease  is  primarily  and  chiefly  one  of  the  cerebral  functions 
is  now  all  but  universally  held,  and  the  present  use  of  the  word 
"  hysteria  "  does  not  imply  the  theory  involved  in  its  derivation. 

It  should,  however,  be  remembered  that  there  is  a  difference 
between  the  popular  and  the  medical  use  of  the  word.  To  the  public, 
the  name  is  chiefly  associated  with  the  simulation  of  symptoms,  or  at 
least  with  the  idea  that  the  patient  could  prevent  the  symptoms  if  she 
liked.  But  the  malady  is  a  real  one,  and  to  a  large  extent  beyond  the 
direct  influence  of  the  patient's  will.  It  should  also  be  remarked 
that  the  word  is  applied  more  widely  to  women  than  to  men  ;  the  same 
conditions  are  often  termed  "  hysteria  "  in  the  former,  and  "  hypo- 
chondriasis "  in  the  latter. 

Etiology. — Both  race  and  civilisation  have  probably  more  influ- 
ence on  the  occurrence  of  hysteria  than  has  been  recognised  or  studied. 
It  is  almost  unknown  among  barbarous  rac  s,  and  seems  to  be  a  pro- 
duct of  the  cerebral  development  that  accompanies  the  process  of 
civilisation.  In  certain  stages  of  civilisation,  peculiar  forms  of  the 
disease  have  attained  great  development,  as  in  Europe  during  the 
Middle  Ages.  Among  races  that  have  attained,  apparently,  an  equal 
civilisation,  hysteria  reaches  a  higher  degree  in  some  than  in  others — 
in  the  French,  for  instance,  and  in  the  English ;  no  doubt  in  conse- 

*  See  Ringer's  'Therapeutics,'  5th  ed.,  1876,  p.  862. 


ETIOLOGY.  985 

quence  of  the  underlying  differences  in  nervous  constitution  that  are 
recognised  in  the  expression  "  national  temperament."* 

Hysteria  has  been  estimated  to  be  twenty  times  as  frequent  in 
■women  as  in  men  (Briquet),  but  the  varying  use  of  the  word  already 
mentioned  reuders  the  facts  difficult  to  ascertain.  Every  form  does 
occur  in  the  male  sex,  and  certain  varieties  are  not  unfrequent. 
The  liability  of  females  is  probably  determined  by  the  character 
of  their  nervous  system,  and  not  by  the  possession  of  certain 
sexual  organs.  Some  disposition  to  hysteria  is  inherent,  if  not  in 
all  women,  at  least  in  the  vast  majority.  The  affection  is  far  more 
common  in  boys  than  in  adult  men ;  the  differences  in  the  ner- 
vous constitution  of  the  two  sexes  are  far  less  before  than  after 
puberty.  Adult  men  who  are  the  subjects  of  the  disease  often 
present  mental  characteristics  resembling  those  of  the  female  sex. 
The  exact  influence  of  age  is  also  difficult  to  ascertain,  because 
the  special  manifestations  of  the  disease  are  the  result  of  an  under- 
lying and  antecedent  morbid  state,  which  develops  so  gradually  that 
its  commencement  can  seldom  be  determined.  The  frequency  with 
which,  distinct  symptoms  commence  in  the  several  decades  of  life  is 
shown  in  the  following  table,  calculated  fi*om  the  figures  given  by 
Briquet  and  Landouzy : 


—10 

—20 

—30 

—40 

—50 

—60 

8 

50 

28 

10 

3 

1 

Per  cent. 

Thus  in  one  half  the  cases  the  disease  is  first  manifested  in  the 
second  decade  of  life.  Of  these,  a  larger  number  begin  between 
fifteen  and  twenty  than  between  ten  and  fifteen.  In  nearly  a  third  of 
the  whole,  the  first  manifestations  occur  between  twenty  and  thirty, 
and  a  much  smaller  number  in  the  first  and  fourth  decades.  The 
cases  met  with  under  ten  generally  commence  after  six,  although 
symptoms  of  similar  character  have  occasionally  been  met  with  at 
three,  four,  or  five  years  of  age  (Barlow).  The  above  statements  are 
true  chiefly  of  females.  Begarding  the  age  at  onset  in  males,  we  can 
only  say  that  the  commencement  is  before  puberty  in  a  larger  propor- 
tion of  males  tban  of  females. 

Heredity  has  an  unquestionable  influence,  and  may  be  direct,  or  a 
general  neurotic  tendency.  One  of  the  most  severe  cases  of  juvenile 
hysteria  I  have  seen  was  in  a  girl  of  nine,  both  of  whose  parents  had 
insane  relatives.  In  another  case,  a  girl  had  peculiar  hysteroid  fits, 
and  both  her  mother  and  grandmother  had  had  similar  fits  at  the 
same  age.  Briquet  found  a  history  of  hysteria  in  the  parents  of 
hysterical  patients  twelve  times  as  frequently  as  in  the  parents  of 

*  The  following  account  of  the  disease  is  based  chiefly  on  its  manifestations  in  the 
English  race.  Some  features,  that  are  merely  alluded  to  here,  have  attracted  great 
attention  abroad.  These  have  been,  for  the  most  part,  fully  described  in  the  lectures 
of  Charcot,  and  in  the  classical  treatise  of  Richer,  from  which  some  illustrations  are 
here  reproduced. 


986  HYSTERIA. 

those  who  were  not  hysterical,  but  such  a  proportion  is  probably 
much  larger  than  would  be  found  to  obtain  in  this  country.  It  must 
be  remembered  that  a  tendency  to  hysteria  finds  favorable  conditions 
for  development  in  the  injudicious  moral  ti-aining  that  is  received  by 
the  children  of  an  hysterical  mother.* 

The  causes  that  directly  determine  the  development  of  hysteria  in 
an  individual  may  be  either  physical  or  mental  influences,  or  both. 
Of  the  two,  the  mental  and  moral  influences  are  the  more  potent  and 
the  more  frequent.  They  may  both  increase  the  predisposition  and 
excite  manifestations  of  the  disease.  The  inherent  predisposition, 
indeed,  probably  depends  on  the  physiological  preponderance  of 
emotion  in  females,  which  is  essential  for  the  part  they  play  in  the 
continuance  of  the  race,  but  which  may  be  perverted  either  by  con- 
genital tendency  or  by  injudicious  training.  License  and  indulgence  in 
childhood  beget  self-indulgence  in  later  life.  When  the  disease  has 
once  developed,  it  is  often  greatly  increased  by  injudicious  manage- 
ment. The  near  relatives  of  the  hysterical  are  often  conspicuously 
deficient  in  judgment,  and  the  little  common  sense  they  may  possess 
is  often  rendered  useless  by  their  affection  for  the  sufferers.  In  some 
cases,  the  symptoms  develop  without  more  exciting  cause  than  the 
trifling  annoyances  of  home  life,  or  the  change  that  the  nervous  system 
undergoes  at  the  time  of  puberty.  More  frequently,  however,  there  is 
some  definite  exciting  influence — rarely  intellectual  exertion ;  in  most 
cases  it  is  an  emotional  disturbance.  It  may  be  a  sudden  alarm, 
which  is  especially  effective  in  children.  It  may  be  merely  the  de- 
pressing emotions  from  which  no  life  is  exempt,  trifling  in  themselves, 
but  potent  because  unresisted.  It  may  be  some  sudden  and  deep 
emotion,  an  unhappy  love  affair,  a  fall  from  luxury  to  the  need  for 
unaccustomed  labour.  The  effect  of  the  real  causes  may  be  merely 
seen  in  depression  or  irritability,  often  with  failing  health,  and  the 
outbreak  may  be  immediately  excited  by  some  trivial  disturbance, 
adequate  only  to  turn  the  scale  too  delicately  poised.  Defective 
general  health,  though  by  no  means  essential  for  the  development  of 
the  disease,  is  yet  a  common  antecedent.  Most  patients  are  anaemic, 
easily  fatigued,  and  often  with  functional  disturbance  of  various 
organs. 

Of  the  physical  conditions  that  may  influence  the  development  of 
hysteria,  disorders  of  the  generative  organs  have  always  attracted 
most  attention.  Some  morbid  state  of  these  organs  is  present  in 
many  cases,  but  the  estimate  that  at  least  one  half  of  the  sufferers 
from  hysteria  are  free  from  such  disease  (Jolly)  is  probably  near  the 
truth.  Further,  such  disease,  when  it  exists,  is  seldom  the  cause  of 
the  nervous  affection.  The  morbid  states  of  these  organs  that  are  met 
with  are  rarely  grave  ;  but  they  are  occasionally  such  as  cause  frequent 
or  continuous  suffering,  and  thus  may  depress  the  nervous  system. 

*  See  on  this  subject  Dr.  Russell  Reynolds'  address  to  the  Sanitary  Congress, 
1887. 


ETIOLOGY.  987 

The  rectification  of  such  disturbance  has,  in  a  few  instances,  been 
followed  by  a  marked  improvement,  but  the  symptoms  of  hysteria 
usually  continue  unmodified  by  the  removal  of  the  local  disturbance, 
and  the  indirect  iofluence  of  the  treatment  is  often  anything  but 
beneficial.  The  effect  of  uterine  disease  or  displacement  which  causes 
no  obtrusive  symptoms  is  more  than  doubtful. 

The  observations  of  Charcot  have  directed  attention  to  the 
ovaries  rather  than  to  the  uterus.  Tenderness  in  the  ovarian  region 
is  unquestionably  frequent,  but  is  not  invariable,  nor  is  it  con- 
fined to  the  subjects  of  hysteria.  It  is  usually  a  neuralgic  affection, 
and  not  an  actual  local  disease.  It  is  very  rare  for  there  to  be  any 
adequate  evidence  even  of  congestion.  When  the  generative  organs 
are  healthy,  the  menstrual  period  is  attended,  in  most  women,  by 
some  discomfort  and  depression,  and  it  is  natural  that  the  symptoms 
of  hysteria,  if  they  exist,  should  be  aggravated  at  these  times.  In 
such  patients,  moreover,  menstruation  is  often  irregular  in  consequence 
of  the  defective  general  health,  and  its  disturbing  influence  is  thereby 
increased.  Severe  cases  of  hysteria  with  much  ovarian  pain  have 
been  said  to  be  cured  by  the  removal  of  both  ovaries  ;  but  too  wide  an 
inference  may  readily  be  drawn  from  the  fact.  The  operation  (of  very 
questionable  propriety)  may  remove  a  source  of  irritation,  but  it  also 
involves  a  profound  moral  influence  and  prolonged  physical  rest. 

Sexual  excess  is  an  occasional  cause  of  hysteria  in  men,  and,  in  its 
solitary  form,  still  more  frequently  in  boys,  but  its  influence  in 
women  is  probably  not  large.  Continence  has  been  supposed  to  be  a 
cause  of  hysteria,  but  probably  is  so  only  when  it  suddenly  succeeds 
habitual  indulgence,  and  its  influence  is  chiefly  confined  to  the  female 
sex. 

Hysterical  symptoms,  especially  convulsions,  sometimes  spread  from 
one  individual  to  another  by  sympathetic  imitation, — "  moral  conta- 
gion," as  it  has  been  termed.  Many  singular  outbreaks  of  this  character 
have  been  recorded.  The  sufferers  living  together  in  a  hospital,  or 
workhouse,  or  school,  have  often  been  exposed  to  similar  predisposing 
influences  ;  and  the  materials  in  all  were  ready  for  explosion. 

In  a  predisposed  person  the  symptoms  of  hysteria  may  be  excited 
or  intensified  by  other  diseases  ;  nervous,  general,  and  local  maladies 
often  determine  the  direction  of  more  enduring  hysterical  disturbance. 
The  symptoms  which  result  from  this  union  of  disorders  may  be  most 
perplexing.  In  typhoid  fever  in  young  girls,  hysterical  tenderness  of 
the  skin  and  spine  may  be  present,  and  anaesthesia,  pharyngeal 
constriction,  rapid  breathing,  and  even  contracture  may  occur 
(Huchard) .  Tuberculosis  is  often  attended  with  hysterical  phenomena, 
which  may  simulate,  or  more  often  mask,  the  symptoms  of  tubercular 
meningitis.  The  secondary  stage  of  syphilis,  especially  among 
prostitutes,  is  often  attended  by  symptoms  of  hysteria,  sometimes 
intense.  Fournier  believes  that  they  result  from  a  specific  action  of 
the  virus  on  the  nervous  system,  but  the  depressing  effect  of   the 


$88  HYSTESIA. 

disease,  coupled  with  the  psychical  influence  of  the  mode  of  life,  is 
probably  sufficient  to  account  for  tbe  condition.  Almost  all  forms  of 
local  inflammation  may  determine  the  occurrence  and  position  of 
hysterical  symptoms.  Thus  arthritis  may  set  up  an  "hysterical 
joint,"  a  laryngeal  catarrh  may  excite  persistent  hysterical  aphonia, 
a  slight  attack  of  bronchitis  may  lead  to  hysterical  dyspnoea  and  rapid 
breathing.  Even  more  potent  is  the  influence  of  injury ;  spinal 
tenderness  may  be  excited  by  a  blow  or  fall,  and  an  injury  to  a 
limb  may  be  followed  by  pain,  anaesthesia,  aud  contracture,  often 
tasking  all  the  skill  of  the  diagnostician  to  separate  its  direct  and 
indirect  effects. 

If  hysterical  symptoms  may  thus  complicate  general  and  local  dis- 
eases, it  is  not  surprising  that  they  still  more  frequently  accompany 
various  diseases  of  the  nervous  system,  functional  and  organic.  The 
effect  of  disease  of  one  part  is  olten  to  disturb  the  functions  of  other 
parts,  and  of  such  disturbance  hysterical  symptoms  are  a  frequent 
result.  As  "Weir  Mitchell  has  well  expressed  it,  "  the  symptoms  of 
real  disease  are  painted  on  an  hysterical  background."  There  is 
hardly  a  single  disease  of  the  nervous  system  by  which  such  symptoms 
may  not  be  evoked  in  predisposed  subjects.  Cerebral  tumours,  tuber- 
-cular  meningitis,  multiple  neuritis,  chorea,  often  cause  conspicuous 
hysterical  phenomena.  The  subjects  of  infantile  hemiplegia,  when 
they  reach  puberty,  frequently  present  symptoms  of  hysteria.  In  one 
case  of  old  hemiplegia,  in  which  true  epileptiform  convulsions  occurred 
in  the  stunted  limbs,  the  patient  suffered  also  from  the  most  severe 
hysteroid  convulsions  I  have  ever  witnessed,  and  also  from  aphonia, 
rapid  breathing,  and  phantom  tumour.  Slight  or  old  organic  diseases 
of  the  spinal  cord  may  have  the  same  effect,  and  an  hysterical  para- 
plegia may  be  grafted  on  slight  real  weakness  of  the  legs.  Diph- 
theritic paralysis  may  pass  into  hysterical  palsy  and  anaesthesia.  I 
have  known  hysterical  convulsions  to  attend  the  onset  of  embolic 
hemiplegia,  proved  to  be  such  by  post-mortem  examination.  Similar 
convulsions  occur  with  great  frequency  after  epileptic  fits  during  the 
ages  at  which  hysteria  is  common  (see  p.  692).  The  most  enduring 
case  of  hysterical  aphonia  I  have  ever  known  was  in  an  epileptic  woman. 
Lastly,  hysterical  symptoms  and  convulsions  may  form  part  of  the 
phenomena  of  hydrophobia,  apparently  as  the  direct  effect  of  the  poison 
on  the  nervous  system. 

Symptoms. — The  manifestations  of  hysteria  may  be  divided  into 
two  classes,  the  continuous  and  the  paroxysmal.  Of  the  former,  the 
most  important  is  the  mental  state,  which,  in  the  majority  of  hysterical 
patients,  presents  marked  characteristics.  These  differ  in  their  details 
according  to  the  ever- varying  peculiarities  of  individual  character. 
Most  prominent  among  them,  and  rarely  absent  in  severe  cases,  is  a 
defective  power  of  will,  imperfect  self-control,  inability  to  resist  the 
impulses  of  inclination.     With  this  is  often  associated  irritability  of 


SYMPTOMS.  989 

temper,  and  an  undue  sensitiveness  to  annoyance,  under  which  the 
trifling  cai'es  and  vexations  of  life  become  grave  troubles.  Occasion- 
ally this  deficiency  of  will-power  is  inconspicuous.  Some  patients  with 
originally  well-balanced  minds,  under  the  depressing  influence  of  ill- 
health  or  care,  may  have  their  mental  strength  insidiously  under- 
mined, or  a  severe  shock  may  disable  the  will,  and  the  symptoms  of 
hysteria  may  develop  sometimes  as  disorders  of  subordinate  functions. 
Occasionally,  physical  and  mental  depression  may  enslave  to  the 
lower  forms  of  hysteria  a  mind  which  before  despised  the  very  name. 
Indeed,  obtrusive  contempt  for  hysteria  is  often  a  suspicious  symptom, 
and  may  be  due  to  dread  of  a  tendency  of  which  the  sufferer  is  not  quite 
unconscious,  and  a  desire  that  no  one  should  suspect  the  truth.  The 
dread  itself  leads  the  mind  to  dwell  on  the  nascent  symptoms,  and 
paves  the  way  for  their  onset.  But  these  cases  are  far  less  cominou 
than  those  in  which  the  will  has  been  deliberately  allowed  to  fall  into 
welcome  servitude.  Self-consciousness  dominates,  more  or  less  com- 
pletely, the  patient's  thoughts  and  even  actions,  and  finds  its  expres- 
sion in  manner,  glance,  and  tone.  There  may  be  obvious  exaggeration 
in  the  description  of  sufferings,  or  an  implied  consciousness  of  much 
more  than  is  expressed.  The  sympathy  that  is  excited  is  a  source  of 
gratification  to  a  patient  whose  sufferings  often  secure  a  relief  from 
other  annoyances  which  to  her  are  greater,  and  the  attention  she  re- 
ceives is  a  new  stimulus  to  her  self-consciousness.  The  motives 
become  stronger  to  yield  to,  than  to  resist,  morbid  tendencies,  which 
are  thus  unconsciously  cultivated.  This  defective  will-power  is  some- 
times associated  with  an  imperfect  perception  of  right  and  wron?, 
where  desire  is  concerned,  and  the  cultivation  of  symptoms,  which  is 
at  first  unconscious  and  involuntary,  may  then  become  conscious  and 
intentional.  Those  that  are  at  first  merely  unresisted  may  be  after- 
wards welcomed,  then  invited,  and  at  last  actually  induced  or  con- 
sciously simulated.  Every  stage  in  this  gradation  of  development 
may  be  met  with  by  itself,  and  sometimes,  from  the  first,  the  sym- 
ptoms are  assumed.  It  must  not,  however,  be  inferred  that  all  mimicry 
of  disease  is  intentional  simulation.  The  nervous  system  is  dominated 
by  idea  and  by  fear,  as  well  as  by  desire ;  the  definite  conception  of 
a  symptom  may  lead  to  its  occurrence  ;  and  when  idea  and  emotion 
are  conjoined,  and  a  symptom  is  not  only  conceived  but  either  dreaded 
or  desired,  its  occurrence  is  still  more  easy.  The  idea  of  a  loss  of 
power  may  render  it  impossible  for  the  patient  to  will  the  movement; 
the  conception  of  a  muscular  spasm  may  induce  the  contraction  ;  and 
if  a  definite  pain  is  thought  of,  before  long  it  may  be  felt,  without  the 
symptoms  being  in  any  case  intentionally  induced.  Medical  inquiries 
and  examinations  often  suggest  to  patients  the  definite  ideis  of 
symptoms,  and  the  physician's  knowledge  of  the  natural  association 
of  symptoms  may  thus  lead  to  their  consistent  grouping  in  a  mimetic 
malady,  even  when  there  is  not,  and  still  more  when  there  is,  deliberate 
simulation.     The  pathogenic  influence  of  idea  is  seen  in  all  varieties 


990  HYSTERIA. 

of  hysteria,  and  sometimes  in  singular  isolation  in  children,  in  forms 
which  Russell  Reynolds  has  designated  "  ideal  paralysis."  The  idea 
is  most  definite,  and  therefore  most  effective,  when  such  symptoms 
have  been  actually  observed  in  another  person.  Hence  the  spread  of 
hysterical  convulsions  and  other  symptoms  by  imitative  contagion.  I 
have  known  two  children  in  a  family  to  suffer,  one  from  a  cerebral 
tumour,  the  other  from  startlingly  similar  symptoms  of  pure  mimetic 
origin,  evoked  by  the  witnessed  sufferings  of  the  first. 

The  excess  of  emotion  in  the  subjects  of  hysteria  commonly  finds 
free  expression.  Laughter  and  tears  come  readily,  and  these  mani- 
festations of  emotion  may  occur  in  paroxysms  on  the  most  trivial 
excitant,  and  attend  or  constitute  the  slighter  form  of  hysterical 
"  fits."  Certain  other  common  symptoms  of  the  disease  are  also  natural 
results  of  profound  emotion,  and  are  morbid  because  spontaneous  or 
too  readily  produced.  One  of  these  is  the  well-known  "  globus 
hystericus,"  a  feeling  of  something  suddenly  closing  the  throat  and 
stopping  the  breath.  It  is  often  described  as  a  ball  rising  from 
the  stomach  to  the  throat;  in  other  cases  it  is  a  mere  sense  of 
constriction  or  swelling  referred  to  the  fauces  or  pharynx  ;  when 
intense  there  is  probably  actual  spasm.  An  identical  sensation  may, 
from  sudden  alarm,  occur  in  those  who  are  not  hysterical.  It  is  a 
frequent  precursor  of  an  hysterical  fit,  but  is  also  very  common  apart 
from  any  other  paroxysmal  symptom.  The  sensation,  in  its  typical 
form,  appears  to  be  similar  to  that  which  immediately  precedes 
many  epileptic  fits,  and  even  some  convulsive  seizures  from  organic 
disease.  It  is  often  accompanied  by  a  sudden  sense  of  suffocation, 
for  which  thei*e  is  no  reason  in  the  interference  with  breathing,  and 
it  appears  to  be  the  expression  of  a  disturbance  in  the  respiratory 
portion  of  the  vagus  centre,  which  is  normally  specially  sensitive  to 
emotion. 

The  same  relation  to  emotion  may  be  traced  in  many  other  sym- 
ptoms of  hysteria,  which  will  be  described  in  detail ;  such,  for  instance, 
as  the  disturbance  of  the  heart's  action,  the  limpid  urine  that  may 
result  from  fear,  and  the  muscular  tremor  of  alarm,  while  many  of 
the  phenomena  of  hysteroid  convulsions  are  but  the  frenzied  mani- 
festations of  horror  or  rage. 

Sensory  Symptoms. — In  hysteria  all  sensations,  general  and  special, 
may  be  felt  with  abnormal  acuteness  ;  those  that  are  in  health  un- 
noticed may  give  rise  to  distress,  and  the  feelings  are  described  in 
exaggerated  language.  The  special  senses  may  even  be  preternatu- 
rally  acute ;  sounds  may  be  heard  which  are  inaudible  to  others,  and 
the  sense  of  smell  is  said  sometimes  to  attain  an  acuity  comparable 
only  to  that  which  it  possesses  in  animals,  so  that  persons  have  been 
distinguished  by  its  means ! 

In  these  cases  of  increased  sensitiveness  painful  sensations  are 
readily  produced  and  are  often  spontaneous,  giving  rise  to  the  varied 
forms  of  hysterical  tenderness  and  neuralgic  pain,  the  locality  of  the 


SYMPTOMS.  991 

two  being  often  tbe  same.  The  tenderness  is  frequently  superficial, 
more  pain  being  produced  by  a  touch  on  the  skin  than  by  pressure  on 
deeper  structures  ;  such  superficial  tenderness  is  common  on  the  shin 
of  the  abdomen,  thorax,  and  scalp,  and  sometimes  affects  one  half  of 
the  body.  There  is  often,  in  certain  localities,  deep-seated  tenderness, 
and  when  considerable,  the  pain  occasioned  by  pressure  is  peculiarly 
distressing,  radiates  to  the  chest  or  throat  or  head,  and  tends  to  cause 
the  dyspncea,  sense  of  faintness,  globus,  and  even  in  highly  developed 
forms  of  hysteria,  convulsive  attacks.  Hence  these  tender  spots  have 
been  termed  "  hysterogenic  "  by  Richer. 

One  of  the  most  frequent  seats  for  this  tenderness  is  the  ovarian 
region,  and  here  it  is  commonly  deep-seated.  Its  position  is  at  the 
intersection  of  a  line  joining  the  antero- superior  iliac  spines  with 
that  which  limits  externally  the  hypogastric  region ;  and  Charcot 
believes  that  a  tender  body,  which  may,  in  a  thin  patient,  be  felt  be- 
tween the  finger  and  the  brim  of  the  pelvis,  is  really  the  ovary,  although 
in  an  opened  body  the  ovary  is  usually  found  within  the  pelvis.  It 
is  doubtful  whether  the  ovary  is  really  felt,  but  it  is  probably  tender, 
and  *>o  also  are  the  adjacent  parts.  Weir  Mitchell  has  observed 
extreme  deep  tenderness  in  this  situation  when  the  ovary  could  be  felt, 
by  vaginal  examination,  to  be  displaced  downwards  out  of  the  usual 
position.  Either  ovarian  region  may  be  tender,  the  left  more  fre- 
quently or  in  greater  degree.  Occasionally,  as  Todd  pointed  out, 
there  is  extreme  superficial  tenderness  in  a  circumscribed  spot  over 
the  ovary.  Tenderness  in  this  region  is,  however,  common  in  women 
who  are  not  hysterical. 

Another  frequent  seat  of  tenderness  is  the  spine,  especially  the 
upper,  middle,  or  lower  dorsal  region.  The  tenderness  may  be  super- 
ficial, but  more  frequently  it  is  deep-seated.  Spontaneous  pain,  felt 
at  more  than  one  place,  is  often  complained  of,  sometimes  severe  and 
burning  in  character,  sometimes  a  dull  aching  which  is  compared  to 
toothache.  It  is  usually  increased  by  exertion.  Occasionally  the 
whole  of  the  vertebral  column  is  tender  and  painful,  and  the  pain 
seems  to  shoot  up  to  the  occiput.  Sacral  pain  may  be  complained  of, 
but  sacral  tenderness  is  rare. 

Deep-seated  tenderness  in  the  left  hypochondriac  region  is  also 
frequent,  and  may  even  be  greater  there  than  in  the  ovarian  region. 
Other  occasional  seats  of  tenderness,  usually  superficial,  are  the  infra- 
mammary  regions,  and  spots  on  the  front  of  the  abdomen  and  thorax, 
or  on  each  side  of  the  dorsal  spine  (Richer),  which  may  be  symmetrical 
on  the  two  sides.  Occasionally  there  is  superficial  tenderness  (of  the 
skin  and  sometimes  of  the  muscles  also)  over  the  whole  abdomen,  and, 
simulating  the  tenderness  of  peritoneal  inflammation,  has  received 
the  absurd  name  of  "  false  peritonitis."  When  there  is  general 
hypersestbesia,  the  whole  surface  is  "  hysterogenic ;"  a  prick  on  the 
forearm,  for  instance,  may  cause  sharp  pain,  darting  to  the  throat 
and  causing  globus. 


992  HYSTERIA. 

The  spontaneous  pain,  common  in  the  left  infra- mammary  region,  is 
apparently  identical  in  character  with  that  which  is  so  common  in  the 
same  situation  in  anaemia.  Still  more  frequent,  and  very  distress- 
ing, are  the  pains  which  occur  in  the  head.  The  pain  is  sometimes 
frontal,  temporal,  or  occipital,  but  much  more  frequently  vertical,  and 
because  it  is  severe  and  occasionally  described  by  patients  as  like  a 
nail  being  driven  in,  it  has  received  the  name  of  the  "  clavus 
hystericus." 

The  hyperaesthesia  of  the  special  senses  often  occasions  distress, 
which  may  be  described  as  actual  pain.  Intolerance  of  light  is 
very  common,  and  is  fostered  by  the  dark  blinds  provided  by  sym- 
pathetic friends.  Subjective  sensations  of  various' kinds  may  be  com- 
plained of :  noises  in  the  ears,  flashes  of  light  or  colour,  or  much  less 
frequently  sensations  of  taste  or  smell.  Pricking  or  tingling  seusa- 
tions  in  the  limbs,  or  vague  feelings  of  numbness,  are  very  common, 
and  are  often  unilateral,  affecting,  for  instance,  one  half  of  the  tongue. 
Another  sensation  which  is  frequently  described  is  that  of  cold  water 
trickling  down  the  spine.  It  is  sometimes  associated  with  a  nervous 
shivering,  analogous  to  that  which  is  produced  in  healthy  persons  by 
a  slight  degree  of  cold  combined  with  nervous  excitement.  Some 
joint  may  be  the  seat  of  spontaneous  pain,  attended,  occasionally,  with 
slight  swelling  such  as  may  also  occur  in  other  parts,  apparently  from 
vaso-inotor  disturbance. 

Lessened  sensibility  is  very  common,  although  often  overlooked 
because  the  patient  seldom  complains  of  it,  and  she  may,  indeed,  be 
unaware  of  its  existence.  Sometimes  it  occurs  on  the  legs  in  associa- 
tion with  motor  weakness,  but  as  an  isolated  symptom  it  usually 
affects  part  or  the  whole  of  one  half  of  the  body,  constituting 
"  hysterical  hetnianaesthesia,"  and  may  involve  the  special  senses. 
When  complete,  a  touch  cannot  be  felt ;  a  needle  may  be  run  into 
the  skin  without  causing  any  sensation ;  neither  cold  nor  heat  can  be 
perceived,  and  the  skin  may  even  be  burned  without  pain.  The  loss 
extends  up  to  the  middle  line,  and  may  involve  the  mucous  membrane 
of  the  conjunctiva,  nose,  mouth,  vagina,  and  also  the  deeper  struc- 
tures, muscles,  and  bones.  There  are,  however,  certain  anomalous 
features.  Ovarian  and  other  deep-seated  tenderness  continues  on  the 
affected  side ;  reflex  action  is  unchanged,  the  pupil  still  dilates  when 
the  skin  is  stimulated,  and  the  fingers  can  still  be  used  (e.  g.  for 
needlework)  without  the  guidance  of  the  eye.  When  incomplete, 
sensation  may  be  lost  to  either  pain  or  touch,  rarely  to  temperature 
only.  Often  the  sensation  of  touch  is  lost, and  of  pain  only  lessened; 
a  prick  may  not  be  perceived,  but  faradism  with  a  wire  brush  may  be 
felt  acutely.  When  partial  in  distribution,  the  arm  suffers  more  than 
the  leg,  and  the  loss  may  be  limited  to  the  arm  and  cease  abruptly  at 
the  shoulder  or  on  the  chest ;  the  arm  and  leg  may  be  affected,  and 
not  the  trunk  or  face.  The  loss  may  reach  the  middle  line  in  front, 
and  stop  far  short  of  it  behind.     Loss  of  tactile  sensibility  may  be 


SYMPTOMS.  993 

more  extensive  than  loss  to  pain.  Occasionally  only  small  areas  are 
anaesthetic.  The  limbs  are  sometimes  pale,  and  colder  than  those  of 
the  other  side ;  a  prick  upon  them  may  not  bleed,  but  this  is  on  the 
whole  rare.  Usually  there  is  no  difference  in  aspect  or  vascularity; 
and  the  mucous  membranes  are  never  paler.  In  health,  pin-pricks  in 
many  places  do  not  bleed.  Heinianaesthesia  is  more  common  on  the 
left  side,  and  usually  there  is  considerable  ovarian  tenderness  on  the 
affected  side.  Exceptionally  I  have  found  no  ovarian  tenderness,  or 
tenderness  on  the  opposite  side. 

The  loss  may  come  on  spontaneously,  or  may  follow  a  hysteroid  fit. 
It  may  be  present  one  day  and  gone  the  next ;  in  one  such  case,  a 
prick  on  the  previously  anaesthetic  arm  caused  so  much  pain  as  to 
induce  a  hysteroid  convulsion,  and  when  this  was  over,  the  hemianaes- 
thesia  had  returned,  in  typical  and  complete  form.  An  increase  may 
follow  the  testingfcof  sensibility,  and  it  is  possible  that  an  examination 
sometimes  induces  the  anaesthesia.  The  area  affected  may  vary  from 
day  to  day,  and  may  increase  at  menstruation. 

The  anaesthesia  may  also  change  from  one  side  to  the  other  without 
apparent  cause,  or  such  a  "transfer"  maybe  induced;  a  phenomenon 
discovered  by  Charcot,  and  much  studied  in  France.  The  agents  that 
cause  the  transfer  may  be  (1)  such  as  stimulate  the  skin  and  dilate  the 
vessels,  e.  g.  blisters,  sinapisms,  or  faradism ;  (2)  the  application  for 
half  an  hour  of  certain  metals,  especially  gold,  or  of  a  large  magnet  or 
electro-magnet,  which  need  not  be  actually  in  contact  with  the  skin. 
Painting  with  collodion  sometimes  succeeds.  The  transfer  is  seldom 
lasting ;  after  a  few  hours  or  a  day  the  loss  reverts  to  the  original  side. 
In  the  elaborate  hysterics  of  France,  sensitiveness  to  certain  metals 
has  been  described  (Burq,  Dutnontpallier,  &c),  and  it  has  even  been 
asserted  that  patients  may  be  cured  by  the  internal  administration  of 
the  metal  to  which  they  are  externally  sensitive  !  Mysterious  and 
unknown  forces  have  been  invoked  to  explain  the  phenomena  of 
"  metallo-therapy,"  but  they  have  received  little  confirmation  else- 
where. Wood  has  been  found  as  effective  as  gold,  and  so  has  a 
mental  shock  or  the  inhalation  of  nitrite  of  amyl.*  "  Metallic  idio- 
syncrasies "  have  been  practically  unconfirmed,  and  the  general  evi- 
dence is  conclusive  in  support  of  the  opinion  that  the  agents  act 
through  the  mind  of  the  patient — a  theory  in  harmony  with  what  we 
know  of  the  pathology  of  the  disease,  and  with  many  facts  in  its 
history,  which  show  how  much  care  is  needed  in  drawing  conclusions 
from  the  mysterious  blending  of  psychical  and  nervous  disturbance 
in  its  manifestations.  If  there  is  one  lesson  more  clearly  written  in  its 
history  than  another,  it  is  that  the  more  complex  symptoms  are  best 
interpreted  by  the  light  of  those  that  are  more  simple.  The  most 
powerful  magnets  that  can  be  made,  have  not  the  slightest  influence 
on  the  functions  of  the  nervous  system  in  a  normal  state. 

As  part  of  the  hemiansesthesia,  and  capable  of  transfer  with  it,  there 
*  See  a  case  recorded  by  Urbantschitsch,  'Arch.  f.  Ohrenheilk./  Bd.  xvi,  p.  171. 

vol.  ii.  63 


994  HYSTERIA. 

is  a  remarkable  affection  of  the  special  senses.  These  may  all  be 
lessened  on  the  affected  ride.  The  impairment  of  vision  (carefully 
studied  by  Charcot  and  Landolt)  is  in  the  form  of  "  crossed  ambly- 
opia," such  as  sometimes  results  from  organic  disease  (pp.  22,  159). 
Acuity  of  vision  and  the  field  are  both  greatly  reduced  on  the  anaes- 
thetic side  ;  the  colour-fields  are  diminished  in  the  order  of  theirnormal 
extent,  and  they  may  be  lost  in  the  same  order,  violet  first,  then  green, 
red,  yellow,  and  blue.  The  loss  may  be  demonstrated  by  the  "  con- 
fusion test  "  (see  p.  146)  as  well  as  by  the  method  of  naming  colours. 
The  effect  of  electrical  stimulation  on  the  retina  is  lessened,  but  the 
action  of  the  pupil  is  normal.  A  similar  but  much  slighter  affection 
of  sight  mav  be  found  in  the  other  eye. 

Vision  may,  as  I  have  seen,  be  impaired  alone,  and  then  almost 
always  on  one  side  only.  There  may  be  absolute  loss  of  sight,  or  only 
amblyopia  and  reduction  of  the  field  to  a  small  #rea  around  the 
fixing  point.  The  iris  still  acts  perfectly  to  light,  and  the  fundus 
oi-uli  is  normal.  The  loss  is  usually  sudden ;  sometimes  it  follows  a 
hvsteroid  fit.  It  is  usually  transient,  passing  away  in  a  few  days  or 
weeks.  An  instance  of  more  permanent  loss  of  sight  of  this  character 
is  mentioned  on  p.  165  ;  in  this,  such  unilateral  amblyopia  lasted  until 
the  death  of  the  patient,  about  ten  years  later,  sometimes  improv- 
ing a  little,  and  then  relapsing,  but  without  change  in  the  action  of 
the  pupil  or  in  the  fundus.  Yery  rarely,  hysterical  patients  have 
transient  bilateral  loss  of  sight. 

Hearing  is  involved  in  the  hemianesthesia,  but  scarcely  ever  alone. 
The  loss  is  usually  greater  for  sounds  conducted  through  the  bone 
than  for  those  conducted  through  the  air.*  The  nerve  also  loses  its 
normal  sensitiveness  to  electrical  stimulation. 

Motor  Symptoms. — Paralysis  is  very  common,  and  may  involve 
almost  any  part  of  the  motor  apparatus.  The  onset  may  be  sudden 
or  gradual ;  it  may  follow  a  convulsive  seizure,  or  may  be  excited  by 
emotion.  Some  transient  palsy  may  follow  each  fit,  paraplegia  after 
one,  hemiplegia  after  another.  When  the  onset  is  sudden,  the  palsv 
is  usually  at  first  incomplete,  and  increases  under  the  influence  of 
the  idea  and  fear  of  loss  of  power.  It  must  never  be  forgotten 
that  the  palsy  of  an  hysterical  patient  may  not  be  wholly  functional ; 
real  paralysis  of  organic  origin  may  be  increased  by  the  mental  state. 

The  most  common  form  of  hysterical  paralysis  is  that  of  the  larvnx, 
causing  the  well-known  hysterical  aphonia.  There  is  loss  of  voice,  i.  e. 
of  phonation,  so  that  the  patient  always  speaks  in  a  whisper.  Some- 
times this  is  merely  voluntary  ;  in  a  state  of  general  hyperesthesia  the 
sound  of  the  voice  distresses  the  patient,  who  habitually  whispers, 
although  perfectly  able  to  phonate.  More  often  there  is  an  actual 
inability  to  utter  vocal  sounds.  In  the  common  form  the  laryngoscope 
shows  that  the  vocal  cords  tire  far  apart,  and  are  not  approximated 
during  phonation  as  in  health;  there  is  defective  phonic  adduction 
*  Walton,  '  Brain,'  Jan.,  1883,  p.  458. 


SYMPTOMS.  995 

(see  p.  290).  The  glottis  can  be  closed  efficiently  in  coughing,  except 
in  very  rare  and  extreme  cases.  Sometimes  patients  can  sing  well, 
although  speech  is  whispei'ed,  and  they  have  been  known  to  speak  in 
a  loud  voice  during  sleep.  A  scream  may  often  be  obtained  by  strong 
faradism  applied  either  outside  or  inside  the  larynx.  Hysterical 
aphonia  may  come  on  spontaneously,  but  is  frequently  excited  by 
emotion ;  a  circumstance  which  is  not  surprising  when  it  is  remembered 
that  the  larynx  is  the  channel  through  which  certain  emotions  are 
most  readily  manifested.  It  is  also  occasionally  excited  by  laryngeal 
catarrh — the  real  loss  of  voice  from  cold  persisting  after  the  catarrh 
has  ceased.  The  aphonia  is  not  usually  attended  by  any  unpleasant 
sensation,  but  in  one  severe  case  the  loss  of  voice  was  referred  to  a 
feeling  "  as  if  a  bar  of  iron  were  laid  across  the  chest."  Speech  often 
returns  suddenly.  The  duration  of  the  aphonia  is  extremely  variable, 
and  it  is  prone  to  relapse.  One  patient  had  been  aphonic  for  ten  years, 
with  occasional  intervals,  during  which  the  slightest  fright  would  at 
once  remove  her  voice. 

Paralysis  of  the  abductors  of  the  vocal  cords  is  an  exceedingly  rare 
consequence  of  hysteria.  The  symptoms  are  those  described  in  the 
account  of  laryngeal  paralysis.  A  few  cases  are  on  record,  and  I  have 
seen  one  very  striking  instance,  mentioned  on  p.  290.  It  is  probable 
that  this  paralysis  in  hysteria  has  been  sometimes  mistaken  for  laryn- 
geal spasm. 

In  rare  cases  of  hysterical  aphonia  the  tongue  shares  the  laryngeal 
inaction,  and  loss  of  articulation  is  added  to  that  of  phonation,  so  that 
even  whispered  speech  is  lost,  and  the  patient  can  express  herself  only 
by  signs.  In  one  girl,  any  sudden  emotion  would  induce  this  state ;  it 
was  accompanied  by  a  sensation  "  as  if  the  tongue  were  being  twisted 
up."  Simple  aphonia  may  deepen  into  such  absolute  speechlessness. 
Sometimes  there  is  a  form  of  respiratory  stammering.  In  a  girl  with 
hysteroid  fits,  one  or  two  deep  inspirations  always  preceded  every 
attempt  to  speak,  and  sometimes  interrupted  a  sentence  or  a  word. 
During  her  tits  she  talked  with  perfect  fluency.  Rarely,  actual  stam- 
mering may  be  a  part  of  severe  hysterical  disturbance. 

Paralysis  of  the  limbs  is  also  common,  and  may  assume  the  form 
of  hemiplegia,  of  j>a-raplegia,  or  of  general  loss  of  power.  Certain 
forms  of  hysterical  ataxy  of  movement  may  also  be  ranked  in  the 
same  category.  In  this  country,  paraplegia  is  certainly  more  common 
than  hemiplegia.  As  a  rule,  the  onset  in  all  forms  is  sudden,  and 
often  follows  some  emotion.  The  loss  of  power  is  usually  moderate 
in  degree  at  first,  and  gradually  increases.  The  power  which  remains 
is  put  in  action  irregularly.  Resistance  to  passive  movement,  for 
instance,  is  not  sustained,  but  varies,  at  one  moment  being  slight,  at 
another  considerable.  If  an  attempt  is  made  to  execute  a  given 
movement,  opponents  of  the  acting  muscles  may  be  felt  to  contract. 
If  the  patient,  for  instance,  attempts  to  extend  the  knee,  the  flexors 
of  the  knee  may  contract  so  as  to  hinder  the  movement.     When 


996  HYSTERIA. 

there  is  some  power  of  movement,  this  is  accompanied  by  tremor, 
presently  to  be  described.  There  is  no  muscular  atrophy,  or  only 
very  slight  wasting  from  long  disuse.  Electric  irritability,  as  a  rule, 
remains  perfectly  normal.  So  constantly  is  this  true,  that  the  nature 
of  the  rare  cases  in  which  a  marked  change  in  electric  irritability  has 
been  found,  is  open  to  grave  doubt.  Loss  of  sensation  may  or  may 
not  be  conjoined  with  the  loss  of  power. 

Paraplegia  is  excited  by  emotion  with  especial  frequency.  Even  in 
health  a  sensation  of  weakness  in  the  legs  may  be  caused  by  sudden 
alarm,  and  this,  in  hysteria,  may  be  followed  by  a  progressive  loss  of 
power.  It  is  common  for  the  onset  of  persistent  weakness  to  be  pre- 
ceded by  occasional  momentary  "  giving  way  ofs  the  legs,"  at  once 
recovered  from — a  very  characteristic  feature.  It  has  been  regarded 
as  a  form  of  "  astasia-abasia,"  but  the  term  is  better  confined  to  the 
cases  in  which  this  peculiar  symptom  occurs  apart  from  hysteria 
(see  p.  794). 

In  other  cases,  some  unpleasant  sensation  or  pain  in  the  legs  seems 
to  excite  the  palsy.  The  pain  may  be  that  of  a  real  disease,  or  it  also 
may  be  of  hysterical  origin,  and  to  its  influence  that  of  emotion  is 
frequently  added.  Spinal  pain  is  very  common  in  these  cases,  and, 
being  increased  by  standing,  may  distinctly  excite  the  paralysis. 

There  is  rarely  absolute  loss  of  power ;  the  legs  can  commonly  be 
moved  about  in  bed,  although  slowly  and  jerkily,  but  on  an  attempt 
to  stand  they  give  way  at  once,  and  the  patient  sinks  to  the  ground. 
If  the  loss  of  power  is  slighter  in  degree,  the  patient  may  be  able  to 
walk  a  little,  but  with  slow  short  shuffling  steps,  rarely,  however, 
catching  the  toes  against  the  ground.  Retention  of  urine  is  uncom- 
mon, and  there  is  never  incontinence  of  either  urine  or  faeces. 
Myotatic  irritability  may  be  perfectly  normal ;  it  is  so  in  more  than 
half  the  cases.  In  many,  however,  especially  in  those  with  persistent 
spinal  tenderness,  there  is  slight  increase  of  this  irritability;  the 
knee-jerk  is  excessive,  and  the  patient  is  peculiarly  sensitive  to  the 
tap  on  the  patellar  tendon  or  on  the  top  of  the  depressed  patella,  which 
causes  a  reflex  start  or  jerk  of  the  trunk,  and  often  a  sharp  pain  in  the 
back.  On  the  other  hand,  when  there  is  no  excess,  the  knee-jerk  may 
seem  to  be  absent,  but  this  is  always  due  to  the  movement  of  the  leg 
being  prevented  by  involuntary  tonic  contraction  of  the  flexors  of  the 
knee,  detected  without  difficulty  by  a  finger  placed  on  the  hamstring 
tendons.  As  a  rule  there  is  no  foot-clonus.  A  uniform  persistent 
clonus,  such  as  is  so  common  in  organic  disease,  is  extremely  rare,  but 
occasionally  a  spurious  clonus,  due  to  a  half- voluntary  contraction  in 
the  calf  muscles,  may  be  found.  When  the  foot  is  first  pressed  back 
there  is  no  clonus,  but  presently  a  contraction  in  the  calf  causes  a 
slight  extension  movement  of  the  foot,  and  with  it  a  clonus  occurs, 
which  vaiies  from  moment  to  moment,  sometimes  almost  ceasing,  and 
again  renewed  by  a  fresh  contraction  of  the  muscle.  This  form 
is  characteristic   of  hysteria.     When  there   is   a  true   characteristic 


SYMPTOMS.  .  997 

clonus,  it  is  probable  that  there  is  an  alteration  in  the  nutrition  of 
the  motor  elements,  although  this  may  have  arisen  from  functional 
disturbance. 

Hemiplegia  sometimes  comes  on  suddenly,  but  more  often  slowly. 
It  is  at  least  three  times  as  frequent  on  the  left  side  as  on  the  right. 
The  loss  of  power  is  never  complete ;  the  leg  is  often  more  affected 
than  the  arm,  and  the  face  always  escapes  entirely, — important  dis- 
tinctions from  hemiplegia  of  organic  source.  Loss  of  sensation  usually 
accompanies  the  loss  of  power,  but  is  more  extensive  in  its  distribu- 
tion, affecting  often  the  face  and  special  senses.  Reflex  action  from 
the  skin  is  not  lessened  on  the  paralysed  side,  as  it  so  often  is  in  ordi- 
nary hemiplegia.  The  knee-jerk  may  he  normal  or  it  may  be  increased, 
sometimes  on  both  sides.  The  spurious  foot-clonus  just  described  may 
sometimes  be  obtained  on  the  affected  side  and  not  on  the  other.  The 
jerky  character  of  the  muscular  contraction  in  the  arm  may  render  its 
movement  unsteady,  when  the  leg  is  simply  weak.  Not  rarely  some 
persistent  contracture  of  arm  or  leg  accompanies  the  palsy. 

Bilateral  paralysis,  a  sort  of  double  hysterical  hemiplegia,  is  some- 
times observed,  although  loss  of  sensation  may  be  one-sided.  In  one 
case,  a  month  after  a  whitlow  on  the  finger,  the  patient,  a  girl,  had 
some  general  pain,  followed  by  inability  to  move  the  legs  or  arms,  to 
swallow,  or  to  speak.  The  fingers  became  strongly  flexed,  with  the 
thumb  thrust  between  the  two  middle  fingers.  In  this  state  she  lay 
for  a  month.  Then  the  fingers  became  relaxed,  the  arms  were  moved 
a  little,  and  at  times  a  word  or  two  was  jerked  out  with  difficulty.  The 
influence  of  faradism  restored  her  speech  in  a  few  days,  and  in  a  fort- 
night she  had  regained  full  power  of  limb. 

Disorder  or  ataxy  of  movement  occurs  in  the  hysterical  in  many 
forms,  and  may  exist  alone  or  accompany  loss  of  power.  One  form, 
well  described  by  Briquet,  in  which  movements  are  steady  under  the 
guidance  of  the  eye,  but  become  irregular  as  soon  as  this  guidance  is 
withdrawn,  is  supposed  to  be  due  to  "  muscular  anaesthesia."  But  this 
pathological  condition  has  been  invoked  without  sufficient  reason  to 
explain  other  forms  of  inco-ordination.  The  varying  force  of  muscular 
contraction,  which  may  be  often  recognised  in  the  resistance  to  passive 
movement,  imparts  a  jerky  unsteadiness  to  voluntary  movements. 
Sometimes  these  are  steady  enough  while  the  patient  is  in  bed,  but  on 
standing  she  at  once  sways,  first  to  one  side  and  then  to  the  other. 
Or,  without  any  loss  of  cutaneous  or  muscular  sensibility,  the  patient 
may  be  unable  to  stand  with  the  eyes  closed,  although  perfectly  steady 
when  the  eyes  are  open,  the  effect  of  closure  being  greater  than  is 
commonly  seen  in  true  ataxy  apart  from  impairment  of  sensation.  In 
other  cases  there  is  a  tendency  to  fall  backwards. 

In  the  functions  of  the  cranial  nerves,  the  only  other  paralytic 
affection  of  hysterical  origin  is  the  peculiar  form  of  simulated  ptosis 
described  at  p.  201.  Ordinary  facial  palsy,  in  these  patients,  has 
been  described  as  hysterical,  without  any  reason.     Inaction  of  the 


998  ,  HYSTERIA. 

diaphragm  may  closely  simulate  a  true  paralysis.  The  diaphragm 
naturally  acts  less  in  women  than  in  men,  and  may  take  little  or 
no  share  in  deep  voluntary  breathing,  which  is  chiefly  effected 
by  the  superior  thoracic  muscles.  In  proportion  as  respiration  is 
influenced  by  the  will,  the  diaphragm  is  inactive.  The  effect  of  obser- 
vation on  an  hysterical  patient  may  be  to  render  the  breathing  almost 
wholly  volitional,  and  to  throw  the  diaphragm  out  of  action.  Repeated 
examination,  and  the  diversion  of  the  patient's  attention,  will  gene- 
rally reveal  the  absence  of  real  paralysis. 

Spasmodic  Affections. — The  Protean  character  of  hysterical  disorders 
is  nowhere  more  conspicuous  than  in  the  varied  forms  of  spasmodic 
affection  to  which  the  disease  may  give  rise.  They  may  be  persistent 
or  paroxysmal :  the  former  class  includes  the  forms  of  tonic  spasm,  or 
contracture,  and  the  persistent  varieties  of  clonic  spasm  ;  the  latter 
comprehends  the  various  degrees  and  forms  of  hysterical  convulsion. 

The  term  "  contracture  "  is  applied  to  the  condition  in  which  the 
muscles  become  rigid  in  tonic  spasm,  fixing  a  limb  or  limbs  in  a 
certain  posture,  for  a  few  minutes  or  for  a  longer  time.  The  contrac- 
ture commonly  succeeds  a  by  steroid  fit.  Occasionally  it  is  excited 
by  some  local  injury  or  local  pain,  as  that  of  neuralgia  or  rheuma- 
tism ;  less  commonly  it  comes  on  spontaneously.  In  most  cases  it 
is  uniform  while  it  lasts,  but  occasionally  the  muscular  spasm  may  be 
felt  to  vary  in  intensity  from  time  to  time.  It  is  usually  greatest 
when  attempts  are  made  to  overcome  it ;  the  varying  resistance  of 
the  muscles,  then  felt,  is  characteristic,  and  of  much  diagnostic 
importance.  The  contracture  usually  persists  during  ordinary  sleep, 
and  is  only  relaxed  by  the  deepest  chloroform  narcosis.  In  extremely 
rare  cases,  in  which  it  has  existed  unchanged  for  years,  structural 
alterations  appear  to  take  place  in  the  muscles  ;  the  contracture  leads 
to  organic  shortening,  and  can  no  longer  be  removed  even  by  chloro- 
form (Charcot). 

One  form  of  contracture  is  that  of  the  muscles  of  mastication, 
causing  hysterical  trismus,  in  which  the  teeth  cannot  be  separated  for 
more  than  a  quarter  of  an  inch.  Usually  succeeding  a  fit,  it  often 
continues  until  another  convulsion,  and  then  is  gone.  Sometimes 
it  comes  on  spontaneously.  It  seldom  lasts  more  than  a  few  days, 
but  is  prone  to  recur.  One  patient,  for  instance,  had  an  attack, 
lasting  a  quarter  of  an  hour,  three  or  four  times  a  day  for  several 
weeks.  Very  rarely  there  is  transient  contracture  in  the  depressors 
of  the  jaw,  keeping  the  mouth  wide  open. 

Contracture  in  the  limbs  may  involve  the  arm,  alone  or  with  the 
leg  on  the  same  side,  or  the  two  legs  may  be  affected,  or  it  may  be 
general.  The  arm  is  the  most  frequent  seat.  It  is  alwavs  rigid  in 
flexion ;  the  elbow  is  bent  at  a  right  angle,  or  even  still  more  flexed  ; 
the  wrist  is  flexed;  the  fingers  are  sometimes  flexed  at  all  joints,  as 
in  the  "  late  rigidity  "  of  hemiplegia,  with  the  thumb  beneath  them  or 
thrust  between  the  first  and  second  fingers.     The  contracture  in  the 


SYMPTOMS.  999 

fingers  is  not  lessened  "when  the  wrist  is  passively  flexed,  as  it  is  in 
the  late  rigidity  of  hemiplegia.  Sometimes  the  digits  are  flexed 
at  the  metacarpophalangeal,  and  extended  at  the  distal,  joints, 
from  the  preponderant  contracture  of  the  interossei ;  the  posture 
then  resembles  tetany.  The  forearm  may  be  pronated  or  supinated. 
Contracture  in  the  arm  may  follow  a  fit,  and  may  be  transient 
or  continue  till  another  fit.  Injury  is  "a  very  common  cause  of  con- 
tracture; from  this,  it  usually  comes  on  gradually  and  slowly  ;  as  long- 
as  it  is  local,  it  is  often  thought  to  be  due  to  a  neuritis  ;  but  if,  as  is 
sometimes  the  case,  it  spreads  beyond  the  arm,  involving  the  leg  on 
the  same  side,  or  becoming  universal,  its  nature  is  clear.  As  an 
instance  of  this  cause  may  be  mentioned  the  case  of  a  girl  of  sixteen, 
who  let  a  hot  iron  fall  on  her  left  wrist,  burning  it  slightly.  Imme- 
diately she  felt  a  pain  in  the  thumb  and  lost  feeling  in  it.  A  week 
later,  and  in  the  course  of  a  few  days,  first  the  thumb  and  then  the 
fingers  became  flexed  and  rigid,  one  after  another.  Then  the  elbow 
became  partially  flexed,  and  soon  afterwards  the  foot  was  strongly 
extended  and  the  toes  bent  downwards.  In  the  hand  and  foot  there 
was  fine  tremor  during  observation.  Sensibility  was  lost  in  the  whole 
arm  but  nowhere  else.  Ovarian  tenderness  existed  on  the  same  side, 
and  the  contracture  could  be  partially  removed  by  firm  pressure  there, 
or  by  faradisation  of  the  limbs,  but  quickly  returned.  Under  moral 
treatment,  however,  it  gradually  passed  away,  and  at  the  end  of  two 
months  no  trace  of  it  remained. 

Hemiplegic  contracture,  such  as  the  above  case  illustrates,  is  not 
very  rare.  Some  loss  of  power  is  usually  associated  with  it,  and,  as 
in  simple  paralysis,  the  face  is  always  free  from  rigidity.  Anses- 
thesia  is  rarely  absent  on  the  hemispastic  side,  and  the  loss  of  sensi- 
bility may  be  complete  and  involve  the  face  and  trunk  as  well  as  the 
limbs.  Sometimes,  as  in  the  above  case,  the  loss  of  sensibility  is 
partial  and  is  confined  to  the  most  contractured  limb,  or  there  may 
be  absolute  loss  in  it  and  a  slighter  loss  over  the  whole  of  that  side. 

The  contrast,  in  the  case  just  described,  between  the  form  of  spasm 
in  the  arm  and  leg,  is  common  to  almost  all  cases  of  hysterical  con- 
tracture ;  the  arm  is  fixed  in  flexion,  the  leg  in  extension,  and  the 
latter  may  be  transformed  into  a  rigid  bar,  fixed  to  the  pelvis  by 
unyielding  spasm,  with  the  heel  so  drawn  up  that  the  dorsum  of  the 
foot  is  in  a  line  with  the  front  of  the  leg.  The  foot  is  commonly 
inverted  and  the  toes  flexed.  Partial  contracture  affects  most  the 
extremity  of  the  limb.  In  these  slighter  cases  the  toes  may  be  over- 
extended, in  spite  of  the  heel  being  raised.  In  hysterical  contracture 
with  extension  of  the  ankle,  the  foot-clonus  can  often  be  obtained,  as 
Charcot  has  shown.  It  is  analogous  to  the  physiological  clonus 
which  occurs  in  most  persons  after  standing  for  some  time  on  tiptoe. 

Paraplegic  contracture,  affecting  both  legs,  is  less  common.  The 
position  of  the  legs  is  that  already  described,  rigid  extension;  the 
flexor  spasm,  occasionally  seen  in   organic  disease,  is  scarcely  ever 


1000  HYSTERIA. 

met  with  in  hysteria.  In  very  rare  cases  the  contracture  affects  all 
four  limbs. 

Contracture,  in  any  form,  often  disappears  suddenly  under  the 
influence  of  emotion.  Charcot  has  related  several  cases  in  which 
severe  rigidity,  of  vei-y  long  duration,  was  removed  by  strong  emotion, 
not  induced  with  any  therapeutic  aim. 

Faradisation  of  the  limb  may  also  remove  it  in  some  cases,  and, 
when  the  current  is  not  so  strong  as  to  exhaust  the  irritability  of  the 
nerves,  the  agency  by  which  it  acts  is  probably  psychical.  Usually, 
repeated  applications  are  required,  but  sometimes  the  effect  is 
instantaneous.  One  patient  was  thus  cured  in  a  moment,  but  months 
later  she  relapsed,  and  then  all  treatment  failed  until  she  fell  into  the 
hands  of  a  "miracle-worker,"  at  whose  touch  the  spasm  vanished 
amid  the  plaudits  of  a  public  audience. 

Severe  forms  of  contracture  may  last  for  years,  and,  as  already 
stated,  the  changes  in  nutrition  which  follow,  at  a  distance,  the  dis- 
turbances of  function,  may,  in  time,  attain  such  structural  degree 
that  the  contracted  muscles  are  permanently  shortened.  There  is 
reason  to  believe  that  chauges  in  the  spinal  cord  may  also  result  from 
the  enduring  functional  disturbance,  and,  after  long  years  of  spasm, 
sclerosis  may  develop.  Charcot  has  recorded  such  a  case,  in  which  the 
contracture  was  certainly  at  first  functional,  disappearing  from  time 
to  time,  but  ultimately  it  became  unchanging,  and  after  death  the 
lateral  columns  of  the  cord  were  found  sclerosed.  It  is  to  be  noted 
that  this  change,  as  a  primary  lesion,  is  expressed  by  the  same 
extensor  spasm  as  constitutes  hysterical  contracture,  though  slighter 
in  degree.  "  Plastic  contracture  "  may  be  present  in  the  condition  of 
induced  sleep  or  hypnotism,  to  be  mentioned  later. 

The  contractures  described  above,  involve  groups  of  muscles  accord- 
ing to  their  function.  A  part  of  a  muscle  may  also  pass  into  a  state 
of  spasmodic  contraction,  evidenced,  not  by  the  distortion  of  the  parts 
to  which  it  is  attached,  but  by  the  swelling  of  the  muscular  substance. 
A  local  "  tumour  "  is  thus  produced,  which  may  simulate  a  morbid 
growth.  Several  instances  of  this  have  been  recorded  by  Weir 
Mitchell ;  the  swelling  was  in  the  calf  in  two,  in  the  pectoralis  major 
in  a  third,  the  contracted  part  rising  half  an  inch  above  the  adjacent 
muscle.  Allied  in  nature,  although  less  simple  in  mechanism,  are  the 
"  phantom  tumours  "  of  the  abdomen,  in  which  the  middle  part  of  the 
belly,  usually  below  the  umbilicus,  becomes  prominent  and  appears  as 
if  bulged  forwards  by  a  mass  within.  The  mechanism  by  which  it  is 
produced  appears  to  be  a  relaxation  of  the  rectus  and  a  spasmodic 
contraction  of  the  diaphragm ;  the  intestines,  often  distended  with 
flatus,  are  pushed  forwards  in  the  region  where  the  wall  is  lax.  An 
arching  of  the  vertebral  column  may  sometimes  contribute  to  the 
effect.  Occasionally  the  enlargement  of  the  abdomen  is  general,  the 
wall  being  everywhere  las  and  the  diaphragm  contracted.  The  swell- 
ing disappears  under  chloroform,  and,  as  it  goes,  the  liver  dulness  may 


SYMPTOMS.  1001 

be  observed  to  rise  in  consequence  of  the  relaxation  of  the  diaphragm. 
The  peculiar  affection  termed  "  tetany  "  (p.  698)  sometimes  occurs  in 
the  subjects  of  hysteria,  but  it  is  usually  trifling  in  degree,  and  is 
limited  to  the  hands.  In  some  cases  of  hysterical  tetanoid  contracture 
the  fingers  are  extended  and  separated  by  the  spasm. 

Clonic  Spasm. — Tremor  is  very  common  in  the  hysterical,  especially 
as  an  accompaniment  of  paralysis  and  contracture.  It  is  rarely 
constant,  but  is  usually  evoked  by  movement  and  excitement.  Fre- 
quently it  does  not  attend  the  commencement  of  movement,  but  if  the 
muscular  action  in  the  arms  or  legs  is  maintained  for  a  few  moments, 
the  limb  is  agitated  by  fine  quick  tremor,  varying  in  degree  and  in 
time,  always  increased,  and  sometimes  distinctly  induced,  by  attention, 
and  when  the  mind  is  diverted  the  tremor  may  cease.  When  the  legs 
are  the  seat  of  contracture,  the  shaking  is  often  caused  by  attempts  to 
move  them,  or  even  by  the  manipulation  of  a  medical  examination.  In 
all  these  respects  it  differs  from  the  tremor  of  paralysis  agitans,  while 
the  fineness  of  the  tremor,  and  the  absence  of  actual  inco-ordination, 
distinguish  it  from  that  which  is  characteristic  of  disseminated  scle- 
rosis, although  in  this  disease  there  is  occasionally  tremor  very  much 
like  that  of  hysteria. 

Such  tremor,  widening  in  range  into  what  deserves  the  name  clonic 
spasm,  is  occasionally  paroxysmal,  affecting  the  head  or  limbs,  pro- 
duced by  emotion,  and  often  to  some  extent  under  voluntary  control. 
A  young  unmarried  man,  of  highly  nervous  temperament,  was  liable 
to  outbursts  of  hysteria,  of  which  such  clonic  spasm  was  an  invariable 
part.  Under  the  excitement  of  a  medical  examination,  for  instance, 
his  head  began  to  shake  violently.  He  said  that  the  shaking  in  the 
head  distressed  him  peculiarly,  and  that  he  could  by  an  effort  send 
the  shaking  into  his  leg,  where  it  was  much  more  bearable.  Presently 
the  right  leg  quivered  in  quick  spasm,  approaching  in  rapidity  the  foot- 
clonus,  and  the  head  was  still.  Similar  spasm,  general  in  distribution, 
is  a  conspicuous  feature  of  many  of  the  hysteroid  convulsions  presently 
to  be  described. 

Local  and  persistent  clonic  spasm  is  a  most  troublesome  but  happily 
a  rare  symptom  of  hysteria.  An  example  of  it  was  presented  by  a  girl 
who  had  two  attacks  of  such  spasm  in  the  left  pectoralis  muscle,  jerking 
the  shoulder  forwards  with  great  force.  The  spasm  was  regular  in 
time,  but  irregular  in  force,  and  during  the  waking  hours  it  never 
ceased.  Each  attack  lasted  for  several  months.  A  circular  blister 
around  the  arm  arrested  the  first,  but  had  no  effect  upon  the 
second,  which  resisted  all  treatment  until  a  journey  to  the  south 
of  Europe  cured  it.  A  similar  spasm  may  sometimes  be  seen  in  the 
muscles  of  the  neck,  causing  a  sort  of  spurious  torticollis.  It  is  usu- 
ally bilateral,  jerking  the  head  backwards  or  forwards  ;  the  movement 
is  slight  in  range  and  quick  in  time,  and  thus  differs  from  the  more 
extensive  and  deliberate  movements  presently  to  be  described. 

Certain  forms  of  widely  distributed  clonic  and  irregular  spasmodic 


1002  HYSTERIA. 

movements  have  been  called  "  hystei'ical  chorea,"  but  they  differ 
much  in  their  characters,  and  to  most  of  them  the  term  chorea  can 
only  be  applied  when  used  as  a  generic  designation  for  all  persistent 
involuntary  movements.  It  is  not  uncommon,  however,  for  witnessed 
chorea  to  be  reproduced  by  the  imitative  tendency  of  hysteria ;  the 
mimetic  malady  may  closely  resemble  its  original,  the  movements 
being  varied  and  irregular,  but  much  more  often  the  muscular  con- 
tractions are  more  sudden  and  shock-like  than  in  true  chorea, 
resembling  in  this  the  "  electric "  form.  The  imitative  form  is 
usually  transient,  and  quickly  vanishes  when  the  patient  is  with- 
drawn from  the  influence  of  example.  Occasionally,  similar  forms  of 
choreoid  affection  come  on  in  these  patients  apart  from  imitation,  and 
these  are  frequently  most  obstinate  affections,  lasting  sometimes  for 
years.  Often  the  movements,  in  the  bands  especially,  bave  a  rhyth- 
mical character.  There  may  be,  for  instance,  quick,  regular,  flexor 
movements  of  the  fingers  of  each  hand,  all  joints  being  bent.  Tbe 
movement  is  always  increased  by  notice,  and  as  it  lessens  in  degree  it 
may  occur  only  when  the  attention  is  directed  to  it.     (See  also  p.  610.) 

Rhythmical  movements  of  more  complex,  and  therefore  more 
deliberate  character,  and  of  wider,  range,  have  also  been  included 
under  the  term  "hysterical  chorea"  by  the  French  (after  Germain 
See,  &c),  and  constitute  the  disease  long  known  as  "chorea  major  " 
by  the  Germans.  The  movements  are  wide  in  range  and  regular  in 
sequence,  and  consist  of  alternating  contractions  in  opposing  muscles, 
especially  the  flexors  and  extensors  of  limbs  and  trunk ;  they  cause 
an  oscillatory  motion  as  regular  as  the  movement  of  a  pendulum, 
ceasing  only  during  sleep,  and  lasting  for  days,  weeks,  or  months. 
The  head  may  be  thus  moved  from  side  to  side,  backwards  or 
forwards,  the  jaws  up  and  down ;  or,  less  commonly,  the  tongue  may 
be  alternately  protruded  and  withdrawn,  the  eyelids  rapidly  closed 
and  opened.  Much  more  frequently  one  limb  is  thus  moved,  or  the 
arm  and  leg  on  one  side,  with  or  without  the  trunk,  very  rarely  all 
four  limbs.  Briquet  has  related  a  case  in  which  the  leg  was  flexed 
until  the  foot  touched  the  forehead  and  again  extended,  in  regular 
sequence  for  more  than  a  year,  in  spite  of  treatment,  until  the  move- 
ments were  arrested  by  violent  emotion.* 

Rhythmical,  co-ordinated  spasm  of  these  forms  is  analogous,  as 
Charcot  has  pointed  out,  to  that  which  occurs,  in  paroxysmal  form,  in 
many  hysteroid  convulsions.  In  all  cases  it  is  probably  pathognomonic 
of  hysteria,  and  may  occur  at  the  onset  of  other  forms  of  hysteroid 
affection.  A  girl  of  seventeen,  while  at  supper,  became  suddenly  faint, 
and  immediately  the  right  arm  became  the  seat  of  rhythmical  flexion 
and  extension  movements  ;  in  half  an  hour  the  leg  was  affected  in  the 
same  way,  and  then  the  other  limbs,  and  for  five  or  six  hours  these 
movements  went  on  without  any  spasm  in  the  tounk.     They  ceased 

*  A  striking  example  of  unilateral  spasm  of  this  character  is  related  by  Charcot, 
'Brit.  Med.  Journ.,'  1878,  i,  p.  221. 


SYMPTOMS.  1003 

when  sleep  was  obtained  by  a  hypodermic  injection  of  morphia,  and 
there  was  no  return,  but  the  patient  woke  to  pass  into  a  state  of  con- 
tracture and  paresis  which  lasted  for  several  months. 

Convulsive  Attacks. — Among  the  paroxysmal  symptoms  must  be  in- 
cluded the  most  frequent  of  all  hysterical  phenomena,  the  globus 
hystericus,  and  the  paroxysmal  manifestations  of  emotion,  which  have 
been  already  described.  Just  as  emotion  is  naturally  expressed  by 
muscular  actions,  in  the  "jumping  for  joy"  of  a  happy  child,  the 
stamping  of  rage,  or  the  wrung  hands  of  distress,  so  the  violent  emo- 
tional discharge  of  hysteria  may  be  associated,  in  more  severe  cases, 
with  violent  movements  of  the  limbs,  purposive  in  aspect,  but  purpose- 
less in  aim.  The  arms  and  legs  are  dashed  about  with  violence,  the 
head  is  thrown  from  side  to  side,  the  back  may  be  arched  by  contrac- 
tions of  the  spinal  muscles.  This  is  the  mildest  form  of  hysterical 
convulsion,  unaccompanied  by  loss  of  consciousness — the  "  hysteria 
minor"  of  the  French. 

In  still  further  degrees  of  intensity,  the  convulsive  phenomena 
become  much  more  complex  and  severe.  The  attacks  occur  with  less 
dependence  on  exciting  emotion,  and  present  more  distinct  alteration 
in  the  mental  state.  These  are  the  attacks  of  "  hysteria  major  "  of 
the  French,  and  from  a  frequent  resemblance  to  epileptic  attacks,  they 
have  long  been  known  by  some  compound  name,  and  especially,  through 
the  influence  of  Charcot,  as  "  hystero-epilepsy."  The  term,  however, 
when  applied  to  phenomena  of  pure  hysteria,  is  inaccurate,  and  it 
is  better  to  call  these  seizures  "  hysteroid  "*  or  hysteria  major. 

In  the  severe  attacks,  rigid  fixation  of  the  trunk  and  limbs,  often 
opisthotonic,  alternates  with  wild  movements,  in  which  the  limbs  are 
thrown  about  with  great  force  and  rapidity,  the  arms  strike  out,  the  legs 
kick,  the  head  is  dashed  from  side  to  side.  These  phenomena  may  be 
varied  by  quiet  intervals,  often  attended  by  hallucinations  or  deli- 
rium. Consciousness  may  be  apparently  lost,  or  manifestly  per- 
verted, and,  as  a  rule,  the  patient  retains  no  recollection  of  the  fit. 
In  the  most  severe  and  elaborate  forms  of  attacks,  such  as  occur  espe- 
cially among  the  French,  certain  stages  may  be  distinguished,  of  which 
Richer  has  given  careful  descriptions  and  striking  illustrations. f  The 
attack  is  often  preceded  by  a  period  of  mental  disturbance,  with 
hallucinations.  The  onset  is  attended  with  sudden  loss  of  conscious- 
ness, and  general  tonic  spasm,  followed  by  clonic  spasm.  These  con- 
stitute the  first  or  "  epileptic  "  stage.  Then  sometimes,  after  a  brief 
interval  of  coma,  the  second  stage  of  co-ordinated  spasm,  or  "  grands 
mouvements,"  comes  on,  opisthotonos,  bounding  movements  of  extreme 
violence,  succeeded  by  the  third  stage  of  mental  and  emotional  dis- 
turbance, in  which  the  patient  talks  deliriously,  with  manifestations 

*  A  term  suggested  by  Sir  W.  Roberts,  which,  although  not  perfect,  is  less 
inexact. 

f  'Etudes  cliniques  sur  l'Hystero-epilepsie/  a  work  in  which  careful  observation 
exact  description,  and  artistic  skill  are  combined  in  a  remarkable  degree. 


1004 


HYSTERIA. 


2?».   .,. 
Qt-r&gS&lS-,. 

m 


FlG.  175. — "Hysteria  major."     First  or  epileptoid  period.     Phase  of  tonic 
immobility  or  tetanism.     (Richer,  PI.  II.) 

Fig.  176. 


Fig.  177. 


Figs.  176  and  177. — "Hysteria  major.'''  Second  period:  period  of 
clownism.  Fig.  176.  Phase  of  violent  movements.  Fig.  177.  Phase 
of  contortions,  "arc  en  cercle."     (Richer,  PI.  III.) 


SYMPTOMS. 
Fig.  178. 


1005 


FlGS.  178  and  179. — "Hysteria  major."  Third  period:  period  of 
emotional  attitudes.  Fig.  178.  Sad  phase.  Fig.  179.  Gay  phase. 
(Richer,  PI.  IV.) 

of  joy,  anger,  or  erotism.  Tenderness  of  the  ovarian  region  is  almost 
always  present,  and  by  pressure  there  a  fit  of  the  above  description 
may  be  at  any  time  induced,  or  may  at  any  period  of  the  attack  be  at 
once  arrested. 

The  kindness  of  M.  Richer  permits  me  to  reproduce  some  of  his 
illustrations.  The  figures,  although  failing  to  do  justice  to  his 
remarkable  etchings,  yet  afford  a  graphic  illustration,  and  useful 
epitome,  of  the  phenomena  of  the  severe  attacks  a?  observed  at  the 
Salpetriere. 


1006 


HYSTERIA. 


Fig.  180. 
B  C 


D 


F&tl* 


^m 


5> 


^ 


-^r'— Jk    MN1 


0g 


^s§^ 


*" 


Fig.  181. 
G 


H 


■j 


SYMPTOMS. 


1007 


Fig.  182. 
J  K 


Figs.  180,  181,  and  182.—"  Hysteria  major."  Synopsis  of  the  features 
and  varieties  of  the  attack  of  Hysteria  major.     (Richer,  PI.  V.) 

The  highest  figure  of  each  vertical  series  (above  the  horizontal  line) 
represents  the  commonest  feature  of  each  successive  stage,  indicated 
by  the  letters ;  while  the  figures  below  in  each  column  represent  fre- 
quent varieties  of  the  common  type  of  that  stage. 

Prodromata    .... 

n,     .      ,         f  Violent  tonic  movements 
Ionic  phases  m     .    .         , .,., 
r  L  Ionic  immobility 

First 


.    ,  J  Clonic  phase 
^  \  Phase  of  resolution 

Second  period  J  Phase  of  contortions 
of  clownism  I  Phase  of  violent  movements -f  ^y^mical 

I  Disordered 

Third  period  of  emotional  attitudes  j  „  J 

Fourth  or  delirious  period  <  ^  ,. '  ,    "  ,       , 

r  i  Generalised  contractures 


A 

E 

C 

D 

E 

F 

G 

H 

I 

J 

K 

L 


In  this  country  the  attacks  rarely  correspond  closely  to  this  descrip- 
tion ;  they  present  similar  phenomena,  but  in  less  regular  sequence, 
and  often  in  isolated  form.  The  initial  stage  seldom  presents  any 
close  resemblance  to  an  epileptic  fit.  There  is  often  initial  tonic 
rigidity,  and  this  is  sometimes  followed  by  a  form  of  clonic  spasm, 
succeeded  by  the  co-ordinated  movements,  but  the  clonic  spasir 
differs  from  that  which  occurs  in  epilepsy,  and  not  unfrequently  th*^ 


patient  passes  at  once  into  the  violent  co-ordinated  movements,  i 


d. 


which  paroxysms  of  tonic  and  clonic  spasm  occur  from  time  to  timf , 

It  may  be  well  to  consider  separately  the  various  phenomena 
these  attacks  as  they  are  met  with  in  this  country.     Their  occurr  "aC  S 
is  often  distinctly  aided  by,  or  due  to,  emotional  disturbance,—  , 


1008  HYSTERIA. 

longed  annoyance  or  sudden  alarm.  The  premonitory  mental  dis- 
turbance with  hallucinations  is  never  met  with,  but  the  attacks  are 
often  preceded  for  some  hours  by  headache  or  some  general  dyses- 
thesia. Immediate  warnings  are  not  uncommon,  especially  a  sense 
of  illness,  the  throat  globus,  giddiness,  palpitation  of  the  heart,  or 
some  sensation  commencing  in  both  feet  and  ascending  to  the  head. 
These  warnings  are  common  in  pure  hy steroid  fits,  but  it  is  important 
to  remember  that  these  attacks  sometimes  occur  as  sequelae  to  epi- 
leptic fits  of  slight  or  moderate  severity  (see  pp.  748,  747),  the  warn- 
ing of  which  must  not  be  mistaken  for  the  warning  of  the  hysteroid 
attack.  In  the  simple  hysteroid  attack  there  may  or  may  not  be 
pallor  before  the  attack  comes  on.  The  patient  may  fall,  occasionally 
with  some  force,  but  never  suffers  the  injuries  so  common  in  epilepsy 
from  falls  upon  dangerous  objects  or  on  the  fire.  Very  often  the  fall 
is  gradual,  a  sliding  to  the  ground  rather  than  a  fall.  When  there  is 
initial  tonic  spasm,  the  limbs  are  usually  rigid  in  extension,  the  toes 
pointed  downwards.  The  arms  may  lie  by  the  side  of  the  body,  or 
be  extended  at  right  angles  to  the  trunk  in  the  attitude  designated 
"  cruciform  "  by  Charcot.  The  fingers  are  usually  flexed  at  all  joints,, 
the  fists  being  clenched.  There  is  never,  in  this  stage,  the  "  interosseal 
position" — the  flexion  of  the  metacarpo- phalangeal  and  extension  of 
the  other  phalangeal  joints,  which  results  from  preponderant  spasm  in 
the  interossei,  and  is  so  common  in  epilepsy  and  in  some  hysterical 
contractures.  During  the  existence  of  the  tonic  stage,  the  foot-clonus 
can  often  be  obtained,  as  Charcot  has  pointed  out. 

The  opisthotonic  spasm  is  one  of  the  most  characteristic  features 
of  hvsteroid  convulsion.  It  is  the  arc  en  cercle  of  French  writers- 
(Fig.  177).  It  occurs  especially  during  the  stage  of  co-ordinated 
movements,  rarely  at  the  commencement  of  the  fit,  although  the  initial 
tonic  spasm  may  pass  into  it.  There  may  be  only  slight  arching  of 
the  spine,  or  the  contraction  of  the  extensor  muscles  may  be  so  severe 
that  the  patient  rests  on  the  back  of  the  head  and  the  heels,  and,  in 
extreme  cases,  the  trunk  is  pushed  up  by  the  feet,  and  the  neck  so 
much  bent  backwards  that  the  vertex,  or  even  the  forehead,  is  the 
anterior  point  of  support,  and  it  seems  as  if  the  neck  would  be  broken. 
It  rarely  continuesyfor  long,  but  the  patient  from  time  to  time  may 
sit  up,  and  then  bound  backwards  into  the  rigid  arch.  Opisthotonos 
may  also  occur  as  the  patient  lies  on  the  side,  the  arc  en  cercle  laterale 
(Fig.  181). 

The  clonic   spasm  varies   very  much  in  its  character.      It  never 

•esembles  precisely  that  of  epilepsy,  in  which  the  movements  are 

iolent  and  shock-like  in  their   character,  and  cease  by  gradually 

scorning  less  frequent,  not  less  strong.     In  hysteria  the  spasm  is 

rely  shock-like,  and  always  maintains  the  same  frequency  until  it 

Idenly  ceases.  It  is  usually  very  quick  in  time.  Occasionally  the 
eption  of  a  universal  clonus,  like  that  of  the  foot,  but  affecting 
te  limbs,  conveys  the  best  idea  of  its  character.     The  fit  may  com- 


SYMPTOMS.  1009 

mence  with  this,  without  any  initial  tonic  spasm.  In  the  rare  cases 
in  which  the  spasin  is  shock-like,  the  shocks  are  infrequent  and 
deliberate,  and  go  on  for  a  long  time.  Much  more  frequently  the 
spasm  is  rather  coarse  tremor  or  quivering.  The  movements  may 
affect  the  hands  and  feet  only,  so  that  these  are  struck  against  the 
ground  with  great  rapidity.  The  orbicularis  palpebrarum  is  often 
alone  affected,  causing  quivering  of  the  eyelids,  or  quick  opening  and 
shutting  movements.  The  tongue  is  never  bitten  in  the  clonic  spasm 
as  it  is  in  epilepsy,  although,  very  rarely,  it  may  be  bitten  accident- 
ally in  the  fall.     Hysterical  patients,  however,  often  bite  their  lips. 

The  co-ordinated  movements  which  constitute  so  large  a  part  of  the 
attack  are,  for  the  most  part,  wild,  irregular  "  fighting  "  or  struggling 
tnovements,  in  which  the  legs,  feet,  and  head  are  thrown  about  with 
great  violence.  The  movements  are  usually  without  serial  order,  but 
occasionally  certain  movements  are  repeated  in  a  rhythmical  manner. 
The  head  may  be  moved  from  side  to  side ;  there  may  be  regular 
flexion  or  extension  movements  of  the  legs  (sometimes  propelling  the 
patient  head  first  along  the  floor),  and  still  more  frequently  a  similar 
rhythmical  movement  in  the  arms.  These  co-ordinated  movements 
are  conspicuously  increased  in  force  by  attempts  to  restrain  them ; 
the  more  force  is  used  the  more  is  needed ;  and  their  violence  is 
often  extreme.  Accompanying  them,  there  is  often  delirious  mental 
disturbance,  most  conspicuous  during  intervals  of  comparative  rest  or 
of  alternating  tonic  spasm.  Sometimes  the  patient  talks  in  an  un- 
natural manner,  manifesting  some  hallucination.  One  girl,  for 
instance,  thought  her  long  black  hair,  which  had  been  flying  about 
her  head,  was  seaweed.  Usually  there  is  more  or  less  emotional  dis- 
turbance, especially  manifestations  of  terror,  which  may  increase  to 
maniacal  frenzy  (Fig.  178),  and  culminate  in  a  paroxysm  of  convul- 
sion. An  ecstatic  stage,  with  passionate  attitudes,  as  depicted  by 
Eicher  in  Fig.  179,  and  also  indicated  in  its  varieties  in  Fig.  182  J, 
is  seldom  met  with  here,  and  it  is  equally  rare  for  there  to  be  a  stage 
of  fixed  contracture,  as  in  Fig.  180  B.  There  is  often  a  strange 
tendency  to  bite  in  a  curiously  animal  manner,  and  occasionally  noises 
of  animals  are  imitated  (therio-mimicry).*  The  patient  will  make  a 
sudden  gnash  at  the  hand  of  an  attendant,  and  if  not  prevented,  may 
inflict  serious  bites  on  her  own  fingers.  In  a  prolonged  seizure  there 
are  often  intervals  of  tranquility,  in  which  the  patient  may  seem 
well,  but,  by  slight  peculiarities  in  manner,  those  who  know  her  are 
aware  that  "  she  is  not  yet  herself,"  and  presently  the  spasm  suddenly 
recommences. 

The  eyelids  in  hysterical  attacks  are  usually  closed,  except  during 
the  delh'ious  phase,  when  the  eyeballs  often  converge  strongly  from 
time  to  time.  Eeflex  action  from  the  conjunctiva  is  usually  lessened. 
General  sensation  is  distinctly  diminished ;  a  pin  may  be  run  into  the 
skin  without  causing  any  evidence  of  pain.  In  rare  cases  the  attacks 
*  See  'Epilepsy  and  other  Chronic  Convulsive  Disorders,'  p.  140. 

VOL.  If.  64 


1010  HYSTEEIA. 

are  attended  or  replaced  by  violent  laryngeal  spasm,  causing  intense 
dyspnoea. 

Pressure  on  the  tender  ovarian  regiou,  or  other  tender  hysterogenic 
spots,  as  already  stated,  sometimes  induces  an  attack,  and  prolonged 
pressure  "will  often  arrest  the  seizure.  Sometimes  the  ovarian  com- 
pression simply  aiTests  the  co-ordinate  movements,  and  causes  tonic 
spasin.  The  fits  may  be  usually  cut  short  more  readily  by  strong  fara- 
disation of  the  skin;  by  Dr.  Hare's  expedient  of  closing  the  mouth 
and  nose  for  twenty  or  thirty  seconds  ;  by  cold  water  thrown  on  the 
face ;  or,  if  the  mouth  be  open,  by  pouring  into  it  a  little  water  so 
that  this  gets  to  the  larynx  and.  causes  a  choking  cough.  These 
methods  clearly  act  by  a  strong  stimulation  of  the  sensory  nerves  or 
of  the  respiratory  centre.  The  duration  of  the  attacks,  if  left  alone, 
varies  extremely..  Some  last  only  for  a  few  minutes  ;  more  frequently 
they  continue  for  a  quarter  to  half  an  hour,  or  even  for  several  hours. 
Occasionally  transient  contracture  of  limbs,  or  trismus,  or  local 
paralysis,  or  ansesthesia  succeeds  an  attack. 

The  severe  hysteroid  seizures  are  very  common  in  young  women  and 
girls  at  the  time  of  puberty,  and  sometimes  earlier,  even  at  seven  or 
eight  years  of  age.  They  are  by  no  means  rare  in  boys,  and.  may 
occur  in  young  adult  men.*  They  are  not  confined,  to  the  waking 
state,  but  may  occur  also  in  sleep.  The  frequency  with  which  they 
are  sequela?  to  slight  epileptic  seizures,  as  already  mentioned,  is  an 
extremely  important  fact. 

Cerebral  Symptoms. — The  conditions  of  hemianesthesia,  paralysis, 
and  contracture  must  be  regarded  as  the  expression  of  a  condition  of 
restrained,  function  (inhibition)  or  unrestrained  activity  of  certain 
cerebral  centres,  sensory  and  motor.  In  rare  cases  a  similar  perversion 
of  function  may  involve  higher  centres ;  the  patient  may  pass  into 
the  peculiar  sleep-like  state  of  "trance"  or  "lethargy,"  with  or 
without  the  condition  of  plastic  rigidity  of  limb  denominated  "  cata- 
lepsy "  (seep.  1032).  Such  conditions  are  met  with  chiefly  in  the 
subjects  of  hysteria  ;  they  may  come  on  in  paroxysmal  attacks,  even  at 
a  certain  time  each  day,  sometimes  in  the  evening.  Although  spon- 
taneous trance  is  rare,  the  condition,  as  Charcot  and  his  pupils  have 
shown,  can  be  readily  induced  in  hysterical  patients,  and  in  the 
hypnotic  state  there  may  be  an  extraordinary  increase  of  excitability 
in  brain,  nerve,  and  muscle  (p.  1032). 

Other  disturbances  of  the  psychical  functions  occasionally  occur  in 
hysteria,  and  are  very  important.  The  ordinary  mental  characteristics 
of  these  patients  have  been  already  described.  In  rare  cases  there 
may  be  such  an  amount  of  mental  disturbance  as  to  raise  the  ques- 
tion whether  the  patient  is  actually  sane,  and  sometimes  the  limits 
of  sanity  are  distinctly  passed.  The  relation  of  insanity  to  hysteria  is 
a  subject,  however,  on  which  generalisation  is  difficult,  and  various 
opinions  are  held  by  competent  authorities.  Mental  derangement, 
*  1  have  related  examples  of  tbese  forms  in  '  Epilepsy,'  p.  165,  inc. 


SYMPTOMS.  1011 

like  other  nervous  diseases  in  females,  may  be  accompanied  with 
symptoms  of  hysteria,  without  the  association  proving  any  essential 
relation.  Sometimes,  however,  pronounced  mental  aberration  seems 
distinctly  to  grow  out  of  the  slighter  psychical  disturbance  of 
hysteria,  and  the  process  may  be  apparently  similar  to  that  which 
leads  to  the  more  grave  corporeal  symptoms.  Just  as  a  mind  unfixed 
by  emotion  may  become  set,  in  its  unbalanced  state,  by  a  fixed  idea  of 
motor  inability,  and  the  latter  may  progress  to  extensive  paralysis  or 
contracture,  so  the  intellect  may  become  the  prey  of  such  an  idea  as 
must  be  regarded  as  an  insane  delusion,  under  the  influence  of  which 
the  mental  powers  may  fail  further.  An  emotional  girl,  for  instance, 
with  frequent  globus,  became  possessed  with  the  idea  that  all  persons 
whom  she  met  were  making  faces  at  her,  and  then  she  manifested 
timidity,  infantile  in  its  degree,  so  that  she  dared  not  go  out  of  the 
house  alone,  and  became  irritable  and  depressed,  with  a  vacant  look, 
and  such  loss  of  memory  as  to  constitute  partial  dementia.  Such 
cases  may  be  most  various  in  their  form,  and  the  ultimate  symptoms 
may  resemble  those  of  simple  insanity,  from  which  they  are  to  be 
separated,  if  at  all,  only  by  the  conditions  of  their  origin. 

There  is  another  important  relation  of  hysteria  to  insanity.  The 
later  stage  of  a  developed  hysterical  fit  is  a  paroxysm  of  mental  dis- 
turbance of  maniacal  violence,  in  which  chaotic  storms  of  emotional 
frenzy  alternate  with  hallucinations  and  delirium.  The  patient  is, 
for  a  few  minutes,  wildly  insane.  Just  as  some  of  the  motor  spasm 
of  the  hy steroid  convulsion  may  continue,  or  may  occur  alone,  as 
persistent  contracture,  so  some  elements  in  the  paroxysmal  mental 
disturbance,  hallucination  or  delirium,  may  occur  alone.  In  an 
hysterical  child,  whose  case  I  have  described  at  length  elsewhere,* 
apart  from  the  delusions  that  accompanied  the  convulsive  seizures, 
there  were  occasional  periods  of  spiteful  mischievousness,  wholly 
foreign  to  her  habitual  character,  and  also  periods  of  a  semi-demented 
state,  lasting  for  days  or  weeks.  The  subjects  of  such  mental  dis- 
turbance may  threaten  or  attempt  suicide,  apparently  with  every 
intention  of  success.  In  another  patient,f  a  girl  of  twenty-six, 
violent  delirium  accompanied  each  hysteroid  convulsion,  and  after  a 
time  paroxysms  of  mental  disturbance  occurred  without  any  preceding 
fit.  After  an  interval  of  improvement,  a  condition  came  on  which 
rendered  her  confinement  in  an  asylum  necessary.  She  recovered, 
but  relapsed,  in  consequence  of  a  mental  shock,  and  passed  into  a 
very  unpromising  state,  with  most  degraded  habits,  but  ultimately 
became  well. 

Visceral  and  Vaso-motor  Symptoms. — The  digestive,  respiratory,  and 
circulatory  systems  are  liable  to  be  deranged  in  hysteria.  Some  of 
the  resulting  disorders  are  very  remarkable  in  character,  and  indicate 
how  profound  may  be  the  secondary  influence  of  the  disease  on  sub- 
ordinate functions. 

*  '  Epilepsy,'  &c,  p.  157.  t  Loc.  cit.,  p.  172. 


1012  HISTEEIA. 

Not  only  may  the  "  globus  hystericus  "  be  accompanied  by  actual 
pharyngeal  spasm,  but  occasionally  such  spasm  occurs  in  paroxysms, 
accompanied  by  an  intense  feeling  of  suffocation.  Swallowing  may 
be  impossible  for  hours,  sometimes  for  days.  The  oesophagus  also 
may  be  the  seat  of  spasm,  and  food  is  then  regurgitated  before  it 
reaches  the  stomach.  Vomiting  is  much  more  commonly  from  the 
stomach  itself,  and  constitutes  one  of  the  most  troublesome  of  the 
visceral  disturbances.  Food  is  rejected,  usually  in  less  than  a 
quarter  of  an  hour  after  it  is  taken.  Sometimes  gastralgia  exists, 
and  the  presence  of  food  in  the  stomach  excites  pain,  which  seems  to 
cause  the  vomiting,  but  more  commonly  the  vomiting  is  painless,  and 
unaccompanied  by  nausea.  The  symptom,  like  many  others  in 
hysteria,  may  be  set  up  in  the  first  instance  by  an  attack  of  real 
gastric  disturbance,  accompanied  by  nausea,  but  it  persists  when  this 
is  over,  as  a  morbid  habit,  involuntary  in  character,  but  often  yielded 
to  by  the  patient,  and  sometimes  actually  induced  by  the  will.  The 
stomach  is  not,  it  is  true,  under  direct  voluntary  control,  but  vomit- 
ing may  be  produced  by  an  emotion  of  disgust,  and  the  needed 
emotion  may  be  called  up  by  an  idea  without  sensorial  agency,  as  is 
evinced  by  the  strange  cases  in  which  the  vomiting  of  pregnancy 
makes  the  husband  retch,  and  at  last  the  latter  becomes  sick  as  soon 
as  he  knows  his  wife  is  pregnant.*  The  connection  may  become  so 
strong  that  food  is  rejected  on  a  mere  thought  of  sickness,  which 
may  arise  unbidden,  and  is  easily  called  up.  It  is  not  probable  that 
the  stomach  returns  all  the  food  taken,  for  patients  kept  at  rest  may 
not  lose  weight,  although  constantly  vomiting  food.  Conjoined  with 
vomiting,  or  existing  alone, there  maybe  absolute  anorexia, and  these 
together  may  render  feeding  by  the  mouth  impossible. 

Such  hysterical  anorexia  has  given  rise  to  the  extraordinary  cases 
of  "  fasting  girls  "  which,  in  all  ages,  have  excited  popular  wonder. 
In  most  of  these,  however,  there  has  been  unquestionable  fraud. 
When  abstinence  from  food  is  complete,  the  body  invariably  loses 
weight,  and  the  absence  of  this  progressive  loss  is  certain  proof  of 
deceit,  which  is  stimulated  by  the  interest  excited,  and  aided  by  the 
friends  to  secure  the  contributions  of  amazed  benevolence.  Even  in 
slight  cases  of  hysteria,  deliberate  deceit  is  more  common  in  this  than 
in  any  other  symptom.  Some  patients,  who  would  not  deliberately 
assume  a  positive  symptom,  fall  easily  into  the  habit  of  fasting  at 
meals  and  eating  on  the  sly.  But  in  some  cases  of  severe  hysteria 
there  is  absolute  abstinence  from  food  for  many  days,  and  even 
during  weeks  the  quantity  taken  may  be  so  small  as  to  be  insufficient 
to  prevent  the  self-starvation  from  producing  conspicuous  effects.  In 
a  case  related  by  Weir  Mitchell,  no  food  was  taken  for  ten  days,  and, 
during  five  weeks,  only  twenty-four  ounces  of  milk  were  swallowed. 
Another  patient  swallowed  neither  solid  nor  liquid  for  twenty-seven 

*  Weir  Mitchell,  '  Nervous  Diseases  in  Women.'  A  similar  case  has  been  related 
to  me  by  Dr.  John  Williams. 


ST1IPT0.HS.  1013 

days.  In  some  of  these  cases,  forced  feeding  by  the  mouth,  or  even 
by  the  rectum,  may  give  rise  to  such  severe  convulsions  that  the 
attempt  has  to  be  relinquished.  The  patients  lose  weight,  and 
become  emaciated  and  feeble  in  extreme  degree;  the  temperature 
may  be  raised,  the  tongue  becomes  dry  and  brown  ;  they  may  pass 
into  a  condition  of  stupor,  and  not  only  appear  in  danger  of  imme- 
diate death,  but  may  actually  sink  from  exhaustion.  In  most  cases, 
however,  when  this  alarming  state  is  reached,  a  little  food  is  again 
taken,  and  the  patient  slowly  revives.  The  danger  is  greater  in  cases 
of  prostration  from  long-continued  vomiting  than  from,  simple  refusal 
of  food,  since  forced  feeding  is  less  effectual.  One  patient  died  on 
the  eighty-second  day  of  the  vomiting,  in  spite  of  the  use  of  the 
stomach-tube.* 

Dyspepsia,  in  every  form  and  degree,  is  common  in  the  hysterical, 
and  the  nerve  disturbance  thereby  excited  may  profoundly  intensify 
other  symptoms.  Sensations  of  "sinking,"  palpitation,  breathless- 
n§ss,  flushing  of  the  face,  pains  in  the  back,  which  often  attend 
dyspepsia,  may  reach  an  extreme  degree  in  the  subjects  of  hysteria. 
Flatulence,  gastric  and  intestinal,  is  very  common,  and  gives  rise  to 
much  discomfort  and  to  varied  sounds,  some  of  which  are  apparently 
the  effect  of  an  involuntary  contraction  in  the  muscles  of  the  abdo- 
minal wall.  Complicating  and  intensifying  these  troubles,  there  is 
often  constipation,  which,  so  common  in  women,  is  peculiarly  obsti- 
nate in  the  hysterical.  The  bowels,  left  alone,  may  act  only  once  a 
week  or  even  once  a  month.  Whether  this  results  from  a  nervous  inhi- 
bition of  the  intestinal  wall,  or  from  mere  indisposition  to  aid  the 
bowels  by  timely  attention,  is  difficult  to  say.  It  is  certain  that  the 
muscular  action  of  the  intestines  may  be  gravely  deranged  in 
severe  hysteria.  A  case  is  recorded  by  Briquet,  in  which  liquids 
injected  into  the  rectum  were  vomited  by  the  mouth.  Even  tincture 
of  litmus  was  vomited  twelve  minutes  after  its  injection  into  the 
rectum,  the  patient  being  watched  by  doctors  and  nurses  the  whole 
time.  That  there  is  a  pathological  inactivity  of  the  bowel  is  probable 
from  the  large  amount  of  purgative  which  is  needed.  Occasionally 
there  is  a  peculiar  sensitiveness  to  the  action  of  the  bowels,  so  that 
the  passage  of  a  stool,  especially  if  relaxed,  may  cause  sensations  of 
faintness,  and  even  actual  syncope. 

Retention  of  urine  is  common  in  the  hysterical,  but  incontinence  is 
almost,  if  not  quite,  unknown.  Calls  to  micturate  are  often  annoy- 
ingly  frequent,  but  this  usually  depends  on  the  character  of  the  urine, 
which  is  often  abundant,  pale,  and  of  low  specific  gravity,  and  seems 
to  irritate  the  bladder  much  more  than  that  which  is  less  dilute. 
Such  urine  is  probably  due  to  dilatation  of  the  renal  vessels.  It  is 
secreted  in  most  persons  under  the  influence  of  emotion,  and  may  be 
almost  constant  in  the  persistent  emotional  state  of  the  hysterical. 
In  rare  cases  the  secretion  is  changed  in  the  opposite  way.  Instead 
*  Guyot,  '  Gaz.  med.  de  Paris/  1882,  p.  206. 


1014  HYSTERIA. 

of  being  increased  it  is  lessened,  and  the  diminution  may  go  on  to 
absolute  arrest — "  hysterical  ischuria  "  and  "  anuria,"  which  have  been 
carefully  studied  by  Charcot.  Complete  suppression  may  last  for  ten 
days  without  any  symptoms  of  ursemic  intoxication,  such  as,  in  anuria 
from  calculous  obliteration  of  the  ureters,  usually  supervenes  before 
the  end  of  a  week,  and  causes  death  in  two  or  three  weeks.  Considei*- 
able  diminution  of  the  urine  is  always  attended  with  vomiting.  The 
quantity  of  liquid  vomited  varies  inversely  with  the  amount  of  urine 
secreted,  and  the  vomit  contains  some  urea.  In  a  case  recorded  by 
Weir  Mitchell,  severe  vomiting  alternated  with  profuse  perspiration, 
which  left  a  thin  film  of  urea  on  the  skin.  "To  the  supplementary 
excretion,  and  to  the  facts  that  little  food  is  retained  and  that  the 
tissue  changes,  the  patient  being  at  rest,  are  extremely  slight,  Chai'cot 
believes  that  the  tolerance  is  to  be  ascribed.  The  symptom  itself  is 
probably  due  to  spasm  of  the  renal  vessels,  and  is  comparable  to  the 
arrest  of  the  secretion  which  occurs  in  an  animal  when  the  abdomen 
is  opened.  Although,  in  considerable  degree  and  duration,  ischuriais 
extremely  rare,  in  slight  and  transient  form  it  is  not  infrequent  (as 
Laycock  pointed  out),  being  often  ascribed  to  retention  in  the  bladder. 

The  disturbance  of  the  functions  of  the  sexual  organs  that  exists 
iu  hysteria  has  been  already  sufficiently  described  in  the  section  on 
causation. 

Respiratory  Organs. — Intensely  rapid  breathing,  fifty,  sixty,  or 
eighty  respirations  per  minute,  is  not  an  unfrequent  symptom,  and  is 
often  termed  "  hysterical  dyspnoea."  There  is  no  real  difficulty  of 
breathing,  and  the  patient's  pulse  may  not  be  more  frequent  than  is 
habitual.  Such  extreme  rapidity,  without  other  signs  of  dyspnoea, 
is  almost  confined  to  this  disease.  When  conjoined  with  hysterical 
pains  in  the  chest,  the  resemblance  to  intra-thoracie  mischief  may 
be  perplexing.  Actual  dyspnoea,  most  intense  in  degree,  may,  how- 
ever, attend  another  hysterical  disorder,  laryngeal  spasm,  which 
may  occur  in  violent  paroxysms.  Stridor  and  cyanosis  attest  the 
severity  of  the  manifest  struggle  for  breath,  the  muscles  of  the  neck 
stand  out  in  violent  action,  blood  may  be  hawked  up  in  the  straining, 
and  the  patient  may  even  appear  to  be  on  the  point  of  death  by 
suffocation.  The  attack  may  sometimes  be  arrested  by  closing  the 
mouth  and  nose  and  causing  actual  apncea,  by  tickling  the  pharynx 
and  thus  inducing  nausea,  and  still  more  effectually  by  an  injection 
of  apomorphia.  Persistent  cough  is  another  occasional  paroxysmal 
symptom — often  hoarse  and  croaking.  Hiccough  is  also  sometimes; 
a  troublesome  and  enduring  symptom. 

Vaso-motor  Symptoms. — Neurotic  disturbances  of  the  vascular 
system  are,  in  slight  degree,  extremely  frequent,  and  often  give  rise 
to  s|reat  discomfort.  Occasionally  they  are  severe  and  even  violent. 
The  heart's  action  maybe  habitually  too  frequent,  and  maybe  readily 
accelerated  or  rendered  irregular  by  any  trivial  emotion,  or  by  the 
common  gastric  derangement,  and  intermission  or  tumultuous  action 


SYMPTOMS,  1015 

may  occur  apparently  without  cause.  There  is  undue  consciousness 
of  the  action  of  the  heart,  normal  or  irregular,  which  is  described  as 
"  palpitation."  It  is  often  a  source  of  much  distress,  and  may  he 
accompanied  by  cardiac  pain  and  giddiness,  by  sensations  of  sinking, 
of  dyspnoea,  and  of  faintness,  by  extreme  pallor,  and  even  by  actual 
syncope.  Sometimes  the  deranged  innervation  is  shown,  not  only  by  an 
habitual  frequency  of  120  or  130  beats  per  minute,  but  by  a  reversal 
of  the  usual  effect  of  posture  on  the  pulse.  The  attacks  of  pain, 
with  pallor,  faintness,  and  dyspnoea,  may  closely  counterfeit  genuine 
anginal  seizures,  especially  when  the  pain,  as  is  sometimes  the  case, 
radiates  to  the  left  arm ;  if  the  symptoms  of  angina  pectoris  are 
known,  dread  of  it  augments  the  distress.  In  special  conditions  of 
depressed  brain  function,  the  heart's  action  becomes  infrequent, 
especially  in  some  of  the  cases  of  spontaneous  trance. 

Disturbances  in  the  peripheral  vaso-motor  system  may  be  associated 
with  the  perturbed  action  of  the  heart,  or  occur  independently. 
Flushing  of  the  face,  sometimes  local  in  distribution,  is  exceedingly 
common.  It  occm*s  spontaneously  or  on  slight  emotion,  and  from 
the  misconstruction  to  which  it  gives  rise  is  a  source  of  great  annoy- 
ance to  the  patient.  Flushing  and  pallor  may  alternate,  or  the  face 
be  red  and  burning  while  the  feet  and  hands  are  cold.  Flushing 
of  the  feet,  with  a  sensation  of  burning  heat,  often  alternates  with 
cold,  and  much  more  rarely  there  is  persistent  fulness  of  the  vessels 
of  both  legs.  Weir  Mitchell  has  recorded  an  extraordinary  case  in 
which  at  times,  through  emotion  or  spontaneously,  a  paralysis  of  the 
abdominal  vessels  seemed  to  concur  with  vascular  spasm  elsewhere, 
so  that  the  flat  abdomen  of  a  thin,  spare  widow  would  attain,  in  the 
course  of  a  few  hours,  a  size  corresponding  to  the  sixth  month  of 
pregnancy,  and  be  turgid  and  pulsating,  while  the  rest  of  the  body 
was  pale  and  bloodless,  the  pulse  at  the  wrist  being  a  mere  thread, 
and  faintness  ensued  if  the  patient  sat  up.  The  state  would  subside 
in  the  course  of  a  few  days,  but  it  was  the  source  of  infinite  annoyance 
to  the  patient. 

Local  perspiration  is  a  rare  symptom.  In  one  case  the  hands  and 
feet  were  the  seat  of  p^fuse  sweating,  which  alternated  with  attacks 
of  lethargy,  transiet-t  double  amaurosis,  paraplegia,  and  anesthesia 
(Siredey). 

Vaso-motor  spasm  seems  sometimes  to  accompany  hemianesthesia, 
so  that  pricks  do  not  bleed,  but,  as  we  have  seen,  it  is  no  necessary 
concomitant ;  in  complete  hemianaesthesia  the  vascularity  of  the  skin 
may  be  normal,  and  pricks  may  bleed  readily. 

Occasionally  local  swellings  occur,  especially  about  the  hands  or 
feet,  or  about  joints,  sometimes  in  the  seats  ©f  neuralgic  pain.  They 
are  due  apparently  to  the  effusion  of  serum  into  the  cellular  tissue  in 
consequence  of  vaso-motor  disturbance,  and  often  occur  near  the  time 
of  menstruation. 

It  is  probable  that,  in  rare  cases,  the  vaso-motor  disturbance  may 


1016  HYSTERIA. 

lead  to  the  occurrence  of  small  haeuioi-rhages  into  the  skin,  but 
extravasations  in  definite  spots,  as  the  "stigmata  of  crucifixion"  are 
always  of  artificial  origin0  Haemorrhage  from  the  stomach  has 
been  thought  to  be  vicarious  with  the  menstrual  flow,  but  in  at  least 
some  of  these  cases,  actual  ulceration  has  existed.  Haemorrhage  from 
the  lungs  is  unknown  except  in  actual  disease,  although  the  straining 
of  laryngeal  spasm  may  rupture  small  vessels  in  the  throat  and  wind- 
pipe, and  small  clots  .may  be  coughed  up.  A  form  of  spurious 
haemoptysis  is,  however,  not  uncommon ;  the  patient  spits  a  brownish- 
red  liquid  consisting  of  saliva  uniformly  mixed  with  blood,  probably 
sucked  from  the  gums. 

When  an  hysterical  patient  emaciates  from  self -starvation,  the  skin 
may  become  dry,  and  the  epidermis  scale  off.  Artificial  skin  erup- 
tions are  often  produced  by  means  of  irritants,  such  as  cantharides,  in 
the  lowest  class  of  hysterical  patients,  who  may  exhibit  much  cunning 
in  baffling  detection. 

The  temperatui-e  in  hysteria  is,  as  a  rule,  normal,  but  in  severe 
cases  a  slight  rise  occurs  at  some  period  of  the  day,  a  circumstance 
which  is  not  surprising  when  the  severe  vaso-motor  symptoms  are  con- 
sidered. The  registering  thermometer,  however,  furnishes  some 
hysterical  patients  with  an  irresistible  temptation  to  fraud.  By  fric- 
tion or  pressure  on  the  bulb,  or  by  the  dexterous  manipulation  of  hot 
bottles  or  poultices,  the  index  may  be  driven  up  even  to  the  top  of  a 
clinical  thermometer,  and  the  patients  enjoy  the  wonder  which  has 
been  excited  when  temperatures  of  120°  or  130°  have  been  registered 
by  special  instruments. 

Course  and  Terminations. — The  severe  nerve  disturbances  of  hysteria 
may  persist  in  continuous  or  recurrent  form  for  a  short  or  a  long  period, 
usually  for  months  and  sometimes  for  years.  Recurring  convulsive 
attacks  and  persistent  contractures  are  perhaps  the  most  enduring. 
But  the  transitory  manifestations  of  the  disease  are  merely  the  sym- 
ptoms of  an  underlying  state,  which  is  from  its  nature  persistent;  its 
duration  is  to  be  measured  by  years,  often  by  a  lifetime.  In  its  slighter 
forms  it  is  as  much  a  temperament  as  a  disease.  If  it  is  moderate  in 
degree,  and  the  patient  can  be  placed  in  favorable  circumstances,  it  may 
after  a  time  cease  to  be  effective,  especially  when  the  emotional 
disturbance  of  youth  has  passed  into  the  steadier  career  of  the  woman  : 
when  its  degree  is  greater  it  may  survive  even  the  latter,  and  the  in- 
fluences that  should  steady  the  mind  may  only  cause  additional  per- 
turbation. 

Over  the  slighter  forms  of  hysteria,  the  moral  influences  involved 
in  marriage  exert  a  distinctly  beneficial  influence,  especially  in  the 
social  class  and  conditions  in  which  it  involves  activity  of  mind  and 
body  for  definite  and  adequate  objects.  But  the  severe  forms  of  the 
disease,  especially  those  with  long-continued  convulsions,  may  be  unre- 
lieved by  marriage  and  even  by  maternity,  and  may  be  distinctly  aggra- 
vated by  the  anxieties  which  are  never  altogether  absent  from  the 


PATHOLOGY.  1017 

married  state,  and  which  not  rarely  constitute  the  greatest  trials  life 
can  bring.  Hence  severe  hysteria  often  persists  to  middle  life  and  even 
beyond  it,  in  some  cases  to  cease,  in  others  to  be  intensified,  at  the 
climacteric  period,  and  occasionally  to  continue  until  old  age. 

The  course  of  the  disease  is  always  varied.  The  infinite  diversity 
of  symptoms  which  different  patients  present,  may  be  almost  paral- 
leled in  the  history  of  individual  cases ;  palsies,  motor  and  sensory, 
contractions  and  convulsions,  dyspnoea  and  dysphagia,  anorexia  and 
aphonia,  faintings  and  vomitings,  may  succeed  one  another  in  appa- 
rently inexhaustible  variety. 

In  what  proportion  of  cases  a  practical  recovery  takes  place  cannot 
be  determined.  As  a  rule,  however  long  the  symptoms  have  lasted, 
they  remain  disorders  of  function  only,  and  their  complete  disappear- 
ance is  always  possible.  To  this  an  exception  must  apparently  be 
made  in  the  case  of  persistent  contractures,  which,  as  already  stated, 
after  lasting  for  many  years,  may  be  attended  with  structural 
changes  in  the  spinal  cord  ;  such  cases  are,  however,  excessively  rare. 

Recovery  from  hysteria  is  probably  always  gradual,  although  it  is 
very  common  for  the  individual  symptoms  to  cease  suddenly,  especially 
under  some  profound  emotion.  The  same  agent  which  disturbed,  in  a 
given  direction,  the  unstable  balance  of  the  nervous  system,  may  read- 
just the  equilibrium,  but  without  rendering  it  more  stable  than  before  ; 
and  such  influences  are  never  permanent  in  their  effects.  Nor  are  they 
always  efficient  even  in  their  limited  degree.  It  has  been  said  that  an 
hysterical  paralytic  will  always  run  out  of  a  burning  house,  but  Weir 
Mitchell  has  mentioned  an  instance  in  which,  under  such  circumstances, 
the  patient  only  fell  down  helpless,  and  another  instance  of  this  has 
come  under  my  own  notice.  A  sufficient  motive  for  sustained,  un- 
selfish exertion  is  much  more  effectual,  and  many  an  hysterical  girl 
has  recovered  health  under  the  necessity  of  rising  from  her  couch 
to  exchange  the  part  of  invalid  for  that  of  nurse. 

Pathology. — Many  points  of  the  pathology  of  hysteria  have  been 
alluded  to  in  the  account  of  the  characters  and  causes  of  the  disease, 
and  our  knowledge  of  the  subject  is  so  scanty  that  little  more  remains 
to  be  said.  The  teaching  of  anatomy  is  purely  negative.  The  changes 
which,  in  rare  cases,  have  been  found  on  post-mortem  examination, 
have  clearly  been  either  accidentally  associated,  or  have  merely  served 
to  evoke  the  condition  which  in  other  cases  exists  as  an  independent 
malady.  The  only  disturbance  common  to  all  forms  of  the  affection 
is  that  of  certain  cerebral  functions,  and  we  are  not  justified  in 
Olooking  beyond  these  for  the  primary  derangement.  It  is  clear  that 
whatever  influence  disorders  of  other  organs  (as  those  of  the  uterus) 
may  exert,  they  merely  excite  the  manifestation  of  a  disease  already 
existing. 

Hysteria  is  probably  the  most  perfect  type  of  a  functional  malady. 
It  not  only  consists  in,  but  arises  by,  a  functional  disturbance,  a  loss 


1018  HYSTERIA. 

of  the  due  balance  between  certain  of  the  higher  functions  of  the 
brain.  But  many,  probably  most,  of  the  definite  groups  of  symptoms 
depend  on  the  secondary  derangement  of  lower  centres.  Thus  henri- 
ansesthesia  must  be  ascribed  to  an  inhibition  of  a  sensory  centre 
relatively  low,  -while  hysterical  anuria  shows  that  the  secondary  dis- 
turbance may  reach  nerve  functions  farthest  removed  from  those  in 
which  it  commences. 

It  is  important  that  this  definite  affection  of  lower  centres  should 
be  clearly  recognised,  because  there  is  still  too  strong  a  disposition  to 
consider  hysteria  not  only  primarily  but  altogether  as  an  affair  of  brain 
and  will.  That  it  is  so  originally  there  can  be  no  doubt,  and  it  is 
also  certain  that  the  disease  can  only  be  really  cured  by  the  restora- 
tion of  the  normal  balauce  of  cerebral  function  ;  but  the  secondary 
disturbance  of  lower  centres  (e.  g.  the  vaso-motor)  may  at  times  pre- 
ponderate over  that  which  can  be  recognised  in  the  highest,  and  may 
be  independent  in  their  degree,  and  in  some  cases  apparently  (though 
not  really)  in  their  occurrence. 

This  disturbance  of  lower  centres  has  disclosed  facts,  hitherto 
scarcely  suspected,  and  of  much  physiological  interest,  regarding 
their  capacity  for  limited  functional  derangement.  We  may  take,  for 
instance,  the  remarkable  phenomena,  above  described,  of  hemianaes- 
thesia  and  of  transfer.  This  unilateral  loss  of  sensibility  not  only  shows 
that  the  sensory  centres  on  one  side  of  the  brain  may  become  inhibited 
in  a  peculiar  way,  partially  or  wholly,  but  that,  by  certain  agents,  a 
partial  arrest  of  the  inhibition  may  be  effected,  so  that  a  given  area 
in  the  anaesthetic  region  again  becomes  sensitive.  The  phenomena  of 
transfer  (of  the  genuineness  of  which,  in  spite  of  its  rarity  out  of 
Trance,  there  can  be  no  doubt)  show  that  there  must  exist  an  intimate 
connection  between  the  sensory  centres  of  the  two  hemispheres,  so 
that  the  restoration  of  functional  action  in  a  part  of  the  inhibited 
centre  is  accompanied  by  an  arrest  of  action  in  the  corresponding  part 
of  the  centre  on  the  opposite  side.  The  validity  of  this  inference  is 
independent  of  the  mode  by  which  the  phenomena  are  effected,  or  of 
the  exact  functional  change  in  which  they  consist. 

Our  knowledge  of  the  nature  of  the  primary  disturbance  that  con- 
stitutes the  essential  element  in  hysteria  is  too  visionary  to  render  its 
discussion  of  practical  value.  Modern  physiology  teaches  that  there 
is  a  complex  interaction  between  all  parts  of  the  nerve-centres,  and 
suggests  that  functional  activity  and  inactivity  are  determined,  not 
only  by  the  power  of  generating  nerve  force,  but  by  varying  degrees 
of  restraint  or  inhibition.  Lower  centres  are  controlled  by  higher 
ones,  and  controlling  centres  are  themselves  subject  to  restraint.  It  is. 
easy  thus  to  conceive  that  some  defect  in  the  higher  centres  may  lead 
to  a  disorder  involving  either  part  or  the  whole  of  the  lower  centres, 
although  we  may  be  quite  unable  to  trace  the  process  by  which  the 
disorder  arises,  or  the  conditions  that  determine  its  limitation. 

In  speaking  of  hysteria  as  a  functional  disease,  it  is  not  denied  that 


DIAGNOSIS.  1019 

changes  in  the  finer  nutrition  of  the  nerve-elements  may  underlie  and 
result  from  it ;  but  they  are  not,  even  in  extreme  degree,  recognisable 
by  our  present  methods  of  observation.  To  this  one  exception  must 
be  made ;  spinal  sclerosis  may  develop  from  contracture — an  almost 
unique  example  of  structural  change  from  functional  disturbance. 

It  is  scarcely  worth  while  to  discuss  the  pathology  of  the  individual 
symptoms  of  hysteria.  The  little  that  is  known  has  been  mentioned 
in  their  description,  and  the  application  to  them  of  the  general  prin- 
ciples just  enunciated  would  be  merely  to  repeat  these  principles  in 
more  special  terms. 

Diagnosis. — The  general  condition  of  hysteria  is  usually  recognised 
without  difficulty.  The  varied  and  varying  discomforts  of  which  the 
patients  complain,  and  for  -which  no  organic  cause  can  be  discovered, 
the  frequent  globus,  and  the  mental  state  are  at  once  readily  recog- 
nised. The  special  symptoms,  when  severe,  present  greater  difficulties, 
and  occasionally  give  rise  to  perplexing  diagnostic  problems.  Not 
less  difficulty  is  presented  by  the  cases  in  which  symptoms  of  hysteria 
accompany  and  complicate  other  diseases.  Slight  organic  disease  may 
be  overlooked  in  the  presence  of  hysteria,  while  the  opposite  error, 
that  of  mistaking  hysteria  for  organic  disease,  is  more  frequent  in  the 
severer  special  manifestations  of  the  functional  malady. 

A  very  important  element  in  the  diagnosis  of  the  special  forms  of 
disease  is  furnished  by  their  conditions  of  origin.  The  patient  is  of 
the  sex  and  age  in  which  the  tendency  to  hysteria  is  strongest,  or,  if  a 
man,  presents  those  nervous  and  somewhat  effeminate  characteristics 
which  usually  accompany  the  disposition  to  the  disease  in  the  male. 
These  considerations  receive  additional  weight  from  the  presence  of 
the  slighter  and  more  constant  indications  of  hysteria  which  have 
been  already  alluded  to.  But  it  cannot  be  too  strongly  insisted  upon 
that  this  element  in  diagnosis,  although  of  great  value,  is  second  in 
absolute  importance.  The  first  and  most  important  consideration  is 
the  absence  of  any  unequivocal  symptom  of  organic  disease.  "Women 
who  suffer  from  other  diseases  of  the  nervous  system  are  frequently 
also  the  subjects  of  hysteria,  and  it  is  clear  that,  in  the  presence  of 
distinct  symptoms  of  organic  disease,  the  evidence  of  hysteria  is  of  no 
significance  as  regards  the  nature  of  the  malady,  and  only  becomes 
significant  when  the  absence  of  evidence  of  such  other  disease  has 
been  ascertained.  The  first  step  in  diagnosis  is  therefore  to  search 
for  any  symptoms  which  indicate  organic  affections,  and  this  involves 
a  knowledge  of  the  diagnostic  symptoms  of  almost  every  other  disease 
of  the  nervous  system,  since  there  is  scarcely  one  which  may  not  be 
simulated  by  this  Protean  malady. 

In  the  absence  of  such  unequivocal  evidence  of  organic  disease,  the 
presence  of  hysteria,  or  of  the  conditions  favorable  to  its  existence, 
becomes  of  important  significance.  It  does  not,  howevei*,  in  itself 
constitute  evidence  that  the  symptoms  are  due  to  this  cause;  the 


1020  HYSTERIA. 

manifestations  of  organic  disease  are  sometimes  in  themselves  equi- 
vocal, and  are  such,  as  may  be  also  produced  by  hysteria.  But,  as  a 
rule,  the  grouping  of  the  symptoms  differs  in  the  two,  and  from  their 
definite  arrangement  and  sequence  a  confident  diagnosis  can  often  be 
made.  Cases  are  occasionally  met  with,  however,  in  which  even  the 
largest  experience  and  the  utmost  diagnostic  skill  are  needed,  and 
may  even  for  a  time  be  baffled. 

Certain  general  characteristics  of  hysterical  maladies  deserve  special 
mention.  Concerning  all  of  them,  it  is  to  be  remembered  that  their 
presence  is  more  significant  than  their  absence.  One  is  the  relation  of 
the  symptoms  to  emotional  disturbance,  alike  in  their  commencement, 
course,  and  manifestation.  They  frequently  follow  a  severe  mental 
shock,  or  are  gradually  evolved  under  the  influence  of  more  persistent 
emotional  disturbance,  and  may  be  intensified  from  time  to  time 
under  the  same  influence.  They  increase  when  the  patient's  attention 
is  directed  to  them,  and  lessen  when  this  is  diverted.  Symptoms 
often  become  greater  during  the  course  of  a  medical  examination. 
Speech,  that  is  at  first  distinct,  becomes  stuttering  and  hesitating,  or 
voiceless ;  limbs  that  are  at  first  relaxed  and  still,  become  rigid  and 
tremulous ;  a  patient  who  at  first  can  stand,  suddenly  sinks  helpless 
to  the  ground.  Symptoms  which  simulate  those  of  organic  disease 
rarely  correspond  closely  to  the  ordinary  type  of  that  which  they 
counterfeit;  some  symptom  exists  in  excessive  degree,  or  is  absent. 

Another  important  indication  is  the  mutability  of  the  symptoms  in 
hysteria.  Grave  troubles  of  one  character  may  suddenly  cease,  and 
give  place  to  other  symptoms  such  as  could  not  result  from  the  same 
organic  cause  as  the  first.  Of  equal  importance  is  the  fact  that  some 
symptoms  of  undoubted  hysterical  character  concur  with,  and  form 
part  of,  a  group  of  disturbances  otherwise  equivocal,  and  give  a  clue 
to  their  character.  For  instance,  a  girl,  in  the  course  of  a  few  hours, 
became  paraplegic,  with  altered  speech  and  attacks  of  spasm  and 
tremor  in  the  limbs ;  the  case  was  regai'ded,  by  some  physicians 
who  saw  her,  as  one  of  acute  spinal  mischief.  But  the  onset  of  the 
svmptoms  was  preceded,  for  some  hours,  by  slow  rhythmical  spasm, 
— alternate  flexion  and  extension  of  the  limbs ;  the  movement  com- 
menced in  one  arm  and  then  gradually  became  universal.  This 
spasm  is  characteristic  of  hysteria,  and  alone  indicated  the  probable 
nature  of  the  disease  ;  confirmed  by  the  absence  of  organic  symptoms. 

At  the  same  time  it  must  not  be  forgotten  that  the  converse  of  this 
holds  good.  Just  as,  on  the  one  hand,  the  occurrence  of  a  character- 
istic hysterical  symptom  may  explain  the  nature  of  other  symptoms, 
in  themselves  equivocal,  so,  on  the  other  hand,  a  single  symptom  of 
organic  disease  may  show  that  equivocal  symptoms  are  not  hysterical. 
For  instance,  a  single  epileptiform  convulsion,  beginning  locally,  may 
prove  that  other  symptoms  (headache,  &c.)  ascribed  to  hysteria  were 
really  due  to  organic  brain  disease.  I  was  once  shown  an  emotional 
young  woman  who  was   supposed  to  be  sufferiug   from   hysterical 


PEOGNOSIS.  1021 

aphonia  and  hysterical  hemiplegia.  A  laryngoscopic  examination 
showed  that  one  vocal  cord  was  completely  paralysed,  the  other 
moving  freely.  Laryngeal  paralysis  due  to  hysteria  is  double  ; 
unilateral  paralysis  is  always  of  organic  origin,  and  the  case  proved 
to  be  one  of  syphilitic  disease  at  the  surface  of  the  medulla  oblongata. 
It  is  unnecessary  to  consider  in  detail  the  diagnosis  of  each  of  the 
forms  of  hysterical  disorder,  since  their  leading  and  characteristic 
symptoms  have  been  already  described,  and  the  diagnosis  rests,  in  each 
case,  on  the  detection  of  these  characters,  and  on  the  general  principles 
just  enunciated.  The  chief  differences  from  the  several  diseases  have, 
moreover,  been  considered  in  the  description  of  the  latter.  The  dis- 
tinction of  the  severe  convulsive  attacks  from  those  of  epilepsy  is 
described  in  the  section  on  the  diagnosis  of  the  latter  disease. 

Prognosis. — In  no  disease  does  the  prognosis,  as  regards  life  and 
recovery,  present  greater  disparity.  The  danger  to  life  from  hysteria, 
even  in  its  most  severe  forms,  is  extremely  small.  Yery  rarely 
exhaustion,  consequent  on  vomiting,  &c,  terminates  in  death,  and  still 
more  rarely  severe  laryngeal  spasm  (or  more  probably  paralysis)  has 
led  to  a  fatal  result.  Other  affections,  however  severe,  are  practically 
devoid  of  danger. 

The  prognosis  as  regards  recovery  varies  with  the  circumstances  of 
the  individual  case,  according  to  the  severity  of  the  disease,  and  to  the 
efficiency  -with  which  appropriate  treatment  can  be  adopted.  As  a 
rule,  the  special  symptoms  of  hysteria  can  be  removed,  but  the  morbid 
state  of  the  nervous  system,  of  which  they  are  the  manifestations, 
persists  in  greater  or  less  degree,  so  that  it  has  been  said  that  complete 
recovery  is  as  rare  as  is  death  from  the  disease  (Jolly).  This  is  an 
exaggeration,  but  it  is  certainly  true  that  medical  skill  can  never,  by 
itself,  secure  recovery,  although,  if  the  patient's  conditions  of  existence 
are  favorable,  if  a  life  of  active  work  and  satisfying  aims  can  be 
substituted  for  the  purposeless  years  which  commonly  succeed  puberty, 
it  is  by  no  means  rare  for  all  traces  of  the  hysterical  temperament  to 
disappear,  and  a  stability  of  character  to  be  developed,  which  can 
endure  even  severe  trials  without  giving  way. 

Of  individual  groups  of  symptoms,  some  are  more  readily  influenced 
by  treatment  than  others.  Motor  paralysis  and  the  slighter  forms  of 
convulsion  are  those  most  easily  removed.  Hysterical  ansesthesia  is 
more  obstinate,  and  usually  persists  long  after  any  accompanying  loss 
of  motor  power  has  passed  away.  The  local  forms  of  spasm,  both 
the  common  contracture  and  the  rare  clonic  spasm,  are  much  more 
enduring,  and  so  also  are  hysterical  vomiting,  local  pains,  and  tender- 
ness, especially  of  the  spine,  and  the  severe  forms  of  hysteroid  con- 
vulsion, which  are  sometimes  even  more  difficult  to  influence  than 
epilepsy  itself.  It  should  be  noted  that  the  hysterical  fits  in  which 
delirium  is  the  most  prominent  feature,  involve  some  danger  of 
insanity.      I  have  more  than  once  known  such  patients  to   become 


1022  HYSTERIA. 

insane.  In  all  conditions  the  general  law  is  true  that  the  prognosis 
is  favorable  in  proportion  as  definite  causes  can  be  traced  and  re- 
moved, especially  deterioration  in  tbe  general  health,  of  remediable 
character. 

Treatment. — The  predisposing  causes  of  hysteria  are  to  some  degree 
avoidable.  The  psychical  condition  from  which  it  springs,  and  in 
which  it  largely  consists,  maybe  in  part  prevented  by  careful  training, 
especially  during  the  transition  from  childhood  to  youth  and  woman- 
hood. The  characters  of  the  training  needed  are  suggested  by  the 
description  of  the  causes  of  the  disease  already  given. 

The  treatment  of  the  developed  malady  is  partly  that  of  the  special 
symptoms,  partly  that  of  the  underlying  condition  which  causes  them. 
The  latter  is  infinitely  the  more  important ;  the  removal  of  special 
symptoms  may  do  nothing  for  the  real  cure  of  the  patient,  and  at  best 
is  but  a  small  step  in  that  direction.  Nevertheless  their  treatment, 
useless  alone,  is  a  valuable  adjunct  to  the  removal  of  their  cause. 

The  causes  of  hysteria  are  partly  moral,  partly  physical;  and  treat- 
ment, to  be  effectual,  must  correspond.  The  success  of  the  measures 
adopted  will  largely  depend  on  a  careful  study  of  each  case,  and  an 
accurate  recognition  of  the  relative  amount  of  physical  and  mental 
disorder. '  The  first  element  in  treatment  is  the  removal  of  whatever 
defect  in  the  general  health  or  local  disorder  of  function  can  be  dis- 
covered. In  very  sevei*e  cases,  and  especially  after  tonics  and  change 
have  been  tried  without  success,  a  method  devised  by  Weir  Mitchell, 
and  extensively  carried  out  in  this  country  by  Playfair,  will  often 
succeed.  It  consists  in  keeping  the  patient  absolutely  at  rest  in  bed, 
and  obtaining  the  tonic  influence  of  exercise  by  daily  massage  and 
electricity — skilled  rubbing  and  kneading  the  muscles,  and  putting 
them  in  action  by  faradism.  At  the  same  time  abundant  food  is 
given  in  an  easily  digested  form.  By  this  method  the  wearying  effects 
of  fatigue  are  avoided,  and  patients  often  gain  flesh  and  colour 
rapidly.  It  must  be  remembered,  however,  that  the  system  is  only 
needed  in  severe  cases,  and  that  the  skilled  rubbing  and  electricity  are 
essential.  Without  these,  rest  in  bed  will  probably  convert  the 
patient  into  a  helpless  invalid.  This  method  has,  however,  another 
use ;  it  affords  an  effective  vehicle  for  moral  treatment.  .For  this 
purpose  the  patient  is  isolated  during  the  course,  except  from  the 
necessary  attendant.  The  isolation  is  not  only  of  great  influence  in 
itself,  but  affords  an  opportunity  for  influencing  the  mind,  and  to  this 
the  unquestionable  success  of  the  treatment  is  largely  due.* 

*  The  details  of  the  treatment  are  described  in  Weir  Mitchell's  books,  '  Fat  and 
Blood '  and  -  Nervous  Diseases  in  Women/  and  by  Playfair, '  The  Treatment  of  Nerve 
Prostration  and  Hysteria,'  1882.  Twenty  years  ago  Russell  Reynolds  ("  On  Para- 
lysis and  other  Disorders  of  Motion  dependent  on  Idea,"  'Brit.  Med.  Journ.,'  Nov. 
6th  1H69,  p.  483)  pointed  out  the  value  of  massage  in  the  treatment  of  these 
palsies. 


TREATMENT.  1023 

Of  organic  derangements  requiring  special  treatment,  those  of  the 
digestive  organs  are  the  most  frequent.  They  need  special  adapta- 
tion of  the  tonic  treatment  and  careful  diet.  Constipation  is  often 
troublesome,  and  may  task  to  the  utmost  the  resources  of  the  physi- 
cian and  the  pharmacopoeia.  It  is  of  the  greatest  importance  to 
secure  daily  action  of  the  bowels,  for  which  moderate  doses  of  aperi- 
ents will  often  suffice,  when  very  large  doses  are  ineffectual  to  over- 
come the  accumulations  of  a  longer  period.  In  obstinate  cases,  in 
which  enemata  have  to  be  employed,  it  is  best  to  combine  these  with 
aperients,  and  the  injection  should  be  given  at  the  time  at  which  the 
medicine  ought  to  act ;  the  two  influences,  thus  united,  will  often  be 
effectual  when  each,  separately,  is  powerless. 

The  ovarian  tenderness  and  pain,  as  a  rule,  need  no  local  treatment ; 
they  are  neuralgic  in  nature,  depending  on  the  general  condition  of 
the  nervous  system,  and  pass  away  with  the  latter.  The  treatment  of 
uterine  derangements  needs  much  judgment  and  caution.  It  has 
been  already  stated  that  uterine  conditions  which  cause  no  obtrusive 
symptoms  have  rarely  any  influence  on  the  disease,  and  they  should 
as  a  rule  be  left  alone.  Both  amenorrhcea  and  menorrhagia  disappear 
when  the  general  health  is  improved.  If  there  are  symptoms  that 
suggest  positive  uterine  disturbance,  such  as  sacral  pain,  "  bearing 
down,"  or  great  menstrual  discomfort,  the  question  of  local" treatment 
has  to  be  entertained.  If  the  patient  is  a  married  woman  it  is  well 
that,  at  the  outset,  the  actual  condition  should  be  ascertained  by  a 
vaginal  examination,  and  any  distinct  derangement  put  right ;  it  being 
remembered,  however,  that  mere  uterine  tenderness  is  often  simply  a 
neurotic  hyperesthesia,  and  is  aggravated  instead  of  being  relieved  by 
local  treatment,  and .  that  even  uterine  displacements  are  not  always 
either  morbid  or  remediable.  If  the  patient  is  unmarried,  local 
treatment,  and  even  a  single  vaginal  examination,  is  often  prolific 
of  indirect  evil,  and  it  is  better,  even  if  the  local  symptoms  are  trouble- 
some, to  see,  first,  the  effect  upon  them  of  the  improvement  of  the 
general  health  and  nerve-state,  and  only  when  this  fails  should  the 
state  of  the  uterus  be  ascertained.  It  is  extremely  doubtful  whether 
any  local  condition,  for  the  discovery  or  treatment  of  which  the 
speculum  is  necessary,  has,  in  the  virgin,  any  influence  on  the  origin 
or  course  of  the  symptoms  of  hysteria. 

The  success  that  has  followed  the  removal  of  both  ovaries  in  very 
severe  and  long-continued  cases  has  been  before  mentioned ;  it  may 
have  been  due  much  more  to  the  indirect  than  to  the  direct  effects  of 
the  operation.  Whether  or  not  this  is  justifiable  in  any  case  is  a 
grave  and  open  question.  It  must  be  remembered  that  there  is  no 
degree  of  the  disease  that  precludes  the  hope  of  great  amelioration  by 
other  means,  and  that  the  operation,  while  it  may  not  lessen  the 
malady,  is  certain  to  have  its  own  serious  consequences. 

The  moral  treatment  of  hysteria,  as  it  is  the  most  important, 
is  also   the   most   difficult;    needing   alike   insight,   ingenuity,    and 


1024  HYSTEK1A. 

perseverance  on  the  part  of  the  physician,  and  making  a  demand  on  the 
patience  and  wisdom  of  the  sufferer  and  her  friends,  which  too  often 
meets  with  so  imperfect  a  response  that  the  best  efforts  are  fruitless. 
In  most  cases  the  conditions  of  home  life  in  which  the  disease  has 
developed  are  not  conducive  to  recovery.  Even  when  the  moral  atmo- 
sphere of  home  does  not  aggravate  the  disease,  its  influence  for  good 
has  probably  been  long  exerted  in  vain,  and  a  wise  change  of  scene  and 
companionship  constitutes  an  important  aid  to  treatment.  In  severe 
cases,  however,  more  than  this  is  needed,  and  it  is  necessary  that  the 
patient  should  be  brought  under  the  moral  influence  of  strangers,  who 
can  combine  tact  in  management,  firmness  iu  control,  and  ingenuity 
in  expedient.  This  influence  may  sometimes  be  found  in  a  family, 
whose  home  life  the  patient  may  share.  This  method,  when  practi- 
cable, is  generally  rapid  and  effectual.  Its  success,  however,  depends 
on  the  person  selected,  who  must  be  cheerful  and  discreet,  and,  if  a 
nurse,  should  possess  at  least  such  education  and  refinement  as  shall 
prevent  annoyance.  The  Weir-Mitchell  treatment  offers,  as  already 
mentioned,  an  alternative  method  of  securing  this  influence. 

The  first  step,  the  separation  of  the  patient  from  her  friends,  is 
usually  the  most  difficult.  Affectionate  relatives  cannot  pei'ceive  the 
wisdom,  much  less  realise  the  need,  for  a  proceeding  which  always  has 
the  aspect  of  harshness,  and  usually  involves  distress  to  the  patient, 
salutary  it  may  be,  but  not  the  less  painful.  As  a  rule  the  more 
prejudicial  to  the  patient  home  influences  are,  the  less  easy  is  it  to 
remove  her  from  them.  Now  and  then  some  secondary  point  in 
treatment  can  be  made  to  justify  the  course  more  readily  than  the 
primary  object.  This  is  the  case  with  the  Weir-Mitchell  treatment, 
in  which  there  is  something  "to  be  done,"  and  An  ostensible  reason 
for  the  removal  of  the  patient.  In  a  severe  case,  if  home  influences 
are  unfavorable,  it  is  wiser  to  decline  to  undertake  treatment  that 
will  probably  end  in  failure,  than  to  have  recourse  to  half-measures. 
These  will  probably  have  no  other  effect  than  greatly  to  reduce  the 
prospect  of  success  fi*om  future  thorough  treatment  of  the  same  kind. 

The  details  of  the  moral  treatment  must  be  varied  according  to  the 
individual  character.  In  every  life  the  forces  differ  by  which  cha- 
racter is  shaped,  and  the  result  is  the  same  in  no  two  persons.  The 
first  aim  of  the  physician  must  be  to  learn  what  those  forces  have 
been,  the  nature  of  the  mind  they  have  moulded,  and  by  what  influ- 
ences its  balance  has  been  disturbed.  The  knowledge  may  be  derived 
from  friends,  from  the  person  to  whose  immediate  charge  the  patient 
is  committed,  or  from  the  patient  herself,  by  ascertaining  her  habitual 
mode  of  life,  her  likes  and  dislikes,  her  tastes  and  occupations,  and 
from  her  account  of  her  own  symptoms. 

The  object  of  moral  treatment  is  to  restore  to  the  will  the  control 
which  it  has  lost.  Sometimes  it  is  motive  that  is  deficient  and  has 
to  be  reinforced,  and  the  influences  employed  must  be  those  to  which 
the  patient's  character  shows  her  to  be  most  amenable.     To  obtain 


TEEATMENT.  1025 

motive  force,  irksome  measures  are  sometimes  necessary,  adopted 
of  course  ostensibly  for  medical  and  not  for  moral  purposes,  and  it  is 
in  these  cases  that  the  Weir-Mitchell  system  is  occasionally  most 
successful.  The  increase  or  relaxation  of  the  strict  treatment  affoi'ds 
an  effective  means  of  punishment  or  reward,  by  which  the  "will 
may  be  stimulated  and  moral  inactivity  dispelled.  In  all  cases 
each  successful  effort  must  be  commended,  and  the  patient  made 
to  realise  the  progress  that  has  been  effected,  and  the  promise  of 
recovery  which  it  supplies.  Care  must,  however,  be  taken  not  to 
push  the  patient  on  too  rapidly.  When  once  the  will  has  been  won 
over,  the  patient  is  apt  to  try  too  much,  and  recovery  from  a  dis- 
couraging relapse  may  be  far  more  difficult  than  was  the  original 
advance.  Power  has  not  only  to  be  evoked  but  consolidated,  and  the 
real  progress  is  often  less  than  that  which  is  apparent.** 

In  many  cases  also  the  art  of  control  over  mind  and  muscle  has 
been  lost,  and  the  will  has  to  be  re-educated  by  slow  and  gradual 
steps.  The  patient  must  be  made  to  realise  that  deliberate  endeavour, 
fruitless  at  first,  will  be  effectual  at  last.  A  direct  effort  to  control 
the  onset  of  a  hysteroid  fit  may  at  first  be  unsuccessful,  but  if  the 
patient  can  learn  by  some  expedient,  such  as  a  sudden  exertion  or  a 
sluice  with  cold  water,  to  keep  off  the  paroxysm,  she  will  gradually 
need  less  and  less  the  adventitious  help,  and  be  able  to  control  the  fit 
by  a  mere  effort  of  the  will.  So  with  paralysis;  a  deliberate  and  well- 
intended  effort  to  walk  may  fail,  but  by  learning  to  stand,  first  with 
support,  then  alone,  and  then  to  walk  with  help,  the  will  slowly  regaius 
its  lost  power.  All  progress  must  be  gradual  to  be  enduring;  haste 
often  causes  a  troublesome  and  disheartening  relapse. 

It  is  perhaps  not  superfluous  to  caution  the  physician  against 
increasing  the  morbid  state  by  any  proceeding  of  his  own.  Attention 
is  a  potent  intensifier  of  the  symptoms  of  hysteria,  and  by  too  fre- 
quent examination  and  demonstration,  certain  phenomena,  such  as 
anaesthesia,  may  be  kept  up,  which  would  disappear  if  disregarded. 
Especially  is  this  caution  necessary  regarding  the  inductiou  of  the 
hypnotic  state  and  of  convulsive  phenomena,  which  is  always  harmful, 
and  sometimes  perpetuates  the  malady. 

Apart  from  the  tonics  already  mentioned,  certain  drugs  have,  for 
many  centuries,  been  held  in  repute  as  powerful  "  antihysterical " 
remedies.  They  are  for  the  most  part  substances  of  nauseous  taste 
(musk,  asafoetida,  valerian,  &c),  and  their  early  use  was  associated 
with  the  theory  that,  by  their  offensive  character,  they  drove  the 
errant  uterus  back  to  its  place.  Although  'by  some  recent  writers 
their  influence  for  good  is  discredited,  they  are  still  largely  employed. 
Most  of  them  undoubtedly  have  a  stimulant  action  on  the  nervous 
system,  which  is  imperfectly  recognised  by  their  designation  as  "  anti- 
spasmodics."     Their  flavour  is  usually  (though  not  always)  most 

*  The  various  points  in  management  are  admirably  discussed  by  Weir  Mitche  1 
(loc.  cit.). 

VOL.  IT.  65 


1026  HYSTERIA. 

distasteful  to  the  patient,  and  the  desire  to  escape  from  the  neces- 
sity of  taking  them  may  constitute  some  stimulus  to  the  will.  This 
indirect  moral  influence  cannot  be  denied,  aud  although  it  is  slight, 
and  may  be  entirely  impotent  against  adverse  circumstances,  yet  it  is 
sometimes  definite.  It  seems  due,  moreover,  in  some  degree,  to  a 
direct  action  on  the  nervous  system,  augmenting  its  functional 
strength.  Distinct  improvement  sometimes  follows  the  use  of  such 
drugs,  even  when  (as  in  hospital  out-patients)  the  patient's  cir- 
cumstances remain  otherwise  unaltered.  Asafcetida,  valerian  (in- 
cluding valerianate  of  zinc),  and  turpentine  are  those  which  have 
been,  in  my  experience,  the  most  useful.  Morphia,  in  doses  of 
_i^.  grain,  is  an  effective  stimulant  when  there  is  much  depression. 
Large  doses  of  opium  were  formerly  given,  but  are  now  little  used. 
Bromides  are  occasionally  of  service  for  insomnia  and  restlessness, 
and  for  mental  disturbance,  but  their  value  in  hysteria  is  not  so  great 
as  their  influence  in  other  diseases  might  lead  us  to  anticipate. 
Narcotics  must  be  employed  only  with  great  caution,  since  the 
tendency  to  their  habitual  use  is  very  strong  in  the  subjects  of 
hysteria,  who  often  take  chloral  or  sulphonal  to  a  harmful  extent. 

Treatment  of  Particular  Symptoms. — The  general  principles  of 
treatment  are  applicable  to  all  cases  of  hysteria ;  the  modifications 
needed  to  suit  the  endless  varieties  of  the  disease  must  be  left  to  a 
large  extent  to  the  common  sense  of  the  practitioner.  Some  special 
symptoms  may,  however,  require  special  measures;  others  will  dis- 
appear when  the  general  disease  is  treated. 

Mere  local  tenderness  of  ovaries,  spine,  &c,  may  usually  be  left 
alone.  Sometimes  its  disappearance  is  facilitated  by  counter-irrita- 
tion, as,  for  instance,  by  repeated  sinapisms,  and  also  by  ruhbing,  at  first 
gentle  and  afterwards  more  firm.  Supports  to  the  spine,  poroplastic 
jackets  and  the  like,  are  better  avoided.  They  may  give  temporary 
relief,  but  the  patient  becomes  dependent  upon  them,  they  cannot 
easily  be  given  up,  and  they  increase  the  difficulty  of  effecting  a 
radical  cure.  The  various  spontaneous  pains  can  rarely  be  left 
without  some  attempt  at  their  relief, — local  application  of  chloro- 
form, counter-irritation,  and  hypodermic  injections  of  simple  water 
of  atropine  or  of  cocaine  are  the  most  useful.  Care  must  be  taken 
to  avoid  increasing  the  amount  of  attention  given  to  the  pain  by  local 
measures.  Patients  should  be  encouraged  to  disregard  it,  and  to 
exert  themselves  in  spite  of  it.  It  is  remarkable  how  much  is  some- 
times endured  in  the  shape  of  counter-irritation,  even  the  actual 
cautery,  by  a  patient  kept  in  bed  on  account  of  hysterical  neuralgia, 
which  is  quickly  forgotten  if  she  can  be  induced  or  compelled  to  get 
up  and  exert  herself  in  some  active  way.  The  various  unpleasant 
sensations  short  of  pain — numbness,  tingling,  and  the  like — need 
only  neglect,  and  hyperesthesia  of  the  special  senses  generally  vanishes 
if  it  is  not  fostered  by  unwise  attention. 

Anaesthesia  also  will  often  pass  away  if  it  is  disregarded  and  is  not 


TREATMENT.  1027 

perpetuated  by  repeated  medical  investigation.  If  its  degree  and 
persistence  render  local  treatment  desirable,  faradisation  with  a  wire 
brusb,  or  sparks  from  a  friction  machine,  are  the  most  effectual. 
Amaurosis  may  be  treated  by  stimulation  of  the  retina  by  a  feeble 
yoltaic  current,  slowly  interrupted.  Los&  of  hearing  and  of  taste  need 
no  special  treatment. 

Hysterical  aphonia  sometimes  yields  at  once  to  exhortation  or  to 
the  introduction  of  the  laryngoscope.  It  can  usually  be  removed  by 
faradism  applied  to  the  exterior  of  the  larynx,  the  patient  being  made 
to  utter  a  sound  during  the  operation.  If  this  fails,  sparks  from  a 
static  machine  may  succeed.  In  obstinate  cases,  faradism  to  the 
interior  of  the  larynx  or  a  circular  blister  round  the  throat,  is  usually 
effectual,  but  I  have  never  found  the  former  necessary.  Aphonia  is 
very  prone  to  relapse  unless  its  removal  is  combined  with  radical  treat- 
ment. In  the  defective  co-ordination  of  the  respiratory  and  laryngeal 
muscles,  Weir  Mitchell  has  found  the  most  effectual  plan  is  to  insist 
on  all  utterances  being  preceded  by  a  deep  inspiration. 

For  paralysis  of  the  limbs,  no  single  remedy  is  so  effectual  as 
faradism.  The  movement  of  the  muscles,  and  the  pain  produced, 
have  often  a  profound  effect.  In  slight  cases  the  full  power  of  move- 
ment may  be  i-estored  by  a  single  application.  More  often  its  use  has 
to  be  repeated,  and  the  effect  is  gradual,  each  application  being  fol- 
lowed by  a  slight  increase  iu  power.  It  is  important  that  the  patient 
should  expect  the  gain  in  power  which  will  follow  its  use.  In  severe 
cases,  the  calls  to  increased  effort  must  be  very  gradual  and  systematic, 
care  being  taken  that  no  attempt  is  allowed  to  fail  entirely,  or  is  pro- 
longed to  fatigue.  In  severe  inco-ordination,  the  power  of  steady 
movement  has  to  be  carefully  and  gradually  trained;  if  necessary, 
first  in  bed  and  then  on  "  all  fours,"  the  erect  position  being  gradu- 
ally assumed.  Great  assistance  is  often  derived,  in  both  ataxy  and 
weakness,  from  a  steady  frame  on  wheels,  or  from  sticks  or  crutches 
which  have  a  concave  handle  for  the  grasp  and  a  large  flat  base, 
eight  inches  by  two,  covered  with  india  rubber,  as  suggested  by  Weir 
Mitchell. 

Contracture  of  limbs  can  sometimes  be  removed  by  an  unfamiliar 
agent  which  produces  a  strong  sensory  and  moral  impression,  such  as 
faradism,  or  static  electricity,  or  a  circular  blister  around  the  limb. 
If  these  fail,  more  gentle  and  continuous  measures  must  be  adopted. 
Violent  physical  force  is  seldom  successful,  and  not  rarely  does  hirm, 
failing  to  relieve  the  symptoms,  and  inducing  other  nerve  troubles. 
Occasionally,  contracture  may  be  removed  by  chloroform,  and  the 
relaxed  limb  fixed  in  some  other  posture  before  the  patient  recovers 
consciousness.  More  permanently  successful,  however,  is  rubbing 
(which  rarely  fails,  for  a  time,  to  lessen  the  contracture),  combined 
with  gentle  passive  movement ;  the  position  of  the  limb  may  be 
slowly  changed  by  means  of  splints.  The  voltaic  current  is  rarely  of 
service.      When  the  contraction   is  lessened,  systematic  voluntary 


1028  HYSTERIA. 

movements  should  be  added.  Many  forms  are  extremely  obstinate, 
and  their  treatment  requires  great  patience  and  perseverance.  Con 
traction  of  the  muscles  of  the  jaw  is  an  exception,  and  generally  dis- 
appears spontaneously  if  disregarded. 

Phantom  tumours  in  the  abdomen  are  best  left  alone.  They  cause 
little  inconvenience,  and  are  often  perpetuated  by  local  treatment. 
Faradism  to  the  muscles  -which  are  relaxed  will  lessen  the  prominence 
during  the  application,  and  this,  somtimes  combined  with  rubbing, 
may  be  employed  if  any  local  treatments  thought  desirable. 

The  tremor-like  forms  of  clonic  spasm  are  merely  accessory  to  the 
weakness  and  contracture,  and  disappear  with  these.  More  violent 
local  s-pnsins  are  often  removed  by  a  circular  blister  around  the  limb, 
but  they  ate  occasionally  extremely  obstinate,  and  resist  all  sym- 
ptomatic treatment,  yielding  only  to  the  radical  amelioration  of  the 
hysteroid  state.  This  is  true  also  of  rhythmical  spasm,  which,  how- 
ever, as  a  rule,  is  more  amenable  to  treatment,  and  is  sometimes 
arrested  by  hypodermic  injection  of  morphia,  atropine,  or  arsenic. 
The  occasional  use  of  morphia  for  such  a  symptom  entails  less  danger 
than  its  employment  for  the  relief  of  pain. 

The  visceral  symptoms  of  hysteria  also  give  great  trouble.  In  ano- 
rexia and  refusal  of  food,  the  patient  must  be  compelled  to  take  liquid 
or  pulpy  food,  and  it  is  often  best  for  the  nurse  to  feed  the  patient. 
If  even  this  is  refused,  the  nasal  tube  may  be  employed,  or  rectal 
injections;  these  operations  are  often  interfered  with  by  the  occur- 
rence of  hysteroid  convulsions,  which  usually  prevent  the  employment 
of  the  stomach-pump.  The  nasal  tube  should  not  be  deferred  too 
long ;  its  moral  effect  is  very  great,  and  may  save  much  further 
trouble.  By  means  of  this,  or  the  oesophageal  tube,  food  may  be  given 
prepared  as  described  below.* 

Hysterical  vomiting  is  often  most  troublesome,  both  on  account  of 
its  ol  stinaey  and  of  the  impaired  nutrition  to  which  it  may  give  rise. 
It  is  best  treated  by  absolute  rest,  liquid  food,  and  the  spare  feeding 
which  rest  renders  adequate.  The  rejection  of  food  should  be  met 
by  judicious  disgust,  and  a  more  liberal  diet  may  be  promised  on  its 
cessation.  Severe  vomiting  is  one  of  the  symptoms  for  the  treatment 
of  which  seclusion  is  most  useful.  "When  other  means  fail,  forced  feed- 
ing by  the  stomach-pump  has  been  successful.  The  avoidance  of  the 
act  of  swallowing  seems  to  have  something  to  do  with  the  retention 
of  food,  since  when  injected  food  has  for  some  time  been  retained, 
that  taken  in  the  ordinary  way  may  still  be  vomited  (Dujardin- 
Beaumetz). 

*  Debove,  who  has  largely  employed  this  forced  feeding,  recommends  that  the 
daily  quantity  should  be  5  piuts  of  milk,  1£  poun  s  of  meat,  12  eggs,  and  the  flour 
of  cooked  and  dried  lentils.  The  raw  meat  is  minced,  warmed,  pressed,  placed  in  a 
stove  and  dried  thoroughly,  and  reduced  in  a  mortar  to  an  extremely  fine  powder. 
The  lentils  should  also  be  cooked  and  then  pounded.  The  whole  is  mixed  with  the 
milk  and  with  tbe  beaten-np  eggs,  and  given  in  four  or  five  injections  into  the 
stomach  ('  Gaz.  ined.  de  Paris,'  1882,  p.  206). 


TREATMENT.  Ilj29 

The  vaso-motor  symptoms  of  hysteria  rarely  yield  to  direct  treat- 
ment. Occasionally  digitalis  lessens  the  palpitation,  and  the  flushings 
and  cardiac  discomfort  are  relieved  by  belladonna ;  but  in  spite  of  the 
apparent  independence  of  these  troublesome  symptoms,  the  radical 
treatment  of  the  disease  is  usually  the  only  means  of  affording  more 
than  temporary  relief. 

The  treatment  of  the  cases  which  present  hysteroid  convulsions 
must  vary  according  to  the  nature  of  the  seizures.  It  has  been  men- 
tioned that  the  attacks,  of  -which  such  convulsions  are  the  conspicuous 
feature,  may  be  really  compound,  consisting  of  a  true  epileptic  fit  and 
of  hysteroid  convulsion  as  a  post-epileptic  phenomenon.  In  such 
cases,  the  treatment  has  to  be  that  for  epilepsy,  and  bromides  do  most 
good.  Where,  however,  there  is  no  real  epileptic  element,  and  the 
attacks  are  purely  hysteroid,  bromides  usually  fail,  and  other  agents 
sometimes  succeed.  Moral  treatment  has  a  great  influence  on  many 
of  these  cases.  The  attacks  often  cease  at  once  when  the  patient  is 
admitted  to  a  hospital.  If  they  do  not,  she  should  be  urged  to 
endeavour  to  control  them.  The  attempt  will  often  be  aided  by  the 
effect  of  drugs  in  render! ug  the  attacks  less  severe,  and  the  patient 
should  be  impressed  with  the  fact  that  attempts  at  control,  which  may- 
have  failed  before,  will,  thus  aided,  be  more  successful.  When  direct 
control  fails,  various  expedients  may  afford  help,  as  cold  water, 
smelling-salts,  &c. 

Drugs  exert  more  influence  on  the  convulsions  than  on  many  of 
the  other  symptoms  of  hysteria.  Those  that  are  most  useful  are 
the  valerianate  of  zinc,  iron,  morphia,  and  turpentine.  Iron  appears 
to  do  good  by  a  special  action  on  the  nerve-centres,  apart  from  its 
haematinic  effect,  and  is  especially  useful  in  the  hysteroid  attacks 
which  occur  in  boys.  Turpentine  may  be  given  in  ten-minim  duses, 
gradually  increased  until  slight  symptoms  of  strangury  are  produced, 
when  it  must  be  omitted  for  a  few  days.  It  is  perhaps  more  useful 
than  any  other  single  remedy. 

The  onset  of  slight  hysterical  seizures,  emotional  in  character,  may 
often  be  averted  by  an  "  antispasmodic  "  draught  of  ether,  lavender, 
&c,  and  sometimes  by  the  inhalation  of  nitrite  of  amyl.  The  de- 
veloped attack  may  also  be  usually  arrested,  although  the  means  most 
effectual  for  this  are  not  the  same  in  all  cases.  A  douche  of  cold 
water  on  the  head  often  succeeds,  but  it  sometimes  needs  to  be  very 
copious  ;  the  first  jugful  may  only  increase  the  violence  of  the  convul- 
sion, and  a  second  may  arrest  it.  When  so  much  water  is  needed,  it 
is  a  clumsy  remedy.  A  few  teaspoonfuls  poured  into  the  mouth,  or, 
if  this  is  closed,  into  the  nostrils,  are  often  at  once  effectual,  appa- 
rently by  stimulating  the  respiratory  centre.  The  same  result  may 
readily  be  effected  by  Dr.  Hare's  plan  of  closing  the  mouth  and  nose 
with  a  towel  for  fifteen  or  twenty  seconds  Sternutatories  usually  fail. 
Auo'.her  method  of  cutting  short  an  attack  is  a  painful  impression. 
If  ovarian  (or  other  hysterogenic)  tenderness  is  known  to  exist,  firm 


1030  TEANCE  AND    CATALEPSY. 

pressure  at  the  spot  will  often  succeed,  but  considerable  force  has  to 
be  employed  to  overcome  the  rigidity  of  the  abdominal  muscles,  and 
tbe  pressure  must  be  maintained  for  several  minutes,  or  the  attack 
■will  recommence. 

Cutaneous  faradisation  is  another  very  effectual  remedy,  and  a 
current  from  a  small  magneto-electric  machine  answers  very  well.  The 
electrodes  may  be  applied  almost  anywhere,  on  the  two  hands,  or  from 
the  neck  to  the  hand ;  a  strong  current  must  be  used.  Where  all  other 
measures  fail,  I  have  found  the  hypodermic  injection  of  a  twelfth  or 
sixteenth  of  a  grain  of  apomorphia  invariably  successful.  It  causes 
vomiting  in  six  or  eight  minutes,  and  with  the  nausea,  which  comes  on 
in  about  four  minutes,  all  spasm  ceases,  and  the  patient  regains 
perfect  consciousness.  In  the  paroxysms  of  laryngeal  spasm,  which 
often  resist  all  other  influences,  apomorphia  is  always  effectual.  If  it 
is  not  at  hand,  nausea  and  vomiting  may  be  induced  by  tickling  the 
fauces.  The  arrest  of  attacks  by  apomorphia  is  not  a  pleasant  pro- 
cess to  the  patient,  and  has  a  powerful  moral  effect  in  lessening  the 
tendency  to  their  occurrence. 


TRANCE   AND  CATALEPSY. 


A  curious  group  of  diseases  have  for  their  characteristic  the  occur- 
rence of  a  state  of  sleep-like  unconsciousness,  which  is  called  "  cata- 
lepsy "  when  it  is  accompanied  by  a  peculiar  plastic  state  of  the 
limbs,  and  "  trance  "  or  "  lethargy  "  when  this  state  of  the  limbs  is 
absent.  These  conditions  are  most  common  in  the  subjects  of  hys- 
teria, but  occur  sometimes  in  states  of  weakness  or  exhaustion  of  the 
nervous  system  when  there  are  no  pronounced  hysterical  symptoms. 
They  may  often  be  induced  by  the  methods  termed  "Mesmerism" 
and  "  hypnotism."  The  conditions  thus  produced  were  long  ago 
studied  by  Braid,  Elliotson,  and  others,  but  the  extraordinary  sus- 
ceptibility presented  by  the  elaborate  hysterics  of  France  has  enabled 
them  to  be  re-investigated  in  a  more  scientific  manner  by  Charcot, 
Eere,  and  others.  These  investigations  have  yielded  many  very 
curious  facts,  the  significance  of  which  is  lessened,  however,  by  the 
extent  to  which  many  of  them  are  the  result  of  a  pathological  educa- 
tion. In  the  case  of  some,  indeed,  this  process  has  passed  beyond  the 
region  of  disease  into  that  of  fraud*  Much  has  been  written  on  the 
subject  during  the  last  few  years,  but  its  practical  importance  in 

*  Of  which  full  particulars  will  bo  found  in  the  articles  of  Mr.  Ernest  Hart, 
"The  New  Mesmerism,"  in  the  'Brit.  Med.  Journ.,'  Jan.  and  Feb.,  1893. 


INDUCED    HYPNOTISM.  1031 

medicine  is  small.  The  phenomena  are  chiefly  important  from  their 
correspondence  with  the  similar  states  that  arise  spontaneously. 
Hence  a  very  brief  outline  of  the  most  important  facts  may  be  given. 


Induced  Hypnotism. 

Three  different  conditions  may  be  produced  in  the  hysterical,  and 
have  been  thus  summarised  by  Charcot  :* 

1.  A  cataleptic  condition  may  arise  under  the  influeuce  of  some  loud 
unexpected  sound  or  dazzling  light,  or  persistent  fixation  of  an  object 
by  the  eyes.  It  may  also  occur  as  a  sequel  to  the  second  form,  the 
state  of  lethargy,  if  the  eyelids  of  the  lethargic  patient  are  raised  in  a 
well- lighted  room.  The  cataleptic  condition  is  characterised  by  rigid 
fixation  of  the  limbs,  with  open  eyes,  a  stiff  look,  and  slow  breathing. 
In  spite  of  the  fixation  of  the  limbs,  they  can  be  moved  passively  with 
great  readiness,  and  remain  in  whatever  posture  they  are  placed  in, 
without  apparent  fatigue.  Very  little  evidence  of  myotatic  irritability 
can  be  elicited,  The  skin  is  completely  anaesthetic,  but  the  organs 
of  special  sense  retain  their  sensibility,  at  least  in  part,  and  through 
their  means  the  subject  can  be  induced  to  perform  automatic  actions 
of  a  more  or  less  complicated  character,  by  imitation,  or  by  the  sug- 
gestions of  description,  but.  when  left  to  herself  relapses  into  the  state 
of  statuesque  rigidity. 

2.  The  lethargic  condition.  A  person  in  the  cataleptic  state  just 
described  may  pass  into  the  lethargic  condition  on  the  occurrence  of  a 
deep  inspiration,  or  the  transition  may  be  induced  by  closing  both  eyes, 
or  by  darkening  the  room.  The  condition  may  be  primarily  induced 
by  prolonged  fixation  of  the  eyes.  In  this  state  the  eyes  are  c'osed  or 
half  closed,  and  the  globes  deviate  upwards  and  inwards.  There  is 
complete  relaxation  of  the  muscles,  and  the  limbs  fall  when  raised. 
Myotatic  irritability  is  greatly  augmented,  and  there  is  an  extra- 
ordinary increase  in  the  mechanical  excitability  of  the  nerves  and 
muscles,  so  that  contraction  follows  not  only  a  tap  on  the  muscles 
but  pressure  on  the  nerves.  A  pointed  object  pressed  on  the  "  motor 
point"  of  a  muscle  will  put  it  in  action  just  as  does  faradism. 
In  the  limbs  and  trunk  tbe  contractions  thus  produced  continue; 
they  may  even  persist  after  the  patient  has  emerged  from  the 
lethargy,  and  can  only  be  removed  by  stimulation  of  the  antagonists. 
In  the  face,  the  contraction  ceases  when  the  pressure  is  discontinued. 
There  is  complete  anaesthesia,  not  only  in  the  skin  but  also  in  the 
organs  of  special  sense.  If  the  eyelids  are  raised  in  a  lighted  room, 
the  lethargy  passes  into  the  first  condition,  that  of  catalepsy,  and  if 
only  one  eyelid  is  raised,  the  change  occurs  only  on  the  corresponding 
side,  so  that  the  two  conditions  co-exist  and  can  be  contrasted. 

*  '  Progres  med.,'  1882,  p.  124;   and  'Lefjons  Mai.  Sys.  Nerv.' 


1032  CATALEPSY. 

3.  The  third  condition  is  termed  somnambulistic.  It  may  develop 
primarily  on  persistent  fixation  of  an  object  by  the  eyes,  or  through 
the  action  of  a  repeated  monotonous  sensory  impression,  and  it  may 
be  produced  also  in  the  condition  of  catalepsy  or  lethargy  by  gently 
rubbing  the  top  of  the  skull.  In  this  condition  the  eyes  are  closed 
or  half  closed  ;  there  is  a  sleepy  look  ;  the  relaxation  of  the  limbs  is 
less  complete  than  in  the  lethargic  condition  ;  mvotatic  irritability  is 
normal,  and  there  is  not  the  hyper- excitability  of  the  nerves  aud 
muscles  that  characterises  the  state  of  letbargy,  but  rigidity  of  the 
limbs  may  be  produced  by  gently  stroking  the  skin,  and  tbere  is  then 
considerable  resistance  to  passive  movement.  Sensibility  is  not  lost, 
and  there  is  an  increased  sensitiveness  to  certain  cutaneous  im- 
pressions. Automatic  actions  of  complex  cbaracter  can  readily  be 
produced  by  example.  This  condition  can  be  made  to  pass  into  the 
letbargic  state,  with  neuro-muscular  hyper-excitability,  by  gentle  pres- 
sure with  the  finger  on  the  eyeballs. 

Similar  phenomena  may  be  produced  in  many  hysterical  patients 
in  this  country.  When  tbe  tendency  to  these  conditions  is  strong, 
the  patients  often  pass  into  them  spontaneously. 


Catalepsy. 

Spontaneous  catalepsy  has  been  met  with  in  both  sexes  and  at  various 
ages,  from  six  to  sixty,  but  it  is  most  frequent  in  the  female  sex  and 
in  early  adult  life.  It  tbus  occurs  chiefly  when  hysteria  is  most 
common,  and  in  most  cases  there  are  other  distinct  symptoms  of  this 
neurosis  ;  when  there  are  not,  the  cause  of  tbe  disorder  is  generally 
such  as  migbt  give  rise  to  an  hysterical  attack.  Nervous  exhaustion 
is  tbe  common  predisponent,  and  frequent  immediate  causes  are  emo- 
tional disturbance,  especially  religious  excitement,  sudden  alarm,  or 
blows  on  the  bead  or  back.  It  occasionally  occurs  in  the  course  of 
mental  affections,  especially  melancholia,  and  has  been  said  to  occur 
in  epilepsy,  but  its  connection  with  the  latter  disease  is  very  doubtful. 
In  an  imperfect  form,  it  has  been  supposed  to  be  a  consequence  of 
malarial  poisoning,  and  has  been  observed  iu  some  toxic  conditions, 
such  as  chloroform  narcosis.  Very  rarely  a  similar  condition  has 
been  met  with  in  the  course  of  acute  organic  diseases  of  the  brain, 
especially  in  meningitis. 

Symptoms. — In  some  cases  headache,  giddiness,  or  hiccough  has 
preceded  the  attack.  The  onset  of  the  special  symptoms  is  usually 
sudden,  commonly  with  loss  of  consciousness.  The  whole  or  part  of 
the  muscular  system  passes  into  a  state  of  rigidity.  The  limbs 
remain  in  the  position  they  occupied  at  the  onset,  as  if  petrified. 
The  muscular  rigidity  is  at  fii-st  considerable,  and  movement  is 
resisted;  but  after  a  short  time  the  limbs  can  be  moved,  and  then 


CATALEPSY.  1033 

remain  in  any  position  in  which  they  may  be  placed.  The  resistance 
to  passive  movement  is  peculiar ;  it  is  as  if  the  limbs  were  made  of 
wax,  and  hence  the  condition  has  been  termed  flexibilitas  cerea.  The 
rigidity  commonly  yields  slowly  to  gravitation.  The  countenance  is 
usually  expressionless.  The  respiratory  movements  and  heart's 
action  are  weakened.  Substances  placed  in  the  back  of  the  mouth 
are  swallowed,  but  slowly.  The  state  of  sensibility  varies  ;  in  pro- 
found conditions  of  catalepsy  it  is  lost  to  touch,  pain,  and  electricity, 
and  no  refbx  movements  can  be  induced  even  by  touching  the  con- 
junctiva. In  other  cases  partial  sensibility  remains,  and  reflex  pheno- 
mena may  be  excited.  In  rare  instances  paroxysmal  hyperesthesia  is 
present.  Consciousness  is  frequently  lost,  but  may  remain  more  or  less 
obscured,  rarely  intact.  The  temperature  is  commonly  lowered.  The 
attack  may  last  a  few  minutes  or  several  hours.  Recovery  is  gradual 
or  sudden ;  it  is  common  for  the  patient  at  first  to  be  unable  to  speak. 
Sometimes  a  strange  periodicity  may  be  observed  in  the  occurrence  of 
the  paroxysms.  In  the  intervals  between  the  attacks,  headache,  gid- 
diness, or  hysterical  manifestations  may  be  present,  or  the  patient  may 
feel  and  seem  perfectly  well. 

Pathology. — In  the  passive  movement  of  a  limb,  the  muscles  have 
their  course  lengthened  or  shortened,  by  the  approximation  or  reces- 
sion of  their  points  of  attachment,  yet  they  remain  in  a  state  of  tonic 
contraction  uniformly  adapted  to  their  shortening  or  elongation.  This 
must  be  the  result  of  adjusted  activity  of  the  motor  cells  of  the  spinal 
cord,  determined  by  the  afferent  impressions  from  the  muscle-nerves, 
the  result  of  increased  or  lessened  tension ;  we  have  seen  (vol.  i)  that 
tension  is  one  of  the  modes  in  which  they  are  stimulated.  If  the 
adjusted  activity  of  the  cells  and  tonic  contraction  of  the  muscles  are 
abnormally  great,  although  varied  in  normal  proportion,  the  state  of 
the  limb  must  be  that  which  exists  in  catalepsy.  We  cannot  be  wrong 
in  assuming  this  mechanism.  But  the  spinal  cells  are  influenced  by 
those  of  the  cerebral  cortex,  which  are  apparently  also  regulated  by 
afferent  impulses  from  the  muscles  (see  vol.  i,  p.  202),  and  it  is  probable 
that  the  over-action  arises  hei'e,  and  that  the  state  of  the  spinal 
mechanism  is  secondary.  This  is  probable,  first  because  no  simple 
excess  of  the  action  of  the  spinal  centres,  known  to  be  such,  gives  rise 
to  the  phenomenon  ;  and  secondly,  because  the  state  can  be  produced 
by  influences  acting  on  the  cortex,  and  disturbing  its  higher  functions. 
The  lower  cortical  centres  seem  to  be  controlled  by  the  higher,  and  the 
control  is  evidently  deficient  in  hysteria,  in  which  catalepsy  especially 
occurs.  A  deficient  control  of  the  motor  centres  of  the  cortex,  per- 
mitting their  over-action,  regulated  by  the  afferent  impulses,  and 
repeated  in  the  spinal  cord,  is  the  best  theory  we  can  at  present  frame 
of  the  process  of  catalepsy. 

The  Diagnosis  of  the  condition  presents  no  difficulty.  Many  cases 
of  simple  trance  have  been  included  under  the  term  "  catalepsy,"  but 


1034  TRANCE 

it  is  better  to  restrict  the  name  to  the  condition  in  which  the  peculiar 
rigidity  exists.  Contracture  of  one  or  more  limbs  may  co-exist  with 
hysterical  trance,  but  the  fixed  rigidity  cannot  be  overcome.  The  pro- 
gnosis is  favorable  in  simple  catalepsy  in  proportion  to  the  freedom, 
during  the  intervals,  from  affections  of  sensibility  or  motion.  In 
pronounced  hysteria  and  psychical  affections,  the  condition  is  often 
obstinate. 

Treatment. — During  the  attack  itself,  little  can  be  done  save  an 
attempt,  which  may  be  repeated  at  intervals,  to  rouse  consciousness  by 
external  stimulation.  The  ordinary  applications,  ammonia  to  the 
nostrils,  cold  douches,  &c,  often  fail.  A  pinch  of  snuff  will,  however, 
often  succeed.  Another  effectual  stimulant  is  faradisrn,  which 
may  be  applied  to  a  limb  or  to  the  back.  The  current  should  be 
gentle  at  first,  and  gradually  increased.  Emetics  are  also  useful  in 
cutting  short  an  attack.  Injections  of  tartar  emetic  into  the  veins 
have  been  used  with  success,  but  can  hardly  be  recommended.  The 
subcutaneous  injection  of  apomorphia,  -^  to  -^  of  a  grain,  is 
a  safe  and  efficient  remedy  for  such  paroxysmal  conditions  (see 
p.  1030).  In  the  intervals  between  the  attacks  the  treatment  is  that 
of  hysteria. 


Trance;  Lethargy. 

Trance  or  lethargy,  as  it  occurs  spontaneously,  is  a  peculiar  sleep- 
like  state,  from  which  the  patient  cannot  be  roused,  or  can  be  roused 
only  imperfectly,  and  which  is  not  due  to  organic  disease  of  the  brain 
or  to  any  poison.  The  morbid  state  in  which  a  patient  has  paroxysmal 
attacks  of  true  sleep,  from  which  he  can  be  completely  roused,  should 
be  distinguished  from  true  trance. 

Causes. — Trance,  like  catalepsy,  occurs  chiefly  in  association  with 
hysteria,  and  has  the  same  general  causation.  But  the  condition  is  rare. 
Briquet  met  with  only  three  instances  among  the  large  number  of  cases 
of  hysteria  he  had  observed.  Only  four  examples  have  come  under 
my  own  notice.  Most  of  the  subjects  are  females  between  twelve  and 
thirty  ;  rarely  it  occurs  in  children  or  young  men  ;  still  more  rarely  in 
adult  men.  Neuropathic  heredity  often  exists ;  the  mother  of  one 
patient,  for  instance,  was  insane.  Among  rare  causes  that  have  been 
described  are  excessive  brain- work,  and  exhausting  diseases  such  as 
typhoid  fever.  Several  cases  have  been  observed  after  influenza. 
Injury  to  the  head  has  sometimes  been  followed  by.it,  apparently 
rather  through  the  emotioual  disturbance  than  through  any  physical 
lesion.  Thus  one  patient,  who  had  an  attack  after  a  blow  on  the 
head,  had  had  similar  attacks  in  connection  with  mental  depression 
(Marduel).     Emotional  disturbance,  or  severe  mental  strain,  is  often 


TRANCE.  .  1035 

the  immediate  excitant,  or  an  attack  may  follow  an  hysterical  convul- 
sion. Weir  Mitchell  has-  described  a  case  in  which  conversation  on 
any  unpleasant  subject  would  bring  on  an  attack.  In  one  celebrated 
case,  that  of  Colonel  Towusend,  the  state  could  be  induced  voluntarily, 
and  in  one  attack  so  induced  he  died.  Voluntary  induction  is  not 
uncommon  in  the  East.  The  production  of  the  state  in  hysterical 
subjects  has  been  already  described. 

A  similar  condition  is  sometimes  observed  in  the  insane,  especially 
in  the  subjects  of  chronic  delusional  insanity.  Sleep,  during  which 
liquids  are  swallowed,  may  last  for  four  or  six  weeks.  Several  such 
attacks  may  be  separated  by  intervals  of  a  few  days  or  a  fortnight. 
They  occur  without  obvious  exciting  cause.* 

Symptoms. — The  onset  of  the  common  form  of  trance  is  usually 
sudden.  In  one  case  that  came  under  my  notice,  a  girl  went  into  a 
room  by  herself,  and  was  found,  shoitly  afterwards,  in  a  state  of 
trance-sleep  that  lasted  forty -eight  hours.  Another  case,  recorded  by 
Madden,  came  on  in  a  similar  manner,  and  lasted  for  a  fortnight. 
The  onset  has  been  occasionally  attended  by  a  sensation  resembling 
the  globus  hystericus.  In  the  cases  after  typhoid,  the  delirium  of 
the  fever  has  passed  into  a  condition  of  comatose  sleep  that  lasted  for 
several  weeks ;  this  sequel  may  be  connected  with  the  marked  mental 
weakness  or  loss  of  speech  that  sometimes  succeeds  this  disease. 
After  influenza,  a  patient  has  suddenly  passed  into  such  trance-sleep, 
and  has  wakened  spontaneously  after  a  few  hours  or  days. 

During  the  trance  state  the  face  is  usually  pale.  The  limbs  are 
relaxed,  as  a  rule,  throughout  the  attack,  but  sometimes  there  has 
been  brief  initial  stiffness,  or  occasional  transient  cataleptic  rigidity ; 
tonic  spasm  and  distinct  hysteroid  convulsions  have  occurred  from 
time  to  time  in  some  cases.  The  eyelids  are  closed,  and  attempts  to 
open  them  are  resisted.  The  eyeballs  are  usually  directed  upwards 
and  to  one  side ;  in  hysterical  trance  they  sorqetirnes  converge.  The 
pupils  are  moderately  dilated  or  contraded,  and  almost  always  act  to 
light.  Reflex  action  in  the  limbs  has  been  lost  in  deep  trance,  increased 
in  slight  cases,  and  cutaneous  stimulation  sometimes  induces  muscular 
contracture.  The  reflex  action  from  the  conjunctiva  and  nose  may 
be  lost,  and  pressure  on  the  ovarian  region,  if  this  was  tender,  may 
have  no  effect.  In  profound  trance  the  mental  functions  seem  to 
be  in  complete  abeyance,  but  in  slighter  degrees  the  patient  may  be 
aware  of  all  that  passes,  although  unable  to  make  even  the  slightest 
manifestation  of  consciousness.  The  special  senses  may  even  be  un- 
naturally acute.  Occasionally  there  is  evidence  of  spontaneous  mental 
action,  analogous  to  dreaming,  manifested  by  exclamations,  and  even 
by  movements;  in  rare  cases  there  is  the  "obedient  automatism."  so 
conspicuous  in  the  induced  trance,  in  which  hallucinations  can  be 
generated,  and  actions  excited,  by  suggestions  made  to  the  patient. 
*  See  Szezypiorski,  'Ann.  med. -psych.,'  Nov.,  1891. 


1036  TfiANfiE. 

The  pulse  is  small  and  the  sounds  of  the  heart  are  weaker  than 
normal,  and  have  even  been  scarcely  audible.  Its  frequency  may  be 
normal,  increased,  or  lessened ;  in  one  case  it  fell  to  40  per  minute 
(Weir  Mitchell).  The  respiration  may  present  similar  changes,  and 
may  become  so  gentle  and  deliberate  as  to  be  scarcely  perceptible  ;  it 
is  said  that  even  a  mirror  over  the  mouth  may  be  undimmed.  Rhyth- 
mical variations  have  been  observed.  The  temperature  is  normal  in 
the  central  parts,  lowered  in  the  periphery.  Urine  may  be  retained 
in  the  bladder  or  passed  into  the  bed.  Thus  the  extreme  degree  of 
trance  may  involve  such  a  depression  of  Jbhe  vital  functions  that  the 
patient  may  seem  to  be  dead.  This  state  has  been  called  "  death- 
trance,"  and  has  furnished  the  theme  for  many  a  sensational  story, 
but  the  most  ghastly  incidents  of  fiction  have  been  rivalled  by 
authenticated  facts.  During  the  recent  influenza  epidemic,  the  pre- 
parations were  advanced  for  the  funeral  of  a  man  who  had  passed 
into  this  condition  ;  just  before  it  was  too  late,  signs  of  life  were 
observed. 

The  duration  of  trance  has  been  a  few  hours,  a  few  days,  or  several 
weeks.  Rarely  it  has  been  said  to  last  for  many  months.  In  cases 
that  last  more  than  a  few  days,  there  are  remissions  in  which  the 
patient,  half  awake,  will  take  food  and  then  relapse  into  stupor.  In 
cases  of  long  duration  the  trance  after  a  time  gets  less  profound. 
The  termination  is  often  marked  by  sighing  breathing,  and,  if  sudden, 
may  be  accompanied  by  vaso-motor  disturbance,  and  even  by  extrava- 
sations into  the  skin.  In  one  case  of  death-trance  it  is  said  that  the 
preparations  for  fastening  down  the  comu-lid  caused  a  copious  sweat 
to  break  out.  After  prolonged  trance  has  passed  away,  profound 
nervous  prostration  remains  for  a  time,  sometimes  with  mental  dul- 
ness.  The  condition  may  recur,  even  many  times.  A  soldier  slept 
for  seventy  or  eighty  hours  on  six  occasions  during  the  course  of  two 
years  (Marduel).  Most  cases  end  favorably.  The  extreme  depression 
of  the  vital  functions  seems  to  enable  life  to  be  maintained  for  a  long 
time  on  a  very  small  amount  of  nourishment.  A  few  cases  of  death 
are  on  record;  in  one  of  these  the  trance  succeeded  typhoid  fever. 

Pathology. — No  changes  have  been  found  after  death  to  explain 
the  nature  of  trance,  which  is  as  mysterious  as  is  that  of  ordinary 
sleep.  It  cannot  be  explained  by  the  assumption  of  mere  cerebral 
anajtnia,  for  this  may  be  profound  without  trance,  and  the  signs  of 
vascular  depression  commonly  succeed  the  onset.  The  phenomena, 
viewed  iu  the  light  of  the  induced  varieties,  suggest  rather  a  .state  of 
inhibition,  or  at  least  inaction,  of  the  nerve-cells  subserving  the  higher 
psychical  functions,  and  that  the  morbid  state  spreads  to  lower  centres 
in  varying  degree. 

Diagnosis. — The  diagnosis  of  trance  rests  on  the  impossibility  of 
rousing  the  sleeper,  combined  with  the  absence  of  any  evidence  of  a 


TBAXCE.  1037 

local  cerebral  lesion  or  a  toxic  cause.  Other  diagnostic  symptoms  are 
the  pallor  and  vascular  depression,  the  occurrence  of  convulsive 
phenomena  of  hysteroid  type,  and  the  previous  existence  of  other 
manifestations  of  hysteria.  These  symptoms  sufficiently  distinguish 
trance-sleep  from  apoplexy,  for  "which,  at  the  onset,  it  is  sometimes 
mistaken.  The  distinction  from  catalepsy  rests  on  the  muscular 
relaxation. 

In  cases  of  "  death-trance,"  in  -which  no  sign  of  vitality  can  be 
recognised,  the  presence  of  life  may  be  ascertained  (1)  by  the  absence 
of  any  sign  of  decomposition;  (2)  by  the  normal  appearance  of  the 
fundus  oculi  as  seen  with  the  ophthalmoscope;  (3)  by  the  persistence 
of  the  excitability  of  the  muscles  to  electricity.  This  excitability  dis- 
appears in  three  hours  after  actual  death.  In  a  case  observed  by 
Eosenthal,  thirty  hours  after  supposed  death  the  muscles  "were  still 
excitable,  and  in  forty-four  hours  the  patient  awoke. 

Prognosis. — In  most  cases  of  lethargy  the  ultimate  prognosis  is 
good.  The  slighter  the  degree  of  the  trance  the  shorter  is  likely  to 
be  its  duration.  The  prognosis  is  grave  only  when  the  lethargy  has 
been  preceded  by  a  state  of  great  physical  depression,  especially  when 
the  condition  has  succeeded  an  acute  disease. 

Treatment. — The  treatment  has  to  be  directed  to  two  ends ;  the 
maintenance  of  life,  and  the  arrest  of  the  trance.  Advantage  must  be 
taken  of  any  intervals  of  semi-consciousness  to  give  nourishment  in  a 
concentrated  form.  If  swallowing  is  continuously  impossible,  food 
must  be  given  by  the  nasal  tube,  or  by  enemata.  Warmth  should  be 
applied  to  the  extremities,  and  care  taken  to  prevent  bedsores.  In 
severe  cases,  every  attempt  at  arrest  is  often  fruitless.  In  cases  of 
moderate  severity  stimulation  of  the  skin  is  effective  in  rousing  the 
patient.  The  most  powerful  cutaneous  excitant  is  strong  faradism. 
In  one  case,  which  had  lasted  for  thirty-six  hours,  I  found  that  (he 
application  of  strong  faradism  to  the  arm  quickly  cut  short  the  trance. 
In  another  case,  which  lasted  for  several  months,  this  treatment  had 
for  a  long  time  no  influence ;  afterwards  the  patient  could  be  partiallv 
roused  for  a  short  time  by  faradism,  and  by  repeating  the  application 
at  the  same  hour  every  day,  a  tendency  to  periodical  waking  was 
established,  the  i*emissions  became  longer  and  more  complete,  and  the 
attack  was  ultimately  brought  to  an  end.  Nervine  stimulants,  such 
as  ether  and  valerian,  may  be  given  by  the  bowel,  or  sulphuric  ether 
may  be  injected  subcutaneously.  Alcohol  must  be  given  with  caution 
and  in  small  quantities;  enemata  of  strong  coffee  are  often  more 
useful.  It  is  probable  that  nitro-glycerine,  or  the  inhalation  of 
nitrite  of  amyl,  would  have  considerable  influence.  Transfusion  of 
blood  has  been  proposed,  and  would  be  justified  in  cases  following  ex- 
hausting disease  when  death  is  threatened.  The  recurrence  of  attacks 
must  be  prevented  by  the  improvement  of  health,  physical  and  moral. 


1038  TRANCE    AND    CATALEPSY. 

Narcolepsy. — The  term  "  narcolepsy  "  has  been  used  in  several 
senses,  but  is  best  applied  to  a  condition,  for  which,  some  name  is 
need  eel,  in  which  there  is  a  tendency  to  fall  into  sound  sleep  for  a 
short  time,  usually  for  a  few  minutes,  rarely  for  -an  hour  or  more. 
The  condition  is  distinguished  from  trance  by  the  brevity  of  the 
attacks  of  sleep,  by  their  strong  tendency  to  recur,  and  by  the  fact 
that  the  patient  can  commonly  be  roused  at  any  time  from  the  condi- 
tion. In  some  cases,  the  malady  has  keen  apparently  the  result  of 
some  peculiarity  of  the  nervous  system.  Thus,  in  one  recorded  case, 
a  man  had  been  liable,  all  through  his  life,  to  such  attacks  of  sleep, 
which  were  induced  by  most  varied  influences.  He  had  a  nasal 
fistula,  and  whenever  a  probe  was  passed  down  this,  he  fell  asleep. 
In  other  cases  the  affection  comes  on  in  adult  life,  and  passes  away 
after  lasting  for  a  few  months  or  yeai*s.  Thus  in  one  girl,  the  attacks 
commenced  at  sixteen,  and  continued  till  she  came  under  treatment 
at  twenty-two.  She  would  suddenly  feel  drowsy,  her  eyelids  drooped, 
in  a  moment  she  was  sound  asleep,  and  after  about  five  minutes 
woke  up  quite  fresh.  Intensely  vivid  dreams  accompanied  the  sleep, 
but  she  never  could  recall  their  details ;  sometimes  she  would  speak 
aloud  in  the  dream.  There  was  no  change  in  the  colour  of  the  face. 
After  deficient  sleep  at  night,  the  sleep  attacks  lasted  longer,  some- 
times even,  half  an  hour.  She  could  be  readily  waked  at  any  time, 
and  by  an  effort  could  keep  off  the  attack,  but  then  could  not  help 
yawning  continually,  and  felt  uncomfortable.  There  was  never 
headache.  Such  attacks  occurred  four  or  five  times  a  day,  when  she 
was  engaged  in  sedentary  occupations  or  studies,  but  when  she  led  an 
active  life,  as  on  a  holiday,  they  would  be  absent  for  two  'or  three 
weeks. 

The  characters  that  separate  this  affection  from  ordinary  trance 
have  been  already  mentioned.  It  is  most  likely  to  be  confounded 
with  minor  epilepsy,  but  from  this  it  is  sharply  distinguished  by  the 
perfect  resemblance  of  the  attacks  to  ordina.y  sleep  in  their  onset  and 
character.  "When  a  feeling  of  somnolence  is  the  warning  of  an  attack 
of  true  petit  mal,  the  unconsciousness  lasts  only  a  few  moments.* 
An  active  life  with  change  of  scene  is  probably  the  most  important 
element  in  treatment.  In  the  case  mentioned  above,  no  drugs  did  so 
much  good  as  a  combination  of  caffeine  and  nitro-glycerine,  which 
almost  entirely  arrested  the  attacks. f 

*  The  term  "  narcolepsy "  has  been  unwisely  applied  also  to  such  epileptic 
attacks. 

f  Some  forms  of  lethargic  sleep  have  been  distinguished  as  "Gayet's  disease"  (a 
rare  form,  fatal  in  a  few  months,  somewhat  like  African  lethargy),  "  Gerlier's  disease  " 
(summer  somnolence  among  the  Swiss),  and  "Wernicke's  disease,"  in  which  sleep 
has  betn  the  result  of  acute  inflammation  of  the  nuclear  grey  matter  beneath  the 
corpora  quadrigemina.  The  fact  that  gradually  deepening  coma  may  be  due  to  such 
an  organic  lesion  does  not  justify  the  ascription  of  all  forms  of  lethargy  to  such  a 
process  (Mauihner,  '  Wien.  Gesellsch.  der  Aerztes,'  May,  1890). 


AFRICAN  LETHARGY.  1039 

African  Lethargy. — A  curious  malady,  presenting  similar  somno- 
lence but  of  very  different  nature,  is  the  "  sleeping  sickness  "  of  the 
West  Coast  of  Africa,  met  with  cLiefly  in  the  Congo  and  Sierra  Leone 
regions.  It  is  said  to  prevail  less  at  the  coast  than  inland,  and  to  be 
especially  severe  in  the  valley  of  the  Congo.  It  affects  exclusively 
negroes  (by  whom  it  is  much  dreaded),  and  occurs  in  both  sexes  and 
at  all  ages,  but  is  most  frequent  in  males  between  twelve  and  twenty. 
Except  that  depressing  emotions  seem  to  predispose  to  it,  the  proxi- 
mate causes  are  entirely  unknown.  Europeans  living  in  the  same 
localities  are  exempt.  Swelling  of  the  cervical  glands  sometimes 
occurs  at  the  onset,  and  they  are  excised  by  the  native  doctors  as  a 
remedial  measure;  but  the  condition  is  not  invariable,  and  its  influ- 
ence is  doubtful.  The  general  health  at  first  is  good.  There  is  a 
gradually  increasing  tendency  to  somnolence,  and  the  patient  will  fall 
asleep  at  various  and  unusual  times,  at  his  work  or  over  his  meals. 
A  tendency  to  persistent  drooping  of  the  upper  lids  sometimes  occurs 
at  the  onset.  At  first  he  can  be  roused,  and  if  treated  by  cutaneous 
stimulation  and  purging,  the  symptoms  may  be  removed  for  a  little 
time,  but  they  soon  recur  and  increase  in  spite  of  treatment ;  the 
periods  of  sleep  grow  longer  and  more  frequent  until  the  patient  is 
always  asleep,  is  reduced  to  a  merely  "  vegetative "  existence,  and 
ultimately  cannot  be  induced  to  take  food.  He  gradually  emaciates, 
and  dies  at  the  end  of  three,  six,  or  twelve  months  from  the  onset  of 
the  symptoms.  Just  before  death  the  disposition  for  sleep  often 
ceases.  The  disease  is  extremely  fatal.  Guerin  met  with  148  cases, 
all  of  which  died.  The  observations  of  Gore  and  others  place  the 
mortality  somewhat  lower — at  about  80  per  cent.  Post-mortem 
examination  has  revealed  only  hypersemia  of  the  arachnoid,  slight 
signs  of  chronic  meningitis,  but  no  considerable  excess  of  fluid  within 
the  ventricles  or  outside  the  brain.  The  cerebral  substance  is  usually 
pale  Filaria  sanguinis  has  once  been  found  in  the  blood,*  but  appa- 
rently only  as  a  coincidence.  In  some  cases  with  organic  brain  disease, 
it  would  seem  as  if  the  symptoms  had  acquired  a  special  character  from 
the  cause  of  the  lethargy,  whatever  it  is.  Poisoning  by  a  fungus 
growing  on  cereals  has  been  suggested,  but  the  malady,  once 
established,  progresses  steadily  in  spite  of  change  of  residence  and  of 
diet.  No  treatment  appears  to  influence  the  symptoms.  Only  one 
observer  (McCarthy)  has  seen  good  from  excision  of  the  cervical 
glands.  This  mysterious  affection — mysterious  in  more  respects  than 
are  recognised  by  those  who  have  theorised  about  it — clearly  needs 
more  systematic  investigation  than  it  has  yet  received. f 

It  is  clear,  moreover,  that  a  tendency  to  somnolence,  increasing  gradu- 
ally to  lethargy  and  coma,  is  the  expression  of  morbid  blood-states  more 

*  S.  Mackenzie,  «  Lancet,'  1890. 

f  The  most  recent  account  of  the  disease  is  by  Junker  v.  Langegg,  *Wien.  med. 
Wochenschr ,'  1891. 


1040  HYPOCHONDRIASIS. 

often  in  tropical  countries  than  in  temperate  regions.  Such  cases 
have  been  observed  in  South  America,  attended  with  pyrexia,  with 
only  trifling  secondary  changes  in  the  brain,  but  with  the  enlarge- 
ment of  the  spleen  that  shows  a  morbid  state  of  the  blood.  The 
symptoms  of  these  cases  differ,  in  essential  particulars,  from  the 
African  malady. 


HYPOCHONDRIASIS. 


Hypochondriasis  is  a  morbid  state  of  the  nervous  system  in  which 
there  is  mental  depression  due  to  erroneous  ideas  of  such  bodily 
ailments  as  might  conceivably  be  present.  This  limitation  is  neces- 
sary to  distinguish  the  condition  from  those  forms  of  actual  insanity  in 
which  there  is  a  delusion  of  the  existence  of  some  impossible  ailment 
— impossible  either  in  its  nature  or  else  by  reason  of  its  incom-' 
patibility  with  life.  A  patient,  for  instance,  who  thinks  that  his 
spinal  cord  has  become  detached  from  the  brain,  or  who  believes  that 
his  throat  is  hermetically  closed,  is  insane,  not  hypochondriacal.* 
The  term  is,  moreover,  almost  exclusively  applied  to  the  condition 
above  defined  when  this  is  met  with  in  men.  A  similar  state  in 
females  is  regarded  as  forming  part  of  "  hysteria."  The  name  has 
come  down  to  us  from  the  times  of  Hippocrates  and  Galen,  and,  like 
"  melancholy,"  had  its  origin  in  the  idea  that  the  conscious  life  was 
largely  influenced  by  "  vapours,"  &c,  produced  in  the  abdominal 
organs.  It  was  not  until  the  early  part  of  the  present  century  that 
the  disease  was  generally  admitted  to  be  one  of  the  brain.f 

Causes. — The  affection  consists  in  a  particular  disposition  of  the 
brain,  which  leads  to  habitual  anxiety  without  adequate  cause,  and  to 
the  concentration  of  this  anxiety  on  the  individual's  own  health. 
This  morbid  tendency  is  often  a  matter  of  individual  temperament, 
which  may  be  the  result  of  neurotic  inheritance ;  the  most  severe 
forms  occur  in  persons  whose  family  presents  a  tendency  to  insanity. 
In  other  cases  there  is  no  morbid  heredity,  but  the  state  is  acquired 
through  persistent  ill-health,  which  sets  up  the  morbid  mental  habit 
of  self- attention  and  concern.  These  two  causal  varieties  may  be 
termed  the  "acquired"  and  the  "temperamental"  forms.  The  age 
at  which  hypochondriasis  comes  on  varies  according  to  its  causes.  It  is 
scarcely  known   in   childhood,  but  when  due  to  inherited   tempera- 

*  It  is  unfortunate  that  alienists  sometimes  apply  the  term  to  the  cases  of  insanity 
with  somatic  delusions;  this  is  contrary  to  its  customary  use,  and  productive  of  con- 
fusion. 

f  An  interesting  sketch  of  the  history  of  hypochondriasis  is  given  in  Gull  and 
Anstie's  article  on  the  disease  in  Reynolds'  'System  of  Medicine,'  vol.  ii. 


SYMPTOMS.  1041 

rnent  it  often  becomes  established  quite  early  in  adult  life,  and  some- 
times is  even  distinct  in  youth.  It  may,  however,  commence  at 
any  period,  and  the  acquired  form  often  commences  in  or  after 
middle  age. 

Hypochondriasis  seldom  develops  without  some  exciting  cause  in 
the  shape  of  a  distinct  bodily  ailment,  although  this  is  often  very 
trifling  in  degree.  It  suffices,  however,  to  give  rise  to  unpleasant 
sensations,  which  excite  attention  and  give  rise  to  concern.  Dyspeptic 
troubles  are  the  most  common  excitants  ;  others  are  palpitation  of  the 
heart,  and  weaknc  ss  of  the  nervous  system  ;  but  there  is  hardly  any 
part  of  the  body  in  which  functional  disturbance  may  not  be  the 
starting-point  of  the  malady.  When  the  attention  has  once  become 
fixed  on  a  bodily  sensation,  and  this  has  become  the  basis  of  a  fancied 
malady,  other  feelings  elsewhere  are  soon  perceived ;  corresponding 
ailments  are  imagined,  and  any  trifling  disorder  is  magnified  into 
a  serious  disease. 

Symptoms. — In  hypochondriasis  there  are  three  chief  elements : 
excessive  anxiety  regarding  the  personal  health ;  undue  attention 
to  any  indications  of  derangement,  especially  to  the  various  sen- 
sations emanating  from  the  organs  of  the  body ;  and  lastly,  as  the 
consequence  of  these,  there  is  some  false  idea  that  disease  is  present 
which  does  not  exist.  Occasionally  the  last  is  absent ;  the  patient 
may  know  and  realise  that  he  is  free  from  any  serious  malady,  but  he 
is  rendered  miserable  by  the  continuous  discomfort  he  experiences. 

This  discomfort,  as  already  stated,  often  has  its  origin  in  some 
actual  disorder,  but  it  is  always  vastly  increased  by  the  habitual  atten- 
tion paid  to  the  sensory  impressions  proceeding  from  the"  organ 
deranged,  or  from  other  parts  when  there  is  no  local  disorder.  The 
influence  of  attention  has  been  already  mentioned  in  the  account  of 
"  cephalic  sensations  "  (p.  863),  which  often  form  part  of  the  symptoms 
of  hypochondriasis,  and  the  statements  thei-e  made  are  applicable  to 
all  the  various  sensory  impressions  from  other  organs  that  disturb 
the  hypochondriac's  life.  It  is  this  continuous  attention  that  per- 
petuates the  morbid  state,  and  renders  its  treatment  so  difficult.  'Not 
only  are  sensations  attended  to  until  consciousness  is  continuallv 
under  their  influence,  but  the  patient  is  always  searching  for  indica- 
tions of  the  ill-health  he  dreads.  He  scrutinises  his  tongue  before 
breakfast  and  his  evacuations  after  breakfast,  and  notes,  during  the 
day,  the  influence  of  each  meal  on  his  abdominal  feelings,  of  exertion 
on  his  pulse,  and  of  mental  work  upon  his  head.  It  is  easy  for  the 
hypochondriac  thus  to  collect  each  day  a  series  of  "  symptoms  "  which 
he  ponders  over,  endeavours  to  interpret,  and  sometimes  records,  in 
minute  detail,  in  a  diary.  As  an  instance  of  this  morbid  self-observa- 
tion and  attentive  regard  to  every  real  or  fancied  sensation,  I  may 
quote  verbatim  the  description  given  to  me  by  one  of  these  unfortunate 
sufferers,  in  whose  physical  condition  no  other  flaw  could  be  found 

vol.  ii.  66 


1042  HYPOCHONDRIASIS. 

than  trifling  occasional  indigestion.  "I  do  not  breathe  free;  I  do 
not  breathe  clear.  After  I  did  my  work  yesterday  there  was  a  pain 
in  my  temples  and  in  the  back  of  my  head.  There  is  a  little  pain  in 
the  heel  when  I  press  upon  it.  I  have  a  sensation  of  tightness  round 
the  sides  of  the  chest.  I  have  also  felt  slight  tightness  about  the 
knees.  The  appetite  is  not  the  thing  at  all.  There  is  slight  disten- 
sion ;  I  have  not  found  it  to-day,  but  I  did  yesterday.  Last  night  I 
felt  the  food  in  my  throat,  and  a  noise  in  the  chest  such  as  you  feel 
in  the  ear.  My  head  is  hot  on  the  top  now.  Talking  even  for  a  few 
minutes  seems  to  affect  the  eyes,  and  an  uncomfortable  feeling  comes 
in  them.  This  morning  in  the  train,  too,  after  it  stopped,  I  seemed 
to  feel  for  a  moment  as  if  I  was  going  backwards  and  forwards.  My 
forehead  gets  hot  when  I  talk.  Some  days  ago  I  had  an  uncomfort- 
able feeling  in  the  loins,  and  afterwards  in  the  bowels,  and  a  week 
ago  I  had  some  pain  in  the  armpit."  This  patient  had  no  false  idea 
of  local  illness;  his  symptoms  were  too  vague  and  varying  to  permit 
him  to  entertain  the  idea,  but  it  was  impossible  to  convince  him  that 
there  was  not  some  grave  general  derangement  of  his  health.  In  the 
subjects  of  the  temperamental  form,  with  neurotic  heredity,  there 
is  often  slight  real  derangement  of  the  nervous  system,  headaches, 
neuralgic  pain,  vague  giddiness,  noises  in  the  ears,  sensations  of 
weakness  of  the  legs,  &c,  which  keep  up  the  mental  state.  Similar 
troubles  occasionally  characterise  also  the  acquired  form,  especially 
in  gouty  subjects. 

In  many  cases,  moreover,  slight  derangement  of  the  functions  of 
some  one  organ  constitutes  an  anchor  for  anxiety;  attention  is  focussed 
on  the  local  sensations  so  that  they  attain  an  ever-growing  intensity, 
and  the  conception  of  a  definite  ailment  becomes  fixed,  sometimes 
ineradicably.  In  some  instances  the  idea  has  its  origin  not  so  much 
in  the  sensations  of  the  patient  himself,  as  in  the  fact  that  circum- 
stances have  brought  the  disease  prominently  under  his  notice.  This 
influence  is,  indeed,  often  operative  when  there  is  no  persistent  hypo- 
chondriasis. Most  medical  students  imagine,  at  some  period  of  their 
career,  that  they  are  the  subjects  of  heart  disease.  But  the  study  of 
medicine  provides  the  antidote,  as  well  as  the  bane,  to  all  healthy 
minds.  With  mental  instability,  however,  an  idea  often  becomes 
firmly  rooted.  An  elderly  man  believed  himself  to  be  the  subject  of 
diabetes,  from  which  a  friend  had  died,  and  he  persisted  in  his  belief, 
in  spite  of  the  assurance  that  there  was  no  sugar  in  his  urine. 

The  subjects  of  this  disorder  may  have  the  appearance  of  perfect 
health,  but  those  in  whom  the  condition  is  of  long  duration  are  often 
caieAvorn  and  depressed  in  aspect,  and  are  preoccupied  in  manner. 
Their  sufferings  are  described  in  language  that  is  obviously  exaggerated. 
The  amount  of  depression  is  often  very  great,  but  in  cases  of  pure 
hypochondriasis  there  is  scarcely  ever  the  suicidal  tendency  common 
in  melancholia.  Many  sufferers  indeed  are  nervous,  timid  persons, 
who  dread  illness  both  for  its  own  sake  and  as  a  possible  path  to  the 


DIAGNOSIS.  1 043 

grave.  Occasionally,  a  temperamental  hypochondriac  may  be  met 
with  who  describes  life  as  shorn  of  all  pleasure  by  his  sufferings,  and 
asserts  that  he  has  suicidal  impulses ;  but  if  the  latter  really  exist, 
there  is  generally  more  than  pure  hypochondriasis. 

To  describe  in  further  detail  the  symptoms  of  these  cases  would  be 
merely  to  multiply  particular  illustrations  of  the  general  facts  above 
stated.  There  is  hardly  a  maladj^  that  is  not  at  times  the  subject  of 
the  morbid  fancy.  The  general  facts  are  true  of  all ;  it  is  only  tbe 
applications  that  vary.  One  class  of  cases,  however,  commonly 
included  in  this  category,  deserves  special  mention,  the  cases  of 
sexual  hypochondriasis.  Most  of  those  who  wrongly  imagine  that 
they  have  some  ailment  of  the  sexual  organs  do  not  really  suffer  from 
hypochondriasis.  This  erroneous  belief  is  justified  because  it  is 
founded  on  evidence  which  is  adequate  to  cause  the  belief  in  those 
who  have  no  means  of  estimating  its  value.  The  idea  of  spermator- 
rhoea, however,  sometimes  does  concentrate  the  attention  on  sensa- 
tions from  those  parts,  and  may  set  up  true  hypochondriasis,  by  the 
tendency  to  attribute  to  the  supposed  disease  any  discomfort  that 
may  be  experienced.  But  there  is  no  such  disease  as  spermatorrhoea. 
The  slow  escape  of  the  continuous  secretion  from  the  testicles  is  a 
normal  and  necessary  event;  neither  it,  nor  the  process  of  secretion, 
has  the  slightest  influence  on  the  nervous  system. 

Diagnosis. — The  diagnosis  of  hypochondriasis  depends,  in  the  first 
place,  on  the  exclusion  of  the  disease  from  which  the  patient  imagines 
that  he  is  suffering.  This  of  course  involves  an  accurate  knowledge 
of  the  symptoms  of  each  malady,  and  it  is  necessary  to  exclude  real 
disease  before  the  obvious  mental  state  can  be  allowed  to  influence 
the  diagnosis.  The  danger  that  a  mistake  of  this  character  should  be 
made  depends  on  two  circumstances.  The  first  is  the  neglect  of  the  con- 
sideration j\ist  mentioned  ;  the  manifest  temperament  leads  to  a  hasty 
diagnosis,  and  deters  from  thorough  examination.  It  is  obvious  that 
hypochondriasis  does  not  exclude  organic  disease,  and  that  hypochon- 
driacs not  only  may,  but  at  some  time  must,  suffer  from  such  disease. 
Secondly,  error  is  sometimes  due  to  the  fact  that  the  patient 
suffers  from  some  uncommon  malady,  the  symptoms  of  which  are 
unfamiliar  or  unexpected.  Thus  a  man  with  very  distinct  sym- 
ptoms of  diphtheritic  paralysis  had  been  told  that  these  were  all  due 
to  nervousness  and  fancy,  because  the, patient  was  a  member  of  the 
medical  profession,  the  diphtheria  had  been  doubtful,  and  it  had  been 
acquired  in  an  unusual  way — by  inoculation. 

The  other  diagnostic  question  is  the  distinction  of  hypochondriasis 
from  insanity.  It  is  in  the  permanent  hypochondriac,  with  a  family 
history  of  insanity,  that  this  difficulty  arises.  The  distinction  depends 
chiefly  on  the  reasonableness  of  the  false  ideas.  A  patient  who  has 
unpleasant  sensations  in  the  abdomen,  and  believes  that  he  is  suffering 
from  cancer,  in  spite  of  the  assurance  that  he  is  n«->t   cannot  on  this 


1044  HYPOCHOXDKIASIS. 

account  be  regarded  as  insane.  But  a  man  who  believes  that  his 
brain  has  been  converted  into  sawdust  is,  by  that  belief,  proved  insane. 
Of  course  pure  hypochondriasis  may  co-exist  with  other  independent 
evidence  of  insanity,  just  as  it  may  with  any  other  malady.  Many 
cases,  however,  are  on  the  border  line  between  soundness  and  unsound- 
ness of  mind — cases  in  which  the  patient  believes  that  he  is  suffering 
from  some  disease,  not  in  itself  unreasonable,  but  still  out  of  the 
question  because  the  evidence  of  it  would  be  tangible,  and  does  not 
exist.  Such  patients  are  often  actually  insane,  although  they  cannot, 
and  ought  not  to  be,  treated  as  such,  unless  the  mind  is  unsound  on 
other  points. 

Prognosis. — The  distinction  between  the  two  forms  of  hypochon- 
driasis, the  acquired  and  the  temperamental,  is  important  in  regard  to 
prognosis.  The  subjects  of  the  latter  form  seldom  recover ;  if  one 
false  idea  is  removed,  another  takes  its  place.  The  acquired  form,  on 
the  other  hand,  sometimes  passes  away  altogether,  and  the  prospect 
of  recovery  from  it  is  good  in  proportion  to  the  shortness  of  time  it 
has  existed,  and  to  the  degree  of  derangement  of  health  in  which  it 
has  arisen. 

Treatment. — The  details  of  the  treatment  of  hypochondriasis  have 
to  be  varied  to  suit  the  exigencies  of  each  case  ;  the  principles  are  the 
same  in  all.  The  first  thing  is  to  correct  whatever  is  actually  wrong, 
both  in  the  patient's  general  health,  and  also  in  the  organs  to  which 
his  attention  is  directed.  In  acquired  cases,  especially,  there  is  often 
some  weakness  of  the  nervous  system  that  may  be  lessened  by  nervine 
tonics  and  by  an  improvement  in  the  patient's  mode  of  life.  The 
second  element  is  the  removal  of  the  false  ideas  and  the  withdrawal 
of  the  attention  of  the  patient  from  his  physical  condition.  The 
statements  made  regarding  the  treatment  of  "  cephalic  sensations  " 
(p.  863)  are  applicable  to  all  forms  of  hypochondriasis,  and  it  is 
unnecessary  to  repeat  them,  or  to  apply  them  in  detail  to  similar  sym- 
ptoms in  other  parts.  It  is  essential  to  make  the  patient  realise  how 
misleading  bodily  sensations  often  are  regarding  the  actual  condition 
of  the  parts  from  which  the  feelings  seem  to  proceed,  and  how  essen- 
tial it  is  that  the  sensations  should  be  disregarded.  He  sbould  also 
be  made  to  understand  that  his  efforts  to  neglect  them  will  not  be  at 
once  successful,  and  that  perseverance  for  a  long  time  will  be  neces- 
sary. A  grave  responsibility  rests  upon  physicians  who  are  consulted 
by  these  patients.  The  mere  consultation,  even  when  the  advice  is 
wise,  helps  to  perpetuate  the  morbid  state,  and  it  is  certain  that  the 
mere  consideration  of  "  What  have  I  to  tell  the  doctor?"  often  does 
more  in  the  way  of  harm  than  the  "  doctor  "  can  do  in  the  way  of 
good.  When  all  that  can  be  done  to  remove  actual  disorder  has  beeu 
accomplished,  it  is  often  right  to  refuse  to  be  any  longer  a  passive 
party   to   the    perpetuation   of   the  symptoms.     Sometimes    such   a. 


NERVOUS    WEAKNESS  1045 

refusal,  if  the  grounds  for  it  are  made  clear,  will  do  more  real  good  to 
the  sufferer  than  can  be  achieved  by  any  other  means. 


NERVOUS   WEAKNESS;    NEURASTHENIA. 

It  has  become  fashionable  to  apply  the  term  "Neurasthenia"*  to 
conditions  of  weakness  of  the  nervous  system.  The  use  of  the  word 
has  brought  with  it  a  tendency  to  regard  the  condition  thus  denoted 
as  a  definite  disease.  Books  have  been  written  about  it,  and  it  has 
been  divided  into  numerous  classes  according  to  the  character  of  the 
symptoms  that  are  present,  and  the  causes  that  give  rise  to  it.  It  is 
convenient  to  be  able  to  designate  the  condition  by  one  word  instead 
of  two,  but  there  is  no  more  justification  for  regarding  neurasthenia  as 
a  definite  malady,  as  a  disease  due  to  a  definite  morbid  process,  or  even 
as  an  affection  characterised  by  a  well-marked  group  of  symptoms, 
than  there  is  for  adopting  a  similar  course  with  regard  to  "  debility  " 
among  general  diseases.  "  Neurasthenia  "  underlies  and  may  cause 
a  large  proportion  of  the  functional  diseases  of  the  nervous  system, 
and  when  "neurasthenic"  patients  seek  advice,  there  are,  in  many 
cases,  symptoms  of  nerve  disturbance  sufficiently  definite  in  character 
to  bring  the  case  into  some  special  category.  Moreover,  the  concep- 
tion has  furnished  material  for  the  exercise  of  an  unlimited  amount 
of  intellectual  ingenuity,  in  a  g^asi-scientific  process  of  elaborate 
description  and  multiple  classification.  Like  other  general  terms,  it 
has  a  tendency  to  hinder  investigation,  and  to  prevent  the  thorough 
study,  and  the  due  discrimination,  of  the  nature  of  maladies,  essential 
alike  for  the  progress  of  medicine  and  the  treatment  of  disease. 

But  the  term  has  taken  possession  of  medical  thought  in  every 
country  to  an  extent  which  compels  its  adoption.  The  cause  which 
has  rendered  it  so  effective  is  obvious.  While  the  undue  extension  of 
the  use  of  the  word,  conspicuous  in  many  quarters,  is  to  be  regretted 
and  deprecated,  there  are  many  cases  for  which  it  is  a  convenient 
designation,  and  to  which  it  may  be  applied  without  other  dis- 
advantage than  the  indirect  sanction  that  may  seem  to  be  given  to  its 
unwise  use.  These  are  the  cases  in  which  there  are  symptoms  of  dis- 
turbance, or  of  impaired  function  of  the  nervous  system,  more  or  less 
persistent,  almost  infinitely  various  in  their  features,  but  which  have 
in  common  the  negative  characteristic  that  they  do  not  conform  to  any 
of  the  types  that  have  received  definite  names.  To  include  the  latter 
under  the  term  is  for  many  reasons  unwise.  Hypochondriacal, 
hysterical,  and  many  other  varieties  of  "  neurasthenia "  have  been 
described ;  but  if  the  fact  that  impaired  nutrition  and  strength  of 
*  Invented  by  an  American  physician,  Dr.  Beard. 


1046  NEBVOUS    WEAKNESS. 

the  nervous  system  is  to  be  made  the  ground  for  including  under  the 
term  all  the  maladies  which  result  from  the  condition,  half  the 
functional  and  nutritional  affections  of  the  nervous  system  should 
he  described  in  one  huge  chapter  under  this  designation.  Equally 
unwise  is  it  to  distinguish  classes  according  to  the  cause  of  the  condi- 
tion, when  its  manifestations  present  no  peculiarities  corresponding  to 
the  particular  causes.  Such  varieties  as  "  syphilitic  neurasthenia," 
"influenzal  neurasthenia,"  "  malarial  neurasthenia,"  have  no  scientific 
justification. 

Even  among  the  cases  of  nerve  disturbance  which  cannot  be  placed 
in  any  recognised  category,  there  are  some  that  ought  not  to  be 
included  in  this,  or,  indeed,  in  any  other  class  of  actual  disease. 
Many  persons  possess  a  congenital  peculiarity  of  nerve-function,  for 
which  they  may  seek  medical  advice,  but  which  is  not  really  morbid. 
Such  is  the  persistence  of  the  "  shyness  "  of  early  life,  or  a  tendency, 
life-long,  to  look  on  the  darker  side  of  things,  or  the  vaso-motor 
activity  which  causes  so  many  persons,  all  through  the  first  half  of 
life,  to  blush  at  the  least  emotion,  and  flush  under  every  favorable 
physical  influence. 

When  these,  and  the  cases  of  a  definite,  long-recognised  type,  are 
excluded,  those  to  which  the  terms  "  neurasthenia "  and  "  neuras- 
thenic "  may  be  applied  with  convenience  and  without  disadvantage 
are  sufficiently  numerous.  In  many  the  condition  is  distinctly  "  con- 
stitutional; "  that  is,  the  defect  in  the  nervous  system  is  inherent  in 
the  individual,  and  a  similar  ancestral  tendency  can  often  be  traced. 
It  dates,  in  some,  from  childhood  ;  in  others,  it  comes  on  after  puberty 
or  in  early  adult  life,  without  any  discoverable  cause.  Of  the  latter, 
a  large  proportion  are  females,  who  are  unable  to  bear  even  the 
average  strain  of  life,  and  break  down  in  various  ways.  They  may  be 
raised  to  a  little  higher  level  of  nervous  health,  but  cannot  be  made 
really  strong.  Males  sometimes  suffer  in  the  same  way,  but  in  them 
depressing  influences  can  more  often  be  traced.  In  both  sexes 
the  state  often  results  from  definite  diseases  of  the  nervous  or 
general  system  or  of  other  organs,  which  leave  lasting  impairment  of 
nerve  strength.  Various  influences,  of  occupation,  amusement,  dis- 
sipation, excess,  may  induce  the  condition ;  to  enumerate  these  in 
detail  is  scarcely  necessary. 

The  deficient  strength  implied  in  the  name,  persistent  as  it  is  in 
the  cases  thus  designated,  is  always  the  expression  of  some  degree  of 
impairment  of  nutrition  in  the  nerve-centres,  brain  or  spinal  cord,  or 
both.  It  generally  involves  many  parts,  and  is  expressed  by  sym- 
ptoms of  great  diversity  ;  those  of  a  certain  class  preponderate  in 
some  cases,  but  in  many,  various  derangements  of  function  alternate 
or  co-exist.  As  a  rule,  deficient  capacity  for  functional  activity  is- 
associated  with  an  undue  readiness  for  slight  action,  which  may  even 
occur  without  its  usual  causes. 

Sensory  symptoms  are  the  most  common,  but  are  confined  to  those 


NERVOUS   WEAKNESS.  1047 

of  "irritative  "  character.  Loss  of  sensation  does  not  exist  in  simple 
"  neurasthenia,"  but  subjective  sensations  are  almost  constant. 
Fatigue  may  be  produced  with  undue  readiness  by  muscular  exertion 
and  by  mental  effort.  Headache  is  common,  and  so  also  are  the 
varied  cephalic  sensations  described  at  a  preceding  page.  Pains 
in  the  back  are  frequent,  sometimes  felt  throughout  the  spine,  some- 
times chiefly  in  the  sacral  region ;  they  are  usually  dull  and 
"  aching  "  in  character.  Spinal  tenderness,  often  at  more  than  one 
place,  is  frequent  in  women ;  walking  and  standing  readily  increase 
the  discomfort  in  the  back,  sometimes  so  as  almost  to  incapacitate 
the  sufferer.  In  the  limbs,  slight  fugitive  pains  are  often  coupled 
with  varied  sensations  of  tingling,  numbness,  and  the  like,  which  may 
be  greater  on  one  side  than  on  the  other.  Muscee  volitantes  annoy 
and  alarm  the  patient,  and  when  there  is  hypermetropia,  the  ciliary 
muscle  is  unable  to  maintain  its  usual  contraction,  so  that  "  asthen- 
opia" is  added,  and  the  use  of  the  eyes  begets  uncomfortable 
sensations  in  them,  superficial  or  deep,  seldom  painful,  although  actual 
pain  may  be  felt  behind  the  eyes  or  in  the  forehead,  after  their 
prolonged  use.  Auditory  hyperesthesia  may  cause  pulsating  tinnitus, 
or,  in  its  central  form,  may  render  every  loud  sound  distressing. 

Muscular  strength  is  only  lessened  in  the  severer  degrees  of  nervous 
weakness,  but  the  power  of  sustained  exertion  is  generally  reduced  ; 
fatigue  is  not  only  sooner  felt,  but  is  often  a  more  unpleasant  sensa- 
tion than  the  fatigue  of  health,  and  whatever  pain  or  discomfort  to 
which  the  sufferer  is  liable  is  apt  to  be  induced.  Even  talking  may 
quickly  cause  a  feeling  of  weariness  and  any  cephalic  sensations  to 
which  the  patient  is  liable.  Many  of  these  sufferers  habitually  talk  in 
a  low  voice,  as  if  every  sentence  involved  an  exertion  almost  beyond 
their  strength.  A  sense  of  muscular  inertia  and  powerlessness  is  very 
frequent,  especially  in  the  earlier  part  of  the  day,  when  there  is  no 
real  lack  of  strength ;  the  effort  needed  for  any  exertion  may  seem 
beyond  that  which  is  possible. 

Symptoms  of  motor  irritation  or  over-actiou  are  very  rare  except  in 
trifling  form.  The  sense  of  stiffness  in  the  limbs  is  not  accompanied 
by  any  real  rigidity.  Some  sufferers  are  very  liable  to  cramp  in  the 
calves  or  feet.  Especially  common  is  the  quivering  contraction  of  some 
muscle,  or  part  of  a  muscle;  the  orbiculares,  glutei,  thigh  or  calf 
muscles  are  frequent  seats.  It  seems  due  to  the  intermitting,  instead 
of  continuous,  release  of  the  nerve-force  which  causes  muscular  tone, 
and  has  no  other  significance  than  a  slight  general  impairment  of 
nutrition  and  function,  although  it  often  causes  grave  anxiety.  Rest- 
lessness is  common,  and  sometimes  an  unendurable  sense  of  "  fidgets" 
causes  movements  almost  choreic  in  their  character  and  constancy, 
accompanied  even  by  actual  starts  of  the  limbs. 

When  there  are  sensory  symptoms  in  the  legs,  or  undue  readiness 
and  degree  of  fatigue  ou  standing  and  walking,  the  knee-jerk  is  often 
increased,  perhaps  from  the  diminished  resistance  in  the  reflex  centres, 


1048  NERVOUS    WEAKNESS. 

due  to  the  fall  of  nutrition  below  tbe  normal  standard.  No  foot- 
clonus  cau  be  obtained.  The  state  of  the  sexual  functions,  in  the 
male,  depends  chiefly  on  antecedent  influences,  but  tbe  mental  pre- 
occupation, engendered  by  the  varied  sensations  which  absorb  the 
mind,  and  the  sense  of  disability,  deepened  by  a  fear  of  impending 
calamity,  often  cause  an  apparent  failure  of  desire  and  power,  super- 
ficial only,  and  ceasing  with  its  cause.  In  women,  the  state  of  the 
menstrual  functions  depends  more  on  the  general  health  than  on  the 
state  of  the  nervous  system,  although  the  latter  may  be  depressed 
by  mental  suffering,  or  by  the  apprehension  of  grave  results  of  irregu- 
larity. 

But  as  the  most  special,  elaborate,  and  complex  part  of  any  system 
is  that  most  prone  to  suffer,  and  exhibits  in  greatest  degree  the 
effects  of  general  impairment,  the  functions  of  the  brain  seldom 
escape  disorder  in  these  cases,  and  often  the  cerebral  disturb- 
ance is  the  most  pronounced  manifestation  of  the  state.  All  the 
functions  are  apt  to  suffer;  mental  power  is  lessened,  the  ability  to 
concentrate  the  attention  fails,  memory  is  imperfect,  and  the  influence 
of  the  will  upon  it,  in  "  recollection,"  is  weakened  in  especial  degree. 
There  is  as  much  conscious  difficulty  in  mental  as  in  physical  exer- 
tion, and,  in  proportion  as  the  sufferer  shrinks  from  the  unpleasant 
effort,  the  resistance  that  has  to  be  overcome  seems  to  increase.  All 
cerebral  processes  that  depend  on  the  will  quickly  cause  fatigue, 
which  is  expressed  by  varied  sensations,  psychical  or  cephalic.  The 
subjective  discomfort  in  the  limbs  and  back  depress  the  brain,  on 
which,  often,  the  effects  of  the  varied  sensory  symptoms  seem  to  be 
focussed.  A  large  proportion  of  these,  indeed,  arise  in  the  sensory 
centres  of  the  brain,  and  the  interaction  of  all  its  parts  is  such  that 
the  disturbance  of  one  region  influences  the  whole.  The  purely 
mental  functions  suffer  with  the  rest ;  mental  depression  is  conjoined 
with  irritability,  and  every  annoyance  is  magnified  into  a  disaster. 
While  actual  giddiness  is  uncommon,  a  sense  of  impending  giddiness 
sometimes  causes  much  distress,  and  may  even,  by  some  indirect 
mechanism,  induce  uncertainty  of  movement. 

Visceral  symptoms,  pain,  discomfort  of  many  kinds,  and  even 
definite  disorders  of  subordinate  functions  are  frequent,  but  those  of 
the  digestive  system  are  of  especial  importance.  They  are  to  be 
recognised,  as  distinctly  augmenting  other  symptoms,  in  about  two 
thirds  of  the  sufferers,  and  a  close  relation  between  gastric  disorder  and 
cephalic  discomfort  is  especially  conspicuous.  A  feeling  of  shortness  of 
breath,  or  oppression  at  the  chest,  is  often  complained  of.  Secondary 
disturbance  of  the  action  of  the  heart  is  frequent,  and  the  readiness 
with  which  the  vaso-motor  system  responds  to  central  and  visceral 
derangement,  is  the  source  of  many  symptoms,  flushing,  pallor,  sense 
of  heat  and  cold,  chills,  and  imaginary  fever,  are  common  complaints. 
Sleep  is  seldom  good,  restlessness  and  insomnia  increase  the  nerve 
prostration,  and  often,  when  the  patient  does  sleep,  he  wakes  un- 


PROGNOSIS.  1049 

refreshed,  weary,  and  languid.  Starts  often  hinder  the  advent  of 
sleep,  and  this,  when  it  comes,  is  disturbed  by  dreams  or  interrupted 
by  sensations  of  tingling  in  the  hands,  sometimes  with  a  feeling  of 
contraction  in  them  when  there  is  none,  sometimes  with  an  actual 
contraction  such  as  that  described  at  p.  704  as  "  nocturnal  tetany." 

The  further  development  of  such  effects  of  malnutrition  usually 
takes  the  form  of  one  of  the  definite  functional  ailments  already 
described,  many  of  which,  as  neuralgia,  hypochondriasis,  hysteria, 
really  consist  in  a  high  degree  and  elaborate  development  of  the 
effects  of  the  condition  now  under  consideration.  The  description  of 
the  symptoms  might  be  multiplied  indefinitely,  and  yet,  so  various 
are  they  that  no  description,  however  lengthy,  would  embrace  half  the 
varied  manifestations  of  mere  nervous  weakness. 

Prognosis. — The  prospect  that  the  condition  will  pass  away  must 
depend  on  its  duration,  and  especially  on  the  degree  to  which  it  is  the 
effect  of  influences  that  can  be  arrested,  or,  on  the  other  hand,  is  the 
manifestation  of  an  inherent  inability  of  the  nervous  system  to  reach 
or  maintain  a  proper  level  of  nutrition  and  function.  Each  case 
must  be  made  the  subject  of  separate  study,  and  the  causal  influences 
must  be  compared  with  the  extent  to  which  the  interaction  of  the 
symptoms  tends  to  keep  them  up,  and  with  the  possibility  of  eman- 
cipating the  sufferer  from  the  pathogenic  influences,  external  to  and 
within  himself.  When  patients  have  been  freed  from  the  acquired 
state,  it  is  extremely  prone  to  return  on  any  impairment  of  the 
general  health  or  strain  upon  the  nervous  system. 

Treatment. — The  advice  that  has  been  given  regarding  the  treat- 
ment of  hysteria,  hypochondriasis,  neuralgia,  headache,  and  cephalic 
sensations,  embraces  most  that  can  be  done  to  remove  the  condition  of 
"  neurasthenia."  All  influences  conducive  to  physical  strength 
should  be  secured,  and  all  causes  of  depression  and  exhaustion  of 
the  nervous  system  should  be  sought  for  and  eradicated.  Powerful 
causes  (as  sexual  excess)  are  sometimes  quite  unrecognised  as  such 
by  their  victims.  A  sea  voyage  and  mountain  air  afford  the  most 
potent  means  of  restoring  the  strength  of  the  nervous  system,  if  this  has 
been  lately  lost.  In  all  cases,  rest  from  work  that  is  obviously  depress- 
ing should  be  secured,  and  the  rest  made  more  effective  by  such  mental 
and  physical  influence  as  can  be  secured  by  change  of  personal  and  local 
surroundings.  In  many,  however,  some  mental  occupation  is  better 
than  perfect  freedom  to  devote  attention  to  the  sensory  discomfort. 
Tonics  should  be  given  of  such  form  as  is  indicated  by  the  symptoms, 
and  drugs  that  lessen  the  instability  of  the  sensory  structures, 
without  depressing  the  system,  are  often  of  service,  such  as  small 
doses  of  Indian  hemp,  given  with  bromide,  belladonna,  or  chloride 
of  aluminium.  The  effect  of  nitro- glycerine,  in  augmenting  the 
arterial  blood-supply,  and  thus  facilitating  improvement  in  nutrition 


1050  NERVOUS   WEAKNESS. 

and  the  influence  of  tonics,  is  often  very  conspicuous.  The  physical 
influence  of  rest  and  massage  are  often  useful  on  account  of  the 
complete  repose  given  to  the  motor  nervous  system.  Hydropathic 
treatment  is  of  service  in  many  cases,  not  only  for  its  direct  effect, 
but  also  for  the  conditions  which  it  indirectly  secures.  The  details  of 
the  treatment  that  may  he  adopted  with  advantage  in  various  cases, 
need  not  be  enumerated  because  they  chiefly  consist  in  the  application, 
to  the  special  state,  of  the  measures  that  are  within  the  familiar  know- 
ledge and  capacity  of  every  well-trained  practitioner. 


INDEX. 


A 


Abducens  nerve,  see  Sixth  nerve 

Abduction  of  vocal  cords,  290 

Abscess  of  brain  {see  Brain,  abscess  of), 

470 
Abscesses,  miliary,  in  hydrophobia,  932, 933 

—  of  cerebellum,  472,  473,  475,  482 

—  of  pons,  482 

Accessory  nucleus,  49;  and  flocculus,  49 
Accommodation,   loss   of,    182;   in   diph- 
theria, 906  ;  and  convergence,  loss  of, 
185 
Accommodative  iridoplegia,  183 
Actinomycosis  of  brain,  467,  478 
Active  congestion,  375 
Acute  ascending  paralysis,  diagnosis  from 
paralytic  rabies,  930 

—  diseases,  paralysis  after,  894 

—  rheumatism,  paralysis  after,  900 
Addison's  disease,  pigmentation  in,  890 
Adduction  of  vocal  cords,  290 
African  lethargy,  1039 

Agraphia,  113,  115,  123;  partial,  123 
Ala  cinerea,  45 
Alalia,  111 

Albuminose  in  diphtheria,  917 
Albuminuria  in  exophthalmic  goitre,  879 
Albuminuric  retinitis,  131 ;  in  lead-poison- 
ing, 955 
Alcoholic  delirium,  971 

—  insanity,  acute,  980 

Alcoholism,  970;  acute,  971;  chronic,  981 ; 
and  encephalitis,  983  ;  and  epilepsy, 
982;  and  hyperpyrexia,  974;  and 
multiple  neuritis,  981 ;  and  myelitis, 
982;  mental  state  following,  976; 
optic  nerves  in,  975  ;  tremor,  974 ; 
treatment  of,  978 


Alexia,  113,  115,  119,  122 
Alternate  hemiplegia,  95,  219,  439 
Amaurosis,  toxic,   163;   and  albuminuric 

retinitis,  163;  lesions  in,  165 
Amblyopia,  crossed,  22,  94,  159,  994 

—  functional,  163,  164 

—  lesions  in,  165 

—  reflex,  164  ;  tobacco,  148  ;  toxic,  163 

—  and  albuminuric  retinitis,   163 ;    and 

alcoholism,  983 
Amnesiu,  107  (see  Memory,  verbal,  121) 
Amnesic  aphasia,  116,  121 
Amygdala,  42 
Anaemia  of  brain,  368  (see  Brain,  anseinia 

of) 

—  in  plumbism,  945,  960 
Anaemic  headache,  860 

—  neuralgia,  816 

Anaesthesia,  crossed,  95 ;  bilateral,  95 ; 
dolorosa,  965  ;  muscular,  997 

Anarthria,  110 

Aneurism,  intra-cranial,  529;  hereditary 
tendency  to,  529 ;  and  embolism 
530;  and  injury,  530;  and  syphilis, 
530;  in  lenticular  nucleus,  531;  in 
special  arteries,  533;  loss  of  smell  in, 
538;  optic  neuritis  in,  533;  rupture 
of,  532,  537;  spontaneous  cure  of, 
537 ;  treatment  of,  539 

—  miliary,  of  retinal  vessels,  132 

—  of  cerebral  vessels,  385,  529 
Angina  pectoris,  821 
Angular  gyrus,  5,  22 
Annectant  gryri,  5 
Anorexia,  130 

Anosmia,  139,  141 

Anterior  auditory  nucleus,  49 

—  cerebral  artery,  63 

—  communicating,  aneurism  of,  531 


1052 


INDEX. 


Anterior  fossa,  tumours  of,  515,  516 

—  pyramid,  28,  29 
Antero-lateral  ascending  tract,  36 
Antispasmodics,  1025 

Anuria,  hysterical,  1014 

Aphasia,  110 ;  amnesic,  116,  121 ;  ataxic, 
114;  congenital,  125  ;  from  function-.il 
disturbance,  124  ;  in  children,  125  ; 
medico-legal  relations  of,  125 ;  motor, 
114,116;  sensory,  112,  119;  visual, 
113,  116 

—  in  typhoid,  895 
Aphemia,  111 

Aphonia,  hysterical,  291,  994,  1027  ; 
spastic,  294 

Aphthongia,  304 

Apoplectiform  bulbar  palsy,  574 

Apoplexy,  100 ;  and  loss  of  consciousness, 
99,  406;  and  syncope,  103;  and 
toxaemia,  103  ;  capillary,  430 ;  cause 
of,  100,  388 ;  congestive,  380  ;  ingra- 
vescent, 101,  406 ;  serous,  101,  582 ; 
temperature  in,  101 

Arachnoid,  inflammation  of,  328 

Argyria,  967    ' 

Arm  centre  in  cortex,  18 

Arrest  of  fits,  737 

Arsenical  poisoning,  963 ;  and  alcoholic 
neuritis,  965 ;  and  lead-poisoning,  966 

Artefacts  in  nervous  tissues,  561 

Arteries  of  brain,  60 

Arteritis,  causing  aneurism,  530 

—  umbilicalis,  in  tetanus,  680 
Artery  of  cerebral  haemorrhage,  405 
Articulation,  defects  of,  110 

—  confluent    or    elisive,    110,    507;     in 

alcoholism,     983;     in     disseminated 

sclerosis,  547,  552 
Arytaenoideus,  284 
Ascending  frontal  convolution,  4 

—  parietal  convolution,  4 
- —  root  of  fifth  nerve,  51 

— glosso-pharyngeal,  46 

Associated  movements  in  hemiplegia,  81 
Astasia-absasia,  794  ;  hysterical,  996 
Asymmetry,  congenital,  871 
Ataxy,  arsenical,  965  ;  diagnosis  of,  918  ; 
in  diphtheria,  908 

—  in  disseminated  sclerosis,  549 

—  in  hysteria,  1027 
Atheroma,  385,  428 
Athetoid  spasm,  509 


Athetosis,  86, 611 ;  in  tumour,  509;  lesion 

causing,  88,  458 
Atrophic  bulbar  palsy,  570 
Atrophy  of  brain,  559,  580 ;  partial,  580 ; 

senile,  581;   and  cerebellum,  580 

—  of  muscles  (see  Muscular) 

—  olfactory,  139 

—  optic,  consecutive,  135,  506;  in  alco- 

holism, 983;  in  bulbar  palsy,  568;  in 
disseminated  sclerosis,  550;  in  goitre, 
877  ;  varieties  of,  137 
Auditory  centre,  24 

—  dyssesthesia,  267 

—  hallucinations  and  tinnitus,  271 

—  hypera?sthesia,  260,  267,  1047 

—  nerve,  nucleus,  47;    diseases  of,  260; 

degeneration     of,     262 ;     in     brain 
tumours,  514 

—  path,  49 

—  vertigo  (see  Vertigo),  782 
Aura,  737 

Automatism  after  epilepsy,  743,  746 

—  obedient,  1032,  1035 

B 

Barking  cough  of  puberty,  294 
Basal  ganglia,  25  ;  diseases  of,  314 

—  tumours,  491,  500,  515 

Basedow's  disease,  817  (see  Goitre,  exoph- 
thalmic, 817) 
Basilar  artery,  60,  65  ;  obstruction  of,  438 
Bell's  paralysis,  230  (see  Facial  paralysis) 
Betz,  cells  of,  11 
Bilateral  lesions,  320 

—  muscles,  76,  77 
Birth-palsy,  413 
Bismuth  and  lead,  961 
Blepharospasm,  168,  259 
Blindness,  hysterical,  994 
Blood-pigment  in  lymphatic  sheath,  378 
Blood-states  causing  thrombosis,  426 
Blood  vessels  of  brain,  60 

Bony  tumours,  491,  499 
Brachial  monoplegia,  80,  308 

—  neuralgia,  809 
Brachium,  42 

Brain,  abscess,  470 ;  optic  neuritis  in,  480 ; 
mental  symptoms  in,  481 ;  and  actino- 
mycosis, 467;  and  meningitis,  484; 
and  tumour,  484 ;  surgery  of,  486 

Brain,  anaemia,  368 ;  congestion  of,  373 ; 
degenerations   of,    541 ;   disease,    72, 


INDEX. 


1053 


125;  hyperemia  of,  373;  hyper- 
trophy of,  582;  inflammation  of,  463, 
464,466;  and  abscess,  466 ;  chronic, 
468;  disseminated,  469;  mycosis  of, 
466;  organic  diseases  of,  368; 
softening,  421,  465 ;  acute,  421 ; 
chronic,  422 ;  chronic  progressive, 
541;  red,  430;  yellow,  430;  optic 
neuritis  in,  434;  tumours  (see  Tumour), 
intra-cranial  and  abscess,  484;  and 
meningitis,  351 
Brain-sand,  499 

Bright's  disease  and  apoplexy,  388 
Broadbent's  hypothesis,  76 
Bromism  in  epilepsy,  762 
Buisson's  treatment  of  hydrophobia,  937 
Bulbar   palsy,  562 ;   acute   inflammatory, 
578  ;  and  ophthalmoplegia,  565  ;  and 
progressive  muscular   atrophy,  568  ; 
and  pseudo-bulbar  paralysis,  572,  599  ; 
and  tumour,  572 ;  chronic,  564;  forms 
of,  567  ;  glycosuria  in,  568;  jaw-jerk 
in,  567 ;  pulse  in,  568 ;  sudden,  574 ; 
strychnine    in,    573 ;    without    ana- 
tomical change,  573 
Bulbous  nerves,  neuralgia  from,  813 
Bulimia  in  brain  diseases,  130 

C 

Cachexia  strumipriva,  889 

Calcarine  fissure,  4 

Calloso-marginal  fissure,  4 

Canine  chorea,  612 

Capillary  apoplexy,  430 

Capsule,  external,  41 ;    internal,  26,  29  ; 

arrangement   of   fibres    in,    27,  29 ; 

localisation  in,  314 ;  posterior  third 

of,  39 
Carcinoma  of  brain,  498 
Cardiac  branches  of  vagus,  295 

—  failure  in  diphtheria,  908 

—  weakness  causing  thrombosis,  426 
Cardialgia,  834 

Caries  of  spine  and  neuralgia,  822 
Carotid,  60;  ligature  of,  for  cerebral  hae- 

morrhage,  412 

—  obstruction  of  internal,  436 
Carpo-pedal  contractions,  770 
Catalepsy,  1010,  1030,  1032 
Caudate  nucleus,  27,  40 
Cavernous  sinus,  thrombosis  of,  453 


Central  arteries,  61 

—  convolutions,  4 

—  ganglia,  26 
Centres,  motor,  13,  16 ;  sensory,  14,  20 

—  arrangement  of,  in  third  nerve,  170 
Centrum  ovale,  29,  313,  394 
Cephalalgia,  see  Headache 
Cephalic  sensations,  863,  1041,  1044 

—  tetanus,  683 
Cerebellar  abscess,  472,  473,  475,  482 

—  arteries,  65  ;  obstruction  of,  440 

—  co-ordination,  58 

—  peduncles,  35,  38  ;  localisation  in,  321 
Cerebellum,  56,  58;  abscesses  in,  472,  473, 

475,  482 ;  haemorrhage  into,  395 ; 
localisation  in,  320;  middle  lobe, 
stimulation  of,  58 

—  aud  paralysis  agitans,  651 
Cerebral  abscess,  &c .,  470  (see  Brain) 

—  arteries,  60 ;  obstruction  of,  437 

—  haemorrhage  (see  Haemorrhage),  384 

—  palsy  of  children,  456 

—  sinuses,  66;  thrombosis  in,  450 

—  veins,  66;  thrombosis  in,  450 
Cerebritis,  acute,  463  (see  Brain  inflam- 
mation) 

Cerebro-spinal  fever,  358;  meningitis, 
358;  contagiousness  of,  360  (see 
Meningitis) 

Cervico-brachial  neuralgia,  809 

Cervico-occipital  neuralgia,  808 

Cheyne-Stokes  respiration,  100,  128,  281 

Chiasma,  optic,  144,  148 

Choked  disc,  137 

Cholesteatoma,  499 

Cholesterine  in  hsematoma,  328    • 

Chorda  tympani,  lesions  of,  226 

Chorea,  591;  electrical,  610,  612,  620, 
627,629;  hereditary,  610, 624;  Hunt- 
ington's, 624;  hysterical,  610,  620, 
988,  1002 ;  insaniens,  605,  619,  620  ; 
laryngeal,  611;  paralytic,  599,  606, 
619;  post-hemiplegic  (see  Athetosis), 
86,  458,  611  ;  pre-hemiplegic,  611 ; 
senile,  626 ;  tetanoid,  709 ;  unilateral, 
600 

—  and  embolism,  616  ;  and  endocarditis, 
603, 613,  617 ;  and  heart  disease,  596, 
602,  603;  and  pregnancy,  596,  618.; 
and  rheumatism,  595,  604,  616 

—  electric  irritability  of  muscles  in,  600; 
mental  change   in,    601,   624 ;  optic 


1054 


INDEX 


neuritis  in,  604 ;  sensibility  in,  601 ; 

urine  in,  603 
Choroiditis,  131 
Chromatopsia,  155 
Ciliary  muscle,  182 
Circle  of  Willis,  60 
Claustrum,  41 
Clnvus  hystericus,  992 
Clownism,  1004 

Cocaine,  influence  of,  on  eyelid,  887 
Coccydynia,  811 
Cochlear  root  of  auditory,  47 
Colour  hemianopia,  155 

—  visi  >n,  representation  of,  21 
Column  of  Burdach,  34 
Coma,  99 

Commissure,  optic,  see  Chiasma 

Conduction-aphasia  116 

Confluent  articulation,  507 

Confusion  test,  994 

Congenital  palsy,  413 

Congestion,  active,  375 ;  passive,  376,  379 

Congestion  of  membranes,  323 

Congestive  apoplexy,  380 

Conjugate  deviation  of  eyes,  78,  186 

Connecting  tracts  in  brain,  25 

Consciousness,  loss  of,  99,  406 ;  effect  of 
pressure  on,  102 

Consecutive  atrophy  of  optic  nerve,  135, 
506 

Constipation  in  brain  disease,  131 

Contracture, hysterical,  998;  plastic,  1000; 
in  brain  tumour,  509  ;  structural,  82 

Contre-coup  and  braiu  inflammation,  464 

Convergence  of  eyes,  loss  of,  185 

Convolutions,  2  ;  central,  4 

Convulsions,  90;  by  steroid,  93, 1029;  infan- 
tile, 769;  unilateral,  92 ;  uraeinic,  776  ; 
in  eclampsia,  768;  in  tumour,  510 

Convulsive  tic,  248 

—  tremor,  630 

Cornu  ammonis  in  epilepsy,  753 

Corona  radiata,  26 

Coronal  fibres,  26 

Corpora  quadrigemina,  27,  42  ;  and  deaf- 
ness, 263 ;  and  eye  movements,  38 ; 
localisation  in,  317;  relation  to  teg- 
mentum, 42;  to  third  nucleus,  53 

Corpus  callosum,  lesions  of,  314 

—  dentatum,  57 

—  striatum,  40,   41  j    haemorrhage    into, 

localisation  in,  315 


Cortex,  2;  blood-supply  of,  62 ;  functional 
regions  of,  12 ;  haemorrhage  on,  394 ; 
irritating  disease  in,  309  ;  localisation 
in,  308 ;  relation  to  skull,  6  ;  structure 
of,  10 

Cortical  centres  in  men,  14 ;  in  monkey,  13 

—  vessels,  60,  62 

Cramp,     drummer's     and    others,    730; 

pianoforte  player's,  729 ;  sempstress's, 

729 ;     smith's,     729 ;     telegraphist's, 

729;    violin  player's,   729;    writer's, 

711 
Cranial  bones,  disease  of,  causing  abscess 

or  meningitis,  484;  thinning  of,   in 

tumour,  503 
Cranial  nerves,  diseases  of,  138  ;  origin  of, 

43 ;  paralysis  of,  in  diphtheria,  910 
Crico-thyroid  muscles,  283,  284 
Crossed  amblyopia,  22,  94,  995 

—  anaesthesia,  95 

—  diplopia,  174 
Crossway,  sensory,  40,  94,  315 
Cruciform  attitude,  1008 

Crura  cerebri,  26,  27,   81 ;    haemorrhage 

into,  394 ;  localisation  in,  317 
Crural  monoplegia,  80 
Crus  cerebri,  lesions  of  (see  Crura),  81 
Crusta,  27 
Crustal  fibres,  31 
Cuneus,  4 

Cutaneous  stimulation  in  hemiplegia,  81 
Cycloplegia,  182 
Cystic  degeneration,  541 
Cysticerci,  500 
Cysts  in  brain,  499;  parasitic,  500 

D 

Deafness,  bilateral,  266 ;  congenital,  24 ; 
nervous  261;  cortical,  24,  263 ;  from 
tumour,  24,  514;  electrical  test  for, 
265 ;  Galton's  whistle  as  test  for,  264 ; 
Einne's  test  for,  264 

Death,  cause  of,  in  brain  disease,  129 

—  trance,  1037 

Decussation,  superior  pyramidal,  34 

Degenerations  of  brain,  541 ;  cystic,  541 ; 
double,  71 ;  secondary,  67 ;  of  pyra- 
midal tracts,  28,  68 ;  in  pons,  70,  71 
in  crusta,  71 

Degenerative  neuralgia,  818 

Deiter's  nucleus,  48 


INDEX. 


1055 


Delirium,  104 ;  quiet  and  active,  105 

—  tremens  (see    Alcoholism),   971 ;     and 

neuritis,  972 
Delusions,    104 ;    in   hysteria,   1011 ;    in 

hypochondriasis,  1043 
Dentate  nucleus,  38 
Dermoid  cysts,  500 
Descending  root  of  fifth  nerve,  51 
Deviation,  conjugate,  186;  primary,  171; 

secondary,  171 
Diabetic  neuralgia,  816 
Diaphragm  in  hysteria,  997 
Diarrhoea,  paralysis  after,  899 
Diffuse  sclerosis,  460 

—  symptoms,  74 

Digestive  organs  in  brain  disease,  130 
Diphtheria,  laryngeal  palsy  in,  285 
Diphtheritic  palsy,  903 ;  of  ocular  muscles, 
190 ;  simulation   of,  1043 ;  and  hys- 
teria, 988 
Diplopia,  172;  crossed,  174;  homonymous, 
174 ;  in  vertigo,  787  ;  prisms  in,  203 
Direct  cerebellar  tract,  34 

—  symptoms,  443 

Discs,  optic,  in  alcoholism,  975 
Disorders  of  movement  after  hemiplegia, 

85 
Disseminated  myelitis,  554 

—  sclerosis,  543  (see  Insular  sclerosis) 
Dissociated  hemiplegia,  80 
Dorso-intercostal  neuralgia,  810 
Double  vision,  172  (see  Diplopia) 
Dreamy  state  in  epilepsy,  739 
Dubini's  disease,  628 

Dura  mater,  inflammation  of,  323 ;  haema- 

toma  of,  325 
Duval's  nucleus,  45 
Dysacusis,  267 
Dysaesthesia,  receptive,  865 
Dysarthria,  110 
Dysentery,  paralysis  after,  899 
Dyslexia,  116,  125 
Dysphonia,  spastic,  294 
Dyspnoea,  hysterical,  1014 

E 

Ear  disease  causing  abscess  of  brain,  470, 

474,  485 

meningitis,  352 

Eclampsia,  768 ;  infantile,  769  ;  puerperal, 

773  ;  and  Bright's  disease,  774 
Electrical  chorea,  610,  612,  620,  627,  629 


Electricity  in  diphtheritic  palsy,  921 
Electricity  in  exophthalmic  goitre,  893 
Emboliform  nuclei,  57 
Embolism,  cerebral,  422,  427;    in   chorea, 
616 ;  in  particular  arteries,  436 

—  of  retina,  132 
Eminentia  teres,  45 
Emissary  veins,  67 

Emotional  movements  in  hemiplegia,  79 
Emprosthotonos,  682 

Encephalitis,  460,  463  (see  Brain  inflam- 
mation) 

—  in  alcoholism,  983 
Encephalomalacia,  422 
Encephalopathia    saturnina,    953;    optic 

neuritis  in,  136 
Endarteritis  in  chorea,  603,  613,  617 
Enlargement  of  head,  582 
Enteralgia,  834  (see  Neuralgia,  visceral) 
Ependymitis,  322 

Epidemic  cerebro-spinal  meningitis,  358 
Epigastric  aura,  738 
Epilepsia  cursiva,  740 

—  larvata,  746 

Epilepsy,  730;  idiopathic,  730;  major 
and  minor,  734 ;  masked,  746 ;  post- 
hemiplegic, 730,  733,749 ;  procursive, 
740;  tetanoid,  741 

—  aura  in,  737;  automatism  after,  743, 

746;  crying  in,  740;  dreamy  state  in, 
739  ;  ligature  in,  737,  742 ;  ligature 
of  vessels  in,  768 ;  paralysis  after, 
743 ;  Tertigo  in,  738,  790,  793 

—  and  alcoholism,  982;  and  exophthalmic 

goitre,  881 ;  and  hysteroid  fits,  757  ; 
and  mental  disturbance,  747 ;  and 
migraine,  848,  853 ;  and  masturba- 
tion, 734 ;  and  traumatism,  733 ;  and 
worms,  733 

—  cornu  ammonis  in,  753 

—  surgical  treatment  of,  767 

—  vaso-rnotor,  theory  of,  755 
Epileptic  cry,  740 

—  hemiplegia,  743 

—  mania,  747 

Epileptiform  neuralgia,  812,  823 
Epileptogenic  zones,  742 
Equilibrium,  maintenance  of,  778 
Erectile  tumour,  499 
Erroneous  projection,  172 
Erysipelas,  paralysis  after,  897 
Erythism,  mercurial,  969 


1056 


INDEX. 


Essential  vertigo,  793 

Exophthalmic  goitre,  871 ;  and  albumi- 
nuria, 879 ;  and  emotion,  873 ;  and 
epilepsy,  881 ;  and  glycosuria,  879 

Exophthalmos,  875 ;  cause,  886 

External  capsule,  29 

—  pachymeningitis,  324 

—  rectus,  paralysis  of,  180 ;  in  tumours, 

513 
Eye,  changes  in,  from  disease  of  fifth,  220 

—  movements  in  hemiplegia,  78 
Eyeball,  motor  nerves   of,    168;   upward 

movements  of,  paralysis  of,  185 
Eyelid,  centres  for,  19 ;  movement  in  ex- 
ophthalmic goitre,  877 ;  cause  of,  887 
Eyes,  prominence  of  {see  Exophthalmos), 
875 

P 

Face  centre  in  cortex,  18 

Facial  hemiatrophy,  866 ;  and  disease  of 
fifth  nerve,  218, 868,  869 ;  and  sclero- 
derma, 868 

—  nerve,  nucleus  of,  49  ;  connection  with 

hypoglossal,  49,  570 ;  with  third,  50 ; 
diseases   of,   229 ;    neuritis  in,  232 ; 
paralysis,  230 ;  path  of,  in  pons,  75, 
229 
in  brain  tumour,  514 

—  paralysis,  230;  double,  234;    nuclear 

and  infra- nuclear,  230;  peripheral  and 
central,  230;  radicular,  230;  supra- 
nuclear, 230 
electrical  reactions  in,  239 ;  in  or- 
bicularis oris,  239 

—  —  hearing  in,  238;  palate  in,  236; 

taste  in,  237 

—  —  in  diphtheria,  906 

secondary  over-action  in,  242 

—  spasm,  248 ;  palate  in,  254 ;  stapedius 

in,  254;  taste  in,  254;  varieties  of, 

248 
Facio-lingual  hemiplegia,  80 
False  peritonitis,  991 

—  torticollis,  670 

Faradisation,  cutaneous,  in  hysteria,  1030 

Fasting  girls,  1012 

Festination  in  paralysis  agitans,  645 

Fibro-glioma,  491 

Fibroid  tumours  of  brain,  499 

Fidgets,  1048 

Fifth   nerve,   213;    ascending   root,    51; 


descending  root,  51 ;  diseases  of,  213  • 
medial  root,  51 ;  motor  root,  diseases 
of,  221 ;  neuritis  in,  215 ;  nucleus, 
50  ;  paralysis  of,  214 

Fifth  nerve  in  brain  tumours,  513  . 

Fillet,  28,  33 ;  commencement  of,  34,  36 
connection  with  cerebellum,  39 

Fissures  of  brain,  21 

Fixed  spasm,  89 

Flavours,  138,  224 

Fleece  of  Stilling,  57 

Flexibilitas  cerea,  1033 

Focal  meningitis,  344 

—  symptoms,  74 
Foetal  tumours,  499 
Forced  positions,  510 

Formatio   reticularis,  28;    and    posterior 

columns,  34 
Fortification  spectrum,  166,  840 
Fossae  of  skull,  tumours  in,  515,  516 
Fourth   nerve,    168;    affection    o.',    182; 

nucleus  of,  52  ;  in  brain  tumour,  513 
Fright  and  chorea,  594,  608 
Frontal  convolutions,  4 
Frontalis  in  hemiplegia,  79 
Functional  diseases,  591 
Functions  of  brain,  1 
Fungus  hsematodes,  496,  498 
Funiculus  cuneatus,  34 

—  gracilis,  34 

G 

Galton's  whistle,  264 

Ganglion  cell  layer,  10 

Gasserian  ganglion,  213;  removal  of,  for 

neuralgia,  830 
Gastralgia,  834 
Gastric  branches  of  vagus,  296 

—  vertigo,  792 
Gastrodynia,  834 
Gelatinous  stratum,  56 

General      paralysis      and      disseminated 
sclerosis,  556 

and  mercurial  poisoning,  970 

and  tumour,  521 

—  symptoms,  125 

Geniculate  ganglion,  disease  of,  229 

—  body,  external  and  internal,  42 
Giant-cells,- 11 

Giddiness  {see  Vertigo),  777 

—  in  brain  tumour,  507 
Glioma,  493,  494 


INDEX. 


1057 


Globus   hystericus,    990,   1008,    1012;  in 

hydrophobia,     936;     in    relation    to 

vagus,  281,  282 
Glosso-pharyngeal  nerve,    anatomy,  276  ; 

ascending  root  of,  46 ;  nucleus  of,  45, 

47 ;  and  taste,  277 
Glottis,  muscles  of,  283 
Glycosuria  in  bulbar  palsy,  568 ;  in  goitre, 

879 ;  in  tumour  of  pituitary,  516 
Goitre,    exophthalmic,   871;    albuminuria 

in,  879;  electrical  resistance  in,  880  ; 

glycosuria     in,     879;     and    astasia- 

abasia,    882 ;    and     diarrhoea,    882 ; 

and  facial  palsy,  882 ;  and  muscular 

atrophy,    882;    and    myelitis,    882; 

pulse   in,    874;    and   sweating,   8S2; 

and    skin    pigmentation,    890;     and 

Addison's  disease,   890;  and   mental 

derangement,  881 

—  simple,  distinction  from  exophthalmic. 

871,  890 
Gout  and  lead-poisoning,  946,  959,  960 
Gouty  neuralgia,  816 
Graefe's  symptom,  877 
Grand  mal,  735 
Granular  disintegration,  687 
Granule  corpuscles,  429 
Graves's  disease  {see  Goitre,  exophthalmic), 

871 
Grey  tubercle  of  Rolando,  35 
Growths,  intra-cranial  {see  Tumours),  488, 

&c. 
Gubler's  tumour  iu  wrist-drop,  950 
Gummata,  493 
Gyrus  fornicatus,  6 

—  lingualis,  6 

n 

Habit-chorea,  633 
Habit-spasm,  633 
Hsematemesis  in  hysteria,  1016 
Haematoidin  crystals  in  brain  cysts,  541 
Hafimatoma  of  dura  mater,  325 
Haemorrhage,  cerebellar,  395,  402 

—  cerebral,     384;     atheroma    in,    385; 

causes  of,  389 ;  and  embolism,  389 ; 
infantile  meningeal,  413;  men- 
ingeal, 390,  396,  404;  subarachnoid, 
388,  390;  seat  of,  405;  traumatic, 
391 ;  ventricular,  391, 395,  402,  409 ; 
and  kidney  disease,  388 ;  diagnosis 
from  thrombosis,  408;    symptoms  of 

VOL.   II. 


in  centrum  ovale,  394 ;  in  cortex  394, 
402;  in  crura,  394,  401 ;  in  medulla, 
401 ;  in  pons,  394,  401 

Haemorrhage,  cerebral,  in  diphtheria,  911 ; 
tying  carotid  for,  412 

Hemorrhagic  pachymeningitis,  325 

Hallucinations,  104  ;  auditory,  and  tinni- 
tus, 271 ;  <  hemiopic,  155  ;  visual, 
166 ;  in  lead-poisoning,  954 

Head  and  eyes,  movement  of,  18;  and 
superior  olive,  59 

—  enlargement  of,  583 

—  pressure,    863    {see     Cephalic    sensa- 

tions) 

—  rotation,  78 

Headache,    856;     anaemic,    860;    bilious, 
836;    blind,   836;    congestive,    859 
neuralgic,   860;    neurasthenic,    861 
paroxysmal,     836;      toxaemic,     859 
with  tumour,  504 ;  in  brain  disease,  96 

Hearing,  disturbance  of,  260;  electrical 
U  st  for,  265 

Heart  in  chorea  {see  Chorea) 

—  in  diphtheria,  908 

—  in  exophthalmic  goitre,  8/4 

—  disease  and  cerebral  haemorrhage,  389 
Hemiachromatopsia,  155 
Hemianaesthesia,  88,  94 ;  hysterical,  992  ; 

in  alcoholism,  982 ;  iu  lead-poisoning, 
953 
Hemianopia,  double,  156,  516 ;  homony- 
mous, 142  ;  hysterical,  158  ;  lateral, 
142;  migrainous,  157, 164,  842;  nasal, 
149 ;  oblique  or  horizontal,  158 ; 
partial,  154;  quadrantic,  154;  tem- 
poral, 148, 149 

—  associated  symptoms,  157 

—  dividing  line  in,  149,  151 

—  for  colours,  21,  155 

—  lesion  in,  21,  94  . 

—  optic  neuritis,  150 

—  peripheral  reduction  of  fields  in,  155 

—  pupil  reaction  in,  163 

—  visual  hallucinations  in,  155 
Hemiatrophy,  facial,  8*>6  ;  and  disease  of 

fifth  nerve,  218,  868,  869 ;  and  sclero- 
derma, 868 
Hemicrania  {see  Migraine),  836 
Heiniopia  {see  Hemianopia) 
Hemiopic  pupillary  inaction,  163 
Hemiplegia,  75;  alternate,  95,219,439; 
complete,  75 ;  crossed,  95,  219 ;  dis- 

67 


1058 


INDEX. 


sociated,  80;  double,  320  (see  Pseudo- 
bulbar palsy) ;  double  hysterical,  997; 
epileptic,  743;  hysterical,  995;  in- 
fantile, 456;  unilateral  convulsions 
in,  462;  recovery  after,  75;  treat- 
ment of,  447  ;  spastic,  86 

Hepatalgia,  835 

Hereditary  chorea,  610 

Herpetic  neuralgia,  814,  820 

Hiccough,  295 

Homonymous  diplopia,  174 

—  hemianopia,  142 
Huntington's  chorea,  624 
Hydatids,  500 

Hydrargyria  (see  Mercurial  poisoning),  968 

Hydrocephalic  cry,  336 

Hydrocephaloid  condition,  370,  455,  770 

Hydrocephalus,  584 ;  acquired,  585,  587 
acute,  332,  584;  chronic,  584 
chronic  external,  584;  chronic  inter 
nal,  585 ;  congenital  internal,  585 
external,  328  ;  internal  and  tumour 
502 ;  primary,  587 ;  sacculated,  585 
secondary  mechanical  form,  587 

—  fluid  in,  585 

—  operation  for,  589 

Hydrophobia,  922,  924  (also  under  Rabies) 

—  cauterisation  for,  940  ;  inoculation  for, 

938 

—  organisms  in,  934 

—  and  tetanus,  691 
Hydrophobic  tetanus,  683 
Hyperacusis,  260,  267 
Hyperemia  of  brain,  373 
Hyperesthesia,  auditory,  260,  267 

—  ocular,  167 ;  retinal,  167 
Hypergensia,  228 
Hyperosmia,  141 

Hyperpyrexia  in  brain  diseases,  126;  in 

alcoholism,  974 
Hypertrophy  of  brain,  583 

—  of  pons,  495,  583 
Hypnotic  state,  1031 
Hypnotism,  1031 
Hypochondriasis,  984,  1040 
Hypoglossal  nerve,  anatomy,  302  ;  nucleus 

of,   44;    and   facial,    49,    570;     and 

spinal  accessory,  45 

in  brain  tumour,  514 

Hysteria,  984;  major  and  minor,  1003 

—  and    chorea,    988;    and    diphtheritic 

palsy,   988 ;    and  disseminated  scle- 


rosis, 557;  and  epilepsy,  757,  988; 
and  hemiplegia,  988;  and  infantile 
hemiplegia,  988 ;  and  meningitis, 
354 ;  and  neuritis,  988 ;  and  organic 
disease,  988  ;  and  tetanus,  692 
Hysteria,  hsematemesis  in,  1016 

—  major,  1003 

—  ovarian  pain  in,  987 

—  temperature  in,  1016 
Hysterical  amblyopia,  163,  164 

—  anuria,  1014 

—  aphonia,  291,  994,  1027 

—  chorea,  610,  620,  988,  1002 

—  dyspnoea,  1014 

—  ischuria,  1014 

—  neuralgia,  815 

—  torticollis,  670 

—  tremor,  1001 
Hystero-epilepsy,  1003 
Hysterogenic  points,  991 

Hysteroid  convulsions,  93,  1003;  and  epi- 
lepsy, 757,  988 

—  symptoms  in  diphtheria,  909,918,988; 

in  exophthalmic  goitre,  881;  in  hydro- 
phobia, 927,  935,  937,  988 


Idiopathic  tetanus,  675,  676 
Illusions,  104 

Inco-ordination  in  tumours,  510 
Infantile  chronic  meningitis,  346 

—  convulsions,  769 

—  eclampsia,  769 

—  hemiplegia,  456;    and  athetosis,  458; 

sensation  in,  459;    mental  defect  in, 
459 

and   hysteria,   988;    and    vascular 

obstruction,  461 

—  meningeal  haemorrhage,  413 

—  oculo-facial  palsy,  197 
Inferior  dental  neuralgia,  807 

—  oblique  paralysis  of,  179 

—  parietal  lobule,  4 

—  rectus,  palsy  of,  178 
Inflammation    of    brain,    acute,    463   (see 

Brain,  inflammation  of) 

—  of  membranes,  323  (see  Meningitis) 
Influenza,  nervous  sequela?  of,  900 
Infra-orbital  neuralgia,  807 
Ingravescent  apoplexy,  101,  406 
Inhibition  in  apoplexy,  102;  from  irrita- 
tion, 73 


INDEX. 


1059 


Initial  rigidity,  82 

Inoculation  for  hydrophobia,  938 

Insanity,  98;  alcoholic,  976,  980;  and 
hypochondriasis,  1043 

Insula,  6 

Insular  sclerosis,  543  (see  Sclerosis,  dis- 
seminated) 

Internal  capsule,  27,  29,  314  (see  Capsule, 
internal) 

—  carotid  artery  (see  Carotid),  60 
obstruction  of,  436 

—  medullary  lamina,  40 

—  pachymeningitis,  324 

—  rectus,  paralysis  of,  324 
Interolivary  layer,  34 
Interosseal  flexion,  87 
Interparietal  fissure,  4 

Iutra-cranial  aneurisms  (.see  Aneurism), 529 

—  pressure  and  fits,  510 

—  tumours  (see  Tumours),  488 
Intra-parietal  fissure,  4 

Iridoplegia,  183;  accommodation  and  re- 
flex, 183 ;  cutaneous,  184 

Iris,  paralysis  of,  183 

Irritability,  muscular,  in  hemiplegia,  83 

Irritable  weakness,  722 

Irritation,  96;  inhibition  by,  73  ;  sensory, 
96 ;  symptoms  of,  in  optic  nerve,  166 

Ischuria,  hysterical,  1014 

Island  of  Reil,  6 


Jacobson,  nerve  of,  229 
Jaw  centres  in  cortex,  18 
Jaw-jerk,  567 
Junod's  boot,  383 

K 

Kidney  disease  and  hamiorrhage,  388 
Knee  of  internal  capsule,  27 
Knee-jerk  in  diphtheria,  90*,  906,  916 

—  cerebellar  tumour,  321,  509 

—  intra-cranial  growth,  321,  509 
Kopf-tetanus,  683 


Labio-glossal  laryngeal  palsy,  564  (see 
Bulbar  palsy) 

Labyrinthine  vertigo,  261,  782  (see  Ver- 
tigo) 

Lagophthalmos,  211 


Lamina,  internal  medullary,  40 
Landry's  paralysis  and  rabies,  930 
Language,  sensory  relations  of,  112 
Laryngeal  crises,  293 
Laryngismus  stridulus,  293,  770 
Larynx,  anaasthesia  of,  292 

—  paralysis  of,  282 ;  in  aneurism,  285 ; 

in  diphtheria,  905 ;  in  erysipelas, 
897 ;  in  multiple  neuritis,  285 ;  in 
lead  palsy,  954 ;  after  typhoid,  897 

—  spasm    of,    292 ;    functional,   293 ;  in 

hysteria,  293  ;  in  tetany,  293 
co-ordinated,  294;  phonic,  294 

—  spinal  accessory  fibres  for,  45 
Late  rigidity,  82 

Lateral  nucleus  of  cerebellum,  35 

—  sinus,  thrombosis  of,  452 

—  ventricles,  haemorrhage  into,  391,  395, 

402,  409 
Lead  colic,  947 

—  line,  946,  960 

—  tremor,  952 

Lead-poisoning,  943  ;  cerebral  symptoms, 
953;  laryngeal  palsy  in,  954;  mental 
symptoms,  954 ;  neuritis  in,  956 ;  optic 
neuritis  in,  955 ;  paralysis  in,  948 ; 
primary  atrophy  in,  951;  retinitis  in, 
955;  spinal  symptoms  in,  952;  wrist- 
drop in,  948 

—  and  general  paralysis,  954 

—  and  mercurial  poisoning,  970 

—  and    progressive     muscular    atrophy, 

961 
Leg,  affection  of,  in  hemiplegia,  76,  77 

—  neuralgia  of,  811 
Leg  centres,  17 

Lemniscus  (see  Fillet),  28,  33,  34,  36 
Lenticular  loop,  36 

—  nucleus,  27,  38 ;  and  cortex,  41 ;  con- 

nections of,  41 
Lenticulo-optic  artery,  61 
Lenticulo-striate  artery,  61 
Lepto-meningiiis,  323,  328 
Lethargy,  1030,  1034 

—  African,  1039 

Levator  palpebral,  paralysis  of,  181  (see 
Ptosis) 

spasm  of,  211 

Ligature  in  epilepsy,  737 

—  of  arteries  in  neuralgia,  831;  in  epi- 

lepsy, 768  ;  in  tetanus,  698 
I  Lingual  dyssesthesia,  306 


1060 


INDEX. 


Lingual  gyrus,  6 

—  paralysis,  302 

—  spasm, 304 
Lip  centre,  18 
Lipomata,  499 

Lips,  origin  of  fibres  for,  49,  570 
Localisation,  308 
Locality,  test  of  the  sense  of,  95 
Lockjaw,  674 
Locus  niger,  27 
Longitudinal  fissure,  2 
Luuibo-abdominal  neuralgia,  810 
Lymphatic    glands     enlarged    in    exoph- 
thalmic goitre,  880 
Lyssophobia,  937 

M 

Malarial  fevers,  paralysis  from,  899 

—  neuralgia,  817 

Mania  and  chorea,  605,  619,  620,  625  (see 
also  Mental  derangement) 

—  epileptic,  747 
Marantic  thrombosis,  450 
Marasmus  and  thrombosis,  450 
Marginal  convolution,  6;  lesion  of,  69 
Masked  epilepsy,  746 

Mastication,  muscles  of,  218 ;  paralysis  of, 

218 ;  spasm  of,  221 
Measles,  paralysis  after,  898 
Mechanical  congestion  of  brain,  390 
Medulla  oblongata,  anatomy,  43;  hemor- 
rhage into,  402;  localisation  in,  319; 
vessels  of,  65 ;  disease  of,  562 

and  exophthalmic  goitre,  885,  888 

Melancholia,     alcoholic,    981     (see     also 

Mental  symptoms) 
Melanotic  tumours,  498 
Membranes,  disease  of,  323 ;  congestion, 

323;  inflammation,  323 
Memory,  defect  of,  107;  in  alcoholism,  981 
Meniere's  disease,  782  (see  Vertigo,  aural) 
Meningeal  hajmorrhage,  390,  396;  infan- 
tile, 413 ;  convulsions   in,  414,  416 ; 
mental  change  in,  416 ;  paralysis  in, 
415;  sight  in,  416;    swallowing   in, 
416 

—  blood-tumour,  325 

Meningitis,  acute,  323;  chronic,  331,  335, 
345;  and  gummata,  335;  chronic 
infantile,  346;  chronic  syphilitic,  345; 
focal,  344;  purulent,  330,  344 ;  simple, 


330;  tubercular,  330,  333,  341  (see- 
Tubercular  meningitis) ;  ventricular, 
332 
Meningitis  in  influenza,  902  ;  in  insolation, 
329;  in  mental  work,  330;  in  pneu- 
monia, 329;  in  septicaemia,  329;  in 
smallpox,  329 

—  diagnosis  of,  from   abscess,  484 ;  from. 

ear  disease,  352 ;  from  hysteria,  354  ; 
from  tumour,  351,  522 

—  symptoms  in  relation   to   form,  341  ; 

locality,  340  ;  temperature  in,  127 

—  epidemic,  cerebro-spinal,  358;  abortive 

form,  363 ;  fulminant  form,  363 

—  —  contagion    in,   360;    eruptions  in, 

361 ;  head  retraction  in,  361 ;  optic 
neuritis  in,  362 

—  —  sequela)   of,   364;    diplococcus   in, 

365 
Meningitophobia,  366 
Meningo-encephalitis,  4G8 
Mental  failure,  107 

—  symptoms,   in   brain    disease,  98;    in 

alcoholism,  973,  976 ;  in  chorea,  605, 
619,  620,  625;  in  epilepsy,  747;  in 
exophthalmic  goitre,  881 ;  in  hydro- 
phobia, 927;  in  influenza,  901;  in 
lead-poisoninor,  954  ;  in  sclerosis,  552 ; 
in  tumour,  506 
Mercurial  erythism,  969 

—  poisoning,  968 

—  tremor, 969;  and  disseminated  sclerosis,. 

970 ;  and  geueral  pa  ralysis,  970  ;  and 
lead  palsy,  970 ;  and  paraly  sis  agitans, 
969 

Mesmerism,  1030 

Metallic  poisoning,  942 

Microcephaly,  580 

Middle  cerebral  artery,  63 

—  fossa,  tumours  of,  516 

Migraine   (or    megrim),     836;    varietie?,. 
845 

—  anaesthesia  in,  841;  aphasia,  transient 

in,  841 ;  double  consciousness  in,  842  ; 
fortification  spectrum  in,  840;  heini- 
anopia  in,  842  ;  herpes  in,  847;  men- 
tal change  in,  842 ;  nausea  in,  840 ; 
vaso-motor  symptoms  in,  844;  visual 
disturbance  in,  839 

—  and  epilepsy,  848,  853 ;  and  vertigo,. 

848 

—  ophthalmique,  193 


INDEX. 


1061 


Miliary  abscesses  in  hydrophobia,  933 

—  aneurisms,  384 

—  sclerosis,  560 
Mimic  spasm,  248 

Mind-blindness,  23,  113,  121,  122,  161 
Mind-deafness,  24 

Miner's  nystagmus,  207     • 

Mobile  spasm  (see  Athetosis),  86,  88,  458, 

509,  611 
Monoplegia,  80,  308,  435 

—  in  cortical  disease,  308 
Moral  sense,  defects  of,  108 
Morbus  medicorum,  865 
Motor  aphasia,  114,  116 

—  centres,   13;    convolutions,  29;  path, 

28 ;  paralysis,  68,  74 ;  in  tumour,  508 ; 

symptoms,  68,  74 
Mouth  centre,  18 
Movement,  disorders  of,  after  hemiplegia, 

85 
Miiller,  muscle  of,  in  exophthalmic  goitre, 

886,  887 
Multiple  cerebral  tumours,  516 

—  sclerosis,    543  (see   Sclerosis,  dissemi- 

nated) 
Mumps,  paralysis  after,  899 
Muscles,  degeneration  of,  in  diphtheria, 

912,  915 
Muscular  atrophy  iu  goitre,  882  ;  and  lead, 

961 

—  irritability  and  nutrition,  83 

—  rigidity,  82;  early,  initial,  late,  struc- 

tural, 82 

—  sense,  95 

—  sensibility,  path  of,  39 

—  tumour,  1000 

Musculo-spinal  paralysis  and  lead  palsy, 
950 

—  ■ —  and  writers'  cramp,  724 

in  typhus,  897 

Mycosis  of  brain,  466 
Mydriasis,  183 

Myelitis  in  alcoholism,  982  ;  in  dysentery, 
899 ;  in  measles,  898 ;  in  rheumatism, 
900 

Myeloid  tumours,  498 

Myoclonus  multiplex,  629 

Myosis,  183  ;  spinal,  185 

Myotatic  irritability  in  hemiplegia,  83 

Myxcedema  in  exophthalmic  goitre,  881 

Myxoglioma,  494 

Myxomata,  498 


N 

Narcolepsy,  1038 

Nausea,  nervous  mechanism  of,  277 

Neck,  centre  for,  19 ;  rigidity  in  abscess, 

340;  in  meningitis,  337 
Necrotic  softening,  422 
Nephralgia,  835 
Nerves,  cranial  origin  of,  43 ;  diseases  of, 

138 

—  optic,  in  alcoholism,  975 

—  in  diphtheria,  912 
Nerve-stretching  in  neuralgia,  831 
Nervi  nervorum,  804 

Nervous  deafness,  261 

Neuralgia,  794;  and  aneurism,  821;  and 
bone  disease,  822 ;  and  lead-poison- 
ing, 817;  and  lightning  pains,  821, 
822  ;  and  neuritis,  795 ;  and  toxicity, 
797 ;  changes  of  air  in,  801 ;  skin 
eruptions  in,  800 ;  tender  points  in, 
800,  804 

—  anaemic,    816 ;    brachial   and   cervico- 

brachial,  809  ;  cervico-occipital,  808  j 
crural,  811 ;  dorso-intercostal,  810 

—  epileptiform,  812;  and  epilepsy,  823 

—  gouty,  816;  herpetic,  814,  820;  hys- 

terical, 815 ;  influenzal,  901;  lurnbo- 
abdominal,  810 ;  malarial,  817 ;  occu- 
pation, 814;  reflex  or  sympathetic, 
812;  rheumatic,  816;  sacral,  811; 
spinal,  811  ;  syphilitic,  817;  sympto- 
matic, 800 ;  tabetic,  798 ;  testicular, 
836 ;  traumatic,  813 

—  treatment  of,  823  ;  surgical,  829 

—  trifacial  or  trigeminal,  806;    inferior 

dental,  807;  infra-orbital, 807;  ocular, 
806 ;  supra-orbital,  806 

—  trunk,  810;  visceral,  832 
Neuralgic  headache,  860 
Neurasthenia,  1045 
Neurectomy  in  neuralgia,  830,  831 
Neuritis,  axial,  148;  periaxial,  956 

—  diagnosis  from  neuralgia,  795 

—  in  diphtheria,  912 

—  in  influenza,  902 

—  in  malaria,  899 

—  in  rheumatism,  900 

—  in  typhus,  897 

—  in  variola,  898 

—  olfactory,    in   brain   disease,  139 ;    in 

alcoholism,  981 ;  in  arsenical  poison- 


1062 


INDEX. 


ing,  966,  in  hysteria,  988 ;  in  lead-poi- 
soning, 956 

Neuritis,  optic,  130,  132 ;  in  abscess,  480  ; 
in  anaemia,  860;  in  aneurism,  533, 
534;  in  arsenical  poisoning,  966;  in 
chorea,  604 ;  in  disseminated  scle- 
rosis, 550;  in  ear  disease,  485;  in 
influenza,  903  ;  in  lead-poisoning, 
955;  in  meningitis,  337;  in  other 
diseases,  136 ;  in  pachymeningitis, 
327 ;  in  scarlet  fever,  899 ;  in  tumour, 
505 

mechanism  of,  136,  505 

unilateral,  337 

Neuromata,  499 

Neuro-paralytic  ophthalmia  in  sinus 
thrombosis,  453  ;  in  tumour,  515 

Neuroses,  occupation  (see  Occupation  neu- 
roses), 710,  728 

Neurosis  writing  (see  Writer's  cramp),  711 

Nocturnal  vertigo,  792 

Nose,  disease  of,  causing  abscess,  476 

Nuclear  ocular  palsy,  194 ;  acute,  198 ; 
chronic,  195  ;  sudden,  197;  tabetic,  190 

Nucleus  ambiguus,  47  (note);  accessorius 
of  hypoglossal,  45 ;  caudate,  40  ;  cen- 
tralis of  hypoglossal,  45 ;  dentate,  38 ; 
lateral,  35;  lenticular,  27,  38,  40; 
postero- external,  34;  postero-median, 
34;  post-pyramidal,  34;  root;  37 

—  of  cerebellum,  57 

—  lemnisci,  37 

Nurses'  contracture,  700  (see  Tetany) 
Nutritional  disease,  72 
Nystagmus,  187,  207 

—  in   albinism,   207 ;    in    anaemia,   370 ; 

in  disseminated  sclerosis,  547,  551, 
557;  in  nervous  disease,  207;  in 
pachymeningitis,  327;  in  tumour, 
513  ;  in  uraemia,  776 ;  in  vertigo,  210, 
787 

—  miners',  207 

—  paralytic,  171 

O 

Oblique  muscles  of  eyes,  179 
Obstruction  of  particular  arteries,  436 
Occipital  bone  in  tetanus  neonatorum,  6S0 
(foot-note) 

—  lobe,  5  ;  atrophy  of,   and  effects,  71 ; 

localisation  in,  312 
Occupation  neuralgia,  719 


Occupation  neuroses  (see  Writers'  cramp, 

&c),  710,  728 
Ocular  hyperaesthesia,  167 
symptoms  of,  170 

—  nerves,  anatomy,  49-53;  disease  of,  16S 

—  movements,  limitation  of,  170 

—  muscles,  paralysis  of,  internal,  182 
paralysis  of,  combined  in  tumour, 

513;  diphtheritic,  190,  906;  in  ex- 
ophthalmic goitre,  882 ;  in  haemor- 
rhage, 191;  in  lead-poisoning,  955; 
in  neuritis,  189  ;  nuclear,  194 ;  recur- 
ring or  periodic,  192;  relapsing,  192; 
rheumatic,  191 ;  syphilitic,  191 ;  ta- 
betic, 190 

—  neuralgia,  806 

—  spasm,  204;  associated,  204;  chronic, 

205 ;  hysterical,  206 ;  irregular,  205 ; 
paroxysmal,  206 

—  vertigo,  172,  782 
Oculo-facial  palsy,  infantile,  197 
Odour,  138 

(Edema  with  neuralgia,  801 

Oidium  albicans  causing  abscess,  471,  478 

Oinomania,  981 

Olfactory  aura,  20 

—  hyperesthesia,  141 

—  nerve,  56;   diseases  of,  138;  in  brain 

tumour,    512;    electrical    stimulation 

of,  141 
Olivary  bodies,  35  ;  superior,  37, 187 ;  and 

facial  nucleus,  49 
Operculum,  4 
Ophthalmoplegia,    194    (see   also   Nuclear 

palsy);     acute,    198;    chronic,     195  j 

sudden,  194,  197 

—  external  and  internal,  194;  peripheral, 

199;  total,  196 

—  and  bulbar  palsyT,  565  ;  and  tabes,  195 ; 

and  exophthalmic  goitre,  882 
Ophthalmoscopic  signs,  131 
Opisthotonos,  in  abscess,  481 ;  in  hysteria, 

1003  ;  in  tetanus,  682 
Optic  atrophy  (see  Atrophy),  135,  &c. 

—  chiasma,    damage   to,   144;    symptoms 

of,  148 

—  nerve     and     visual    symptoms,    142 ; 

damage  to,  144 ;  decussation  of,  143 ; 
function  of,  145 ;  in  brain  tumours, 
512 ;  in  disseminated  sclerosis,   547 
origins  of,  54 ;  symptoms  of  affection 
of,  147 


INDEX, 


1063 


Optic  neuritis   (see  Neuritis,  optic),   130, 
132,  &c. 

—  radiation,  26,  40,  54 

—  thalamus,   40;    and   optic   tract,    40; 

localisation  in,  316 

—  tract,  55;  damage  to,  145 
Orbicularis  in  hemiplegia,  78 
Orbital  disease  causing  abscess,  476 
Orgauic  disease,  72 
Orthotonos,  682 

Osteofibroma  of  brain,  491,  499 
Otitis,  diagnosis  from  meningitis,  352 
Ovarian  tenderness,  987,  991,  992 
Ovariotomy  in  hysteria,  987,  1023 


Pachymeningitis,  323 ;  external,  324 ; 
haemorrhagic,  325;  internal,  324; 
purulent,  324 ;  serous,  326,  328 

—  in  alcoholism,   325;    in    general  para- 

lysis, 325  ;  in  scorbutic  rickets,  325  ; 
in  other  diseases,  325 
Palate,  paralysis  of,  306 ;  in  diphtheria, 
•  905;  in  erysipelas,  897;  in  facial 
paralysis,  236 ;  in  facial  spasm,  254; 
after  typhoid,  897 

—  nerve-supply  to,  307;  origin  of  spinal 

accessory  fibres  to,  45 

Paisy,  shaking  (see  Paralysis  agitans),  636; 
nuclear,  ocular,  194  (see  Ophthalmo- 
plegia) ;  oculo  facial,  197 

Papillitis,  132  (see  Neuritis,  optic) 

Paracentral  lobule,  4 

Parageusia,  228 

Parallel  fissure,  5 

Paralysis  after  acute  diseases  (see  Acute 
diseases),  894 

—  agitans,   636  ;  and   disseminated   scle- 

rosis, 555,  654;  and  injury,  638; 
and  mercurial  tremor,  969;  and  post- 
hemiplegic tremor,  655 ;  and  senile 
tremor,  654 ;  and  tetany,  651 

—  —  electrical  irritability  of  nerves  in, 

653  ;  festination  in,  645 
pains  and  stiffness  in,  639  ;  propul- 
sion in,  645  ;  relation  of  cerebellum  to, 
651 ;  relation  of  emotion  to,  652 ; 
retropulsion  in,  646  ;  tremor  in,  640  ; 
weakness  and  rigidity  in,  644 ; 
varieties  of,  648 

—  bulbar  (see  Bulbar  paralysis),  562 

—  facial,  230  (see  Facial  paralysis) 


Paralysis,  general  and  disseminated  scle- 
rosis, 556;  and  mercurial  tremor,  970 

—  motor,  74;  mental  change  in,  648 

—  post -choreic,  609 

—  post-convulsive,  92 
Paralytic  chorea,  599,  606,  619 

—  rabies,  930,  935,  939 
Paramyoclonus  multiplex,  629 
Paraphasia  in  temporo-sphenoidal  lesions, 

313 
Paraplegia  after  typhoid,  895 

—  alcoholic,  982 

—  hysterical,  995 

—  in  exophthalmic  goitre,  882 
Parasitic  cysts,  500 

Paresis,  74 

Parietal  convolution,  ascending,  4 

—  lobe,  3  ;  localisation  in,  312 

—  lobule,  superior  and  inferior,  4 
Parieto-occipital  fissure,  2,  4 

—  squamosal  suture,  8 

Parkinson's  disease  (see  Paralysis  agitans), 

636 
Paroxysmal  headache,  836 
Partial  hemianopia,  154 
Passive  congestion,  376,  378 
Pasteur's  treatment  of  hydrophobia,  933, 

938 
Peduncles  of  cerebellum,  28,  35,  38,58,321 

—  pressure  in,  515 
Periaxial  neuritis,  956 
Perisplenitis  in  pachymeningitis,  328 
Periodical  paralysis  of  ocular  muscles,  192 
Peritonitis,  false,  991 

Perspiration,  local,  in  hysteria,  1015 
Petit  mal,  735,  744 ;  and  automatism,  743, 

746 ;  treatment,  765 
Petrosal  ganglion,  276 

—  sinus,  thrombosis  in,  453 
Phantom  tumours,  1000,  1028 
Pharyngeal  plexus,  281 

Pharynx,  paralysis  of,  282,  565 ;  in  diph- 
theria, 905 

—  spasm  of,  282 

Phonic  laryngeal  spasm,  293 

—  paralysis,  291;  in  hysteria,  291 
Photophobia,  167 

Pia  mater,  inflammation  of,  328 
Pianoforte  player's  cramp,  729 
Pigmentation,  arsenical,  966 

—  in  Graves's  disease,  890 

—  from  silver,  967 


1064 


INDEX. 


Pineal  gland,  tumour  of,  500 

Pituitary  body,  tumours  of,  516;  glyco- 
suria, 516 

Plaques  jaunes,  430 

Pleurodynia,  834 

Pleurothotonus,  682 

Pli  courbe,  5 

Pneumogastric  nerve,  nucleus  of,  45,  47  ; 
diseases  of,  278 

Point  apophysaire,  800 

Polio-encephalitis,  194,  460 

Polio-myelitis  bulbi,  578 

—  in  goitre,  885 ;  measles,  896 ;  typhoid, 

896 ;  variola,  898 
Pons,  abscess   in,  482 ;  blood-vessels   of, 

65 ;    glioma    of,    495 ;    haemorrhage 

into,  394 ;  hypertrophy  of,  495,  58«i ; 

lesion  of,  degeneration  following,  69; 

lesion   of,    causing    hemiplegia,  81 ; 

localisation  in,  318;  tumours  of,  495 
Porencephalia,  459 
Position,  sense  of,  95 
Post-choreic  paralysis,  609 
Post-convulsive  paralysis,  92 
Posterior  cerebral    artery,  64 ;    aneurism 

of,  536 
~  communicating   artery,   60;  aneurism 

of,  535 

—  crico-arytaenoid  muscle,  284 

—  fo>sa,  tumours  of,  515 

—  horizontal  fibres,  28 

—  pyramid,  28,  29 

—  longitudinal  fibres,  28,  33,  37 
Postero-external  nucleus,  34 
Postero-median  column,  34 
Post-epileptic  automatism,  743,  746 
Posthemiplegic   chorea,   611     (see   Athe- 
tosis) 

disorders  of  movement,  85 

—  epilepsy,  730,  733,  749 
Post-pyramidal  nucleus,  34 
Posture,  perception  of,  39 
Precentral  sulcus,  4 
Precuneus,  4 

Prefrontal  lobe,  6;  localisation  in,  311 
Pregnancy  and  chorea,  596,  618 
Priapism  in  hydrophobia,  928 
Progressive  bulbar  palsy,  564 

—  muscular    atrophy,    568 ;    relation  to 

lead  palsy,  961 

—  ophthalmoplegia,  195  (see  Ophthalmo- 

plegia) 


Projection,  erroneous,  172 

Propulsion  in  paralysis  agitans,  645 

Prosopalgia,    806    (see    Neuralgia,    trige- 
minal) 

Psammoma,  499 

Pseudo-bulbar   paUy,    320;     and    bulbar 
palsy,  572,  577 ;  speech  in,  109 

Pseudo-tabes  in  arsenical  poisoning,  964 

Psychical  processes  and  cortex,  25 

Pterion,  8 

Ptosis,  181 ;  congenital,  200 ;  double,  192 
from    sympathetic     paralysis,    200 
hysterical,      201 ;       morning,      201 
periodical  or  recurring,  192 ;  reflex. 
200 ;  relapsing,  192 ;  in  tetanus,  6S4 

Puberty,  barking  cough  of,  294 

Puerperal  convulsions,  773;  and  Blight's 
disease,  774 

—  tetanus,  675,  678 
Pulmonal  cerebral  abscess,  477 
Pulmonary  branches  of  vagus,  294 
Pulse  in  brain  disease,  127 

—  in  exophthalmic  goitre,  874 
Pulvinar,  40 

Pupil  symptoms,  182,  183,  184 
Pupils  in  apoplexy,  104 

—  in  coma  and  stupor,  99 
Purkinje,  cells  of,  56 
Pyramidal  cells,  large  and  small,  10 

—  fibres,  28,  29 

—  radiation,  26 

—  tracts,  28 ;  degeneration  in,  68 
Pyramids,  anterior  and  posterior,  28,  29, 

34 


Quadrate  lobule,  4 


Q 


R 


Rabies,  in  animals,  922 ;  in  man,  924  (see 
Hydrophobia) 

—  paralytic,   in    animals,   923;    in   man, 

930,  935,  939 
Recrossing  of  fibres  in  cord,  77 
Recti  muscles,  177,  178 
Recurrent  laryngeal  palsy,  282,  289 
Recurring  utterances,  118 
Red  nucleus,  27;  and  cerebellum,  38;  and 

peduncles,  58 

—  softening,  430,  465,  471 

Reflex   action,    superficial,  diminution   of, 
in  hemiplegia,  81 


INDEX. 


1065 


Reflex  action,  increase  of,  in  hemiplegia,  81 

—  amblyopia,  164 

—  epilepsy,  733 

—  neuralgia,  812 

—  ptosis,  200 

Reid's  rules  for  finding  fissures,  9 
Reil,  island  of,  6 

Relapsing  palsy  of  ocular  muscles,  192 
Relation  of  cortex  to  skull,  6 
Respiration  in  brain  disease,  128 

—  Cheyne- Stokes,  100,  128 
Respiratory  column,  47 ;  paralysis,  294 ; 

spasm  in  tetanus,  682 
Restilbrm  body,  35 
Retention  of  urine  in  hysteria,  1014 
Reticular  formation,   28,  33 ;    and  lateral 

nucleus,  35,  37 
Retinitis,  albuminuric,  131 ;  in  lead,  955 
Retraction    of    bead    in  abscess,    481 ;   in 

meningitis,  337,  340, 361 ;  in  tumour, 

512 
Retrocollic  spasm,  655,  667,  670,  672 
Retro-insular  convolution,  6 
Retropulsion,  646 
Rheumatic  neuralgia,  816 

—  neuritis  after  influenza,  962 
Rheumatism,  acute  paralysis  from,  900 

—  after  influenza,  902 

—  and  chorea,  595,  604,  616 
Rickets  and  convulsions,  769 

—  and  hypertrophy  of  brain,  583 

—  scorbutic,  and  pachymeningitis,  325 
Rigidity,  muscular,  82  ;  early,  82 ;  initial, 

82 ;  late,  82  ;  structural,  82 ;  tetanic, 
512;  tetanoid,  321 

—  of  neck  in  abscess,  482  ;  in  meningitis, 

337;  in  tumours,  512 
Rinne's  test  for  deafness,  264 
Risus  sardonicus,  681 
Rolando,  fissure  of,  2,  3 

—  grey  tubercle  of,  35 
Roller's  nucleus,  45 
Roof  nucleus,  37,  57 
Rupture  of  aneurisms,  532,  537 


Sacral  neuralgia,  811 

St.  Vitus's  dance,  591  (see  Chorea) 

Saltatoric  spasm,  631 

Sarcoma,  493,  496 

Saturnism,  local,  953  (see  Lead-poisoning) 

Scanning  utterance,  547,  552 


Scarlet  fever,  paralysis  after,  899 
Sclerosis,  diffuse,  558  ;  lobar,  468 ;  of  brain 
and  inflammation,  468 

—  disseminated,     insular     or     multiple, 

543;  articulation  in,  547,  552;  ataxy 
in,  549;  head,  oscillation  in,  548;  jerki- 
ness  in,  548  ;  mental  change  in,  552  ; 
myotatic  irritability  in,  549;  nys- 
tagmus in,  547,  551 ;  ocular  muscles 
in,  551 ;  optic  nerve  changes  in,  550; 
trophic  changes  in,  553 

and  disseminated  syphilitic  inflam- 
mation, 554;  and  general  paralysis 
556 ;  and  hysteria,  557 ;  and  mer 
curial  tremor,  970;  and  paralysis 
agitans,  555,  564 

relation  to   syphilis,  545 ;  varieties 

of,  544 

Sclerotic   inflammation,   chronic    dissemi- 
nated, 469 

Scorbutic  rickets  and  pachymeningitis,  325 

Scotoma,  central,  162 

Screaming  fits,  771 

Scrivener's      palsy,     711     (see     Writer's 
cramp) 

Secondary  degenerations  in  brain,  67 

—  deviation  of  eye,  171 

—  over-action  of  facial  muscles,  242 
Semilunar  tract,  57 
Sempstresses'  cramp,  729 

Senile  atrophy  of  brain,  581 

—  chorea,  626  (see  Chorea) 

—  softening,  469 

—  tremor,  654,  659 

Sensation,  affection  of,  in  hemiplegia,  88 

—  loss  of,  94 

Sensations,  cephalic,  96,  863  (see  Cephalic) 
Sensibility,  muscular  and  visceral  paths  of, 

39 
Sensory  aphasia,  112,  119 

—  centres,  14,  20 

—  crossway,  40,  94,  315 

—  irritation,  96 

—  path,  20,  33,  39 

—  symptoms,  94;  in  tumour,  512 
Serous  apoplexy,  101,  582 

Shaking  palsy,  636  (see  Paralysis  agitans) 

Shivering,  physiology  of,  691 
Silver-p  oisoning,  967  ;  paralysis  in,  968 
Simple  apoplexy,  101,  104,  407 

—  meningitis,  330 

—  mental  failure,  107 


1066 


INDEX. 


Simulated  fits  and  epilepsy,  760 

Sinus  thrombosis,  450,  453 

Sixth  nerve,  anatomy,  168 ;  affection  of, 

180 ;  nucleus  of,  49 ;  in  brain  tumour, 

513 
Skin,  electrical  resistance  in  exophthalmic 

goitre,   880 ;    pigmentation    of    (see 

Pigmentation),  890,  966,  967 
Skull,  relation  of,  to  cortex,  6 
Sleeping  sickness,  African,  1039 
Slender  column,  46,  47 
Smell,  affections  of,  138—140  ;  aura,  142 ; 

centre  for,  20;  loss  of,  in  aneurism, 

538 ;  perversion  of,  142 ;    subjective 

sensations  of,  141 
Smiths'  cramp,  729 
Softening  of  brain,  421,  465  (see  Brain)  ; 

acute,  421 ;  chronic  progressive,  541 

necrotic,  422 

red,  430,  465,  471 

seat  of,  431 

white,  430,  465 

yellow,  430,  465 

Somnambulistic  state,  1032 

Sore  throat  in  tetanus,  681 

Space-nerve,  260 

Spasm  of  face,  248 ;  in  tetanus,  681 

—  —  palate  in,  254 

stapedius  in,  245 

taste  in,  254 

—  of     masticatory     muscles,     221  ;      in 

tetanus,  681 

—  mimic,  248 

—  of  ocular  muscles,  204 — 206 

—  habit,  633 

—  mobile,  see  Athetosis 

—  retrocollic,  667 

—  saltatoric,  631 
Special  sense,  aural,  92 

Speech,   affection   of,   109 ;    articulator)', 
109;  cerebral,  110;  in  tumour,  110 

—  centres,  24 

—  loss  of,  in  children,  111 

—  processes  in  brain,  111 ;  path  for,  113 

—  sensory  relations  of,  112 
Spermatorrhoea,  1043 
Spherical  nuclei,  57 

Spinal  accessory  nerve,  diseases  of,  278 ; 

external  part,  299  ;  nucleus  of,  45 

—  in  brain  tumours,  514 

— in  progressive  muscular  atrophy, 

301 


Spinal    column,    neuralgia    of,   811 ;    in 
hysteria,  991 

—  disease  and  neuralgia,  822 

and  paralysis  agitans,  654 

Splenius,  spasm  of,  665 
Squint,  171 

Staccato  utterance,  110,  552 

Stapedius,  spasm  in,  254 

Static    reflex    spasm    (saltatoric   spasm)> 

631 
Status  epileticus,  751,  752,  766,  775 
Stellwag's  symptom,  877 
Stephanion,  8 
Sterno-mastoid  paralysis,  300  j  spasm,  300,. 

659,  664 
Stertor,  99 

Stiff  neck  in  tetanus,  680 
Stigmata  in  hysteria,  1016 
Strabismus,  170,  171 
Structural  contracture,  82 

—  damage,  varieties  of,  73 
Stupor,  99 

Subarachnoid  haemorrhage,  390 
Substantia  nigra,  27,  29 
Subthalamic  region,  40 
Sudden  bulbar  palsy,  574 

—  death  in  haemorrhage,  402 

—  paralysis  in  tumour,  517 

—  tumour,  518 

Superior   longitudinal   sinus,   66;  throm- 
bosis in,  453 

—  medullary   velum,    and  fourth   nerve,. 

52 

—  oblique  muscle,  paralysis  of,  179 

—  olivary    body,    37,    187;     and   facial 

nucleus,  49 

—  parietal  lobule,  4 

—  pyramidal  decussation,  34 

—  rectus,  paralysis  of,  178 
Supra-marginal  convolution,  4 

Surgery  of  brain,  anatomical  rules,  7 — 9, 

487,  488 
Surgical  treatment  of  abscess,  487,  488 

—  —  of  tumours,  527 
Syllabic  utterance,  110,  552 
Sylvian  fissure,  2,  3 

—  vein,  66 

Sympathetic  in  exophthalmic  goitre,  884, 
886,  890 

—  in  paralysis,  affections  of,  85 

—  neuralgia,  812 
Symptomatic  neuralgia,  814 


INDEX. 


1067 


Symptoms    of    brain    disease,    72,   125 ; 

direct  and  indirect,  443 ;  diffuse,  74; 

focal,  74  ;  motor,  74 
Syncope  and  apoplexy,  103,  407 

—  and  epilepsy,  756 

Syphilitic  choroiditis,  131 ;  vascular  dis- 
ease, 389,  425,  442;  and  aneurism, 
530 

—  meningitis,  345,  522 ;  neuralgia,  817 ; 

ocular  palsy,  191 

—  tumours,  488,  490,  493,  523 

T 

Tabes,  821,  822 ;  and  arsenical  poisoning, 

964;  and  alcoholism,  982 
Tabetic  paralysis  of  ocuhir  muscles,  190 
Tache  cerebrale,  339 
Taste,  affections  of,  224 ;  and  fifth  nerve, 

216, 225  ;  and  dorso-pharyngeal,  277 ; 

in  facial    paralysis,   237;    in  facial 

spasm,  254 

—  fibres,  course  of,  227 

—  perversion  of,  228 
Teething  fits,  769 
Tegmental  nucleus,  28 

Tegmentum,  27  ;  connections  of,  37,  38 ; 
destination  of,  39 

Telegraphists' cramp,  729 

Temperature,  in  brain  diseases,  126;  in 
apoplexy,  101 ;  in  cerebral  haemor- 
rhage, 388;  in  paralysed  limbs,  84; 
in  hysteria,  1016 

Temporal  hemianopia,  see  Hemianopia 

—  lobe,  5 

Temporo-parietal  convolution,  6 
Temporo-sphenoidal   lobe,   5;   lesions   of, 

24 ;  localisation,  312 

Tenderness,  spinal,  in  neurasthenia,  1047 

Tendon-reflexes  in  hemiplegia,  83  (see  also 
Knee-jeik) 

Teratoma,  499 

Terminal  arteries,  431 

Tetanic  attacks,  93  ;  in  cerebellar  disease, 
93 

Tetanilla,  698 

Tetanoid  chorea,  709 

Tetanus,  674;  and  circumcision,  680  ;  and 
earth-mould,  676 ;  and  hydrophobia, 
691;  and  hysteria,  692;  and  nerve 
irritation,  630  ;  and  strychnia  poison- 
ing, 691 ;  and  tetany,  692,  708 ;  and 
umbilical  conditions,  680 


Tetanus,  abortive,  684;  cephalic,  683;  hy- 
drophobicus,  683;  idiopathic,  675, 
678;  neonatorum,  675, 679 ;  puerperal, 
675,  678 ;  rheumatic,  675,  678 ;  trau- 
matic, 674 

—  bacillus    of,    688;    and    earth-mould, 

676 ;  influence  of  colour  in,  675 ; 
nerve-stretching  in,  694;  opistho- 
tonos in,  682 ;  ptosis  in,  684  ;  spasm 
in,  682  ;  surgical  treatment  of,  694 ; 
tetanine,  689  ;  toxine  of,  689  ;  tying 
vertebrals  for,  698 
Tetany,  698;  and  gastric  dilatation,  700  j 
and  hysteria,  700;  and  myxcedema, 
707 ;  and  rickets,  700 ;  and  thyroid, 
707 

—  epidemics    of,   701 ;    increased  irrita- 

bility of  nerves  in,  703 

—  nocturnal,  704, 1049  ;  sleep,  704, 1049  ; 

varieties  of,  704 

Thalamus,  optic,  40 

Thane's  plan  for  finding  fissures,  8 

Theriomimicry,  1009 

Thinning  of  cranial  bones,  503 

Third  nerve,  168;  affections  of,  180; 
nucleus  of,  53;  recurring  affection  of, 
193 

and  corpora  quadiigemina,  53 

in  brain  tumours,  513 

Thrombosis,  424;  from  atheroma,  428; 
from  syphilitic  disease,  429;  simple, 
426 ;  in  different  vessels,  436 ;  in 
cerebral  veins  and  sinuses,  450;  pri- 
mary, 450;  secondary,  451 

—  and  ear  disease,  454 ;  surgical  treat- 

ment of,  455  ;  and  haemorrhage,  408 

—  venous,   as    cause   of   infantile   hemi- 

plegia, 451,  461 

Thrombotic  softening,  424  (see  Brain  soft- 
ening) 

Thyro-arytasnoid  muscle,  283 

Thyroid  in  exophthalmic  goitre,  875,  881 ; 
excision  effects,  889,  893 

Tic  convulsif,  248 

Tic  douloureux  (see  Neuralgia,  trigeminal), 
806 

—  rotatoire,  662  (foot-note) 

Tinnitus  aurium,  261,  268,  270  ;  in  neur- 
asthenia, 1047 

—  capitis,  270 
Tobacco  amblyopia,  148 
Tone,  83 


1068 


INDEX. 


Tongue,  centre,  18  ;  dyssesthesia  of,  306  ; 
hemiatrophy  of,  303;  paralysis  of, 
302;  in  hemiplegia,  75,  79,  304; 
spasm  of,  304 

Tonsillitis,  paralysis  after,  903 

Torticollis,  659;  congenital  or  fixed,  660; 
false,  670;  hysterical,  670;  spas- 
modic, 660 

Torticollis,  electricity  in,  672;  muscles 
acting  in,  664 ;  surgical  treatment  of, 
673 

—  and  spinal  accessory  nerve,  300 
Toxaemia  causing  brain  symptoms,  103 
Toxaemic  delirium,  106 

Toxic     amaurosis,    163 ;    delirium,    106 ; 

palsy,  967  ;  tumour,  659 
Toxine    produced    by    organism    in  acute 

diseases,   895 ;    in   diphtheria,    917 ; 

of  tetanus,  689 
Trance,  107,  1030,  1034 
Transfer  in  hysteria,  993 
Trapezius,  paralysis  of,  300 
Traumatic  haemorrhage,  391 

—  neuralgia,  813 

—  tetanus,  674 

Tremor,   forms   of,    657;   alcoholic,  974, 
981 ;  asthenic,  659  ;  convulsive,  630 
head,  952;  hysterical,  658, 1001,1028 
mercurial,  969;   post-hemiplegic,  85 
senile,  657;  simple,  657;  toxic,  659 

—  in  paralysis  agitaus,  640;    distinction 

from  senile,  654,   659  ;  in  exophthal- 
mic goitre,  881,  889 ;  after  typhoid, 
897 
Trephining  for  abscess,  486,  487,  488 

—  for  tumour,  527 

Trigeminal  neuralgia,  806  (see  Neuralgia) 
Trismus,  221,  674;   nascentium,  675,  679, 

691 ;  hysterical,  998 
Trophic  changes  in  brain  disease,  84,127; 

in  disease  of  fifth,  217 
Trunk  muscles,  centre  for,  18 

—  neuralgia,  810 
Tubercle  of  Rolando,  35 

—  in  choroid,  132 

Tubercular  meningitis,  330,  333,  341 ;  in 
adults,  343 ;  in  children,  341 ;  par- 
tial, 344;  and  tumours,  351,  352;  and 
typhoid,  350 

—  tumours,    491,    492;    and    meningitis, 

351,  352  ;  and  abscess,  484 
Tuberculosis,  miliary,  335 


Tumours,  intra-cranial,  4S8 

conditions  in,  viz. :  athetosis,  509 ; 

contracture,  509;  convulsions,  510; 
cranial  nerves,  512 ;  death,  cause  of, 
516;  giddiness,  507 ;  headache,  504; 
hydrocephalus,  internal,  502 ;  jerky 
inco-ordination  in,  510 ;  mental  sym- 
ptoms, 506;  motor,  508;  optic  neuri- 
tis, 505;  perforation  of  bones,  504; 
pulse,  515 ;  sensory  symptoms,  512 ; 
sphincter  affection,  515 ;  speech  affec- 
tion, 507;  thinning  of  bones,  503; 
unsteadiness,  510;  vomiting,  507 

Tumours,  intra-cranial,  duration  of,  518; 
cause  of  death  in,  516 

effects  of,  501 

locality  of,  491 

varieties  of,  488,  490,  viz. :  bony, 

499 ;  carcinoma,  498 ;  cholesteatoma, 
499 ;  cysts,  499 ;  erectile  and  vas- 
cular, 499;  fibroid,  499;  gliomata, 
493,  494;  lipoma,  499;  melanotic, 
498;  myxoma,  498;  neuroma,  499; 
psammoma,  499  ;  sarcoma,  493,  496 ; 
syphilitic,  493  ;  teratoma,  499  ;  tuber- 
cular, 491 ;  vascular  and  erectile,  499 

—  —  and  aneurism,   522 ;  and  epilepsy, 

521 ;  and  general  paralysis,  521 ;  and 
hysteria,  520,  988;  and  meningitis, 
503,  522 ;  and  traumatism,  489,  490 

—  of  base,  515,  516 

—  phantom,  1000 
Type-writers,  727 

Typhoid  fever,  aphasia  in,  895  ;  paralysis 
after,  895;  tremor  in,  897;  and 
meningitis,  350 

Typhus  lever,  466;  paralysis  after,  897 

U 

Ulcerative  endocarditis  causing  embolism, 

423 
Ultimuin  moriens,  301 
Uncinate  gyrus,  5 ;  and  olfactory  nerve, 

56;  localisation  in,  313 
Uraemia,  103,  366 ;  convulsions,  768,  776 ; 

and  epilepsy,  759 
Uraemic  convulsions,  768,  774,  776 
Urinary  symptoms,  131 
Urine,  retention  of,  in  hysteria,  1014 
Uterine  phlebitis,  423 
Utterance,  recurring,  118 


INDEX. 


10Q9 


Vagus,  cardiac  branches  of,  295;  diseases 

of,   278;    gastric   branches   of,   296; 

neuritis   of,    295;    nucleus    of,    45; 

pulmonary  branches  of,  294 
Valleix's  points,  800 
Vapours  in  hysteria,  1040 
Variola,  paralysis  after,  898 
Vascular  lesions  in  acute  diseases,   894; 

diphtheria,  909 ;  scarlet  fever,  899 

—  tumour,  499 

Vaso-inotor  and  trophic  changes,  84,  127; 
in  exophthalmic  goitre,  882 

—  symptoms  in  hysteria,  1015 

—  theory  of  epilepsy,  755;  for  tetanus,  698 
Venesection  in  apoplexy,  411 

Venous  circulation  of  brain,  66 

—  thrombosis,  450,  461 
Ventricles,  localisation  in,  322 
Ventricular  haemorrhage,   391,  395,   402, 

409 

—  meningitis,  340 
Verbal  amnesia,  121 
Vermiform  process,  57 

Vertebral  artery,  60;  aneurism  of,  106, 
535;  obstruction  of ,  440 ;  ligature  of, 
for  epilepsy,  768 ;  for  tetanus,  698 

Vertigo,  777 ;  auditory,  261,  782 ;  epi- 
leptic, 738,  793;  epileptoid,  793; 
essential,  793 ;  gastric,  792 ;  laby- 
rinthine, 261,  782 ;  migrainous,  848 ; 
nocturnal,  792;  ocular,  172,  782; 
other  forms,  792 

—  and  arterial   degeneration,    793;    and 

cerebral  disease,  97,  790 ;  and  epilepsy, 
790;  and  nystagmus,  787 ;  and  tinni- 
tus, 787;  and  tumour,  507 
Vessels  of  brain,  60 
Vestibular  root  of  auditory,  48 
Vidian  nerve,  214,  236,  307 
Vieussens,  valve  of,  and  fourth  nerve,  52 
Violin-player's  cramp,  729  (see  Cramp) 
Visceral  neuralgias,  832  (see  Neuralgia) 

—  sensibility,  path  of,  39 
Vision,  examination  of,  146 


1  Vision  in  optic  neuritis,  1 35 ;  in  diphtheria, 
906 

—  surface,  representation  of,  21 
Visual  aura,  92 

—  centre,  21 ;  symptoms,  142 

—  field,    erroneous    projection    of,   172; 

limitation  of,  147 
in  exophthalmic  goitre,  881 

—  hallucinations,  166 

—  symptoms,  142 

Vocal  cord,  paralysis  of,  284,  288 

Voice,  alterations  of,  286 

Voluntary  movements  in  hemiplegia,  79 

—  speech,  see  Speech 
Vomiting  in  brain  diseases,  130 
tumours,  507 

Von  Graele's  symptoms,  877 

W 

Warnings  in  epilepsy,  735 — 740 
Weakness,  irritable,  722 
Weir-Mitchell  treatment,  1022,  1024 
Wernicke's  sign,  163 
White  softening,  430 
Willis,  circle  of,  60 
Word-blindness,  112, 122 
Word-deafness,  112,  119 
Word-processes,  site  of,  in  cortex,  113; 

path  for,  113 
Worms  and  epilepsy,  733 
Wrist-drop,  948 

Writers'  cramp,  711  (see  Cramp) 
Writing,  methods  of,  713 
Wry-neck,  659  (see  Torticollis) 


Yellow  softening,  430 


Zonal  stratum,  40 

Zoopsia,  1007 

Zoster,  herpes,  and  neuralgia,  814,  820 


PRINTED  BY  WM.  F.  FELL  &   CO.,  PHILADELPHIA. 


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Leffmann's  New  Compend.      1.00 

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(Fowne's)  Organ. 

Wolff.     Applied  Medical. 
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CHILDREN. 
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Money.  Treatment  of.  -  3.00 
Muskett.  Treatment  of.  1.75 
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Horwitz.  Surgery.  5th  Ed.  1.00 
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Potter's    Anatomy,   5th  Ed.     1.00 

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Harris.     Principles  and  Prac.  7.00 

Dictionary  of.     5th  Ed.  5.00 

Heath.     Dis.  of  Jaws.     -         4.50 

Lectures  on  Jaws.  Bds.  1.00 

Leber    and     Rottenstein. 

Caries.  Paper,     75 

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Talbot.  Irregularity  of  Teeth.  3.00 
Tomes.     Dental  Surgery.  5.00 

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Warren's  Compend  of.  -  1.00 
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Maxwell.  Terminologia  Med- 
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DIRECTORY. 
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EAR. 
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Dalby.  Diseases  of.  4th  Ed.  3.50 
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cal Electricity.     43  Illus.         1.00 
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EYE. 
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Fox  and  Gould.  Compend.  1.00 
Gower's  Ophthalmoscopy.  5.50 
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1.50 
Practi- 


Wilson 
Wood. 


Sansom. 


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cal  Hygiene.     Illus. 
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Kenwood.      Public     Health 

Laboratory  Guide.  -  3.00 

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Tyson.     Bright's   Disease 

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Davis.     Essentials  of  Materia 

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MICROSCOPE. 

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Carpenter.     The  Microscope. 

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MacDonald.     Examination  of 

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Monthly   Nursing.  .50 

Domville's  Manual.  7th  Ed.  .75 
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Davis.  Obstetrics.  Illus.  2.00 
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POISONS. 

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Formation  of. 


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Gould's  Medical  Dictionaries, 

By  GEORGE  M.  GOULD,  A.M.,  M.D., 

OFHTHALMIC   SURGEON   TO   THE   PHILADELPHIA   HOSPITAL,  EDITOR  OF  "THE  MEDICAL  NEWS.' 

Compact,  Concise  Vocabularies.     Handy  in  size.    Low  in  Price. 
Convenient  for  Reference.    Authoritative. 

BASED  ON  RECENT   MEDICAL  LITERATURE. 


The  New  Medical  Dictionary.      Revised  to  1892. 

INCLUDING  ALL  THE  WORDS  AND  PHRASES  GENERALLY  USED  IN  MEDICINE,  WITH  THEIR 
PROPER  PRONUNCIATION   AND  DEFINITIONS,    BASED  ON    RECENT    MEDICAL    LITERATURE. 

With  Tables  of  the  Bacilli,  Micrococci,  Leucoma'ines,  Ptomaines,  etc.,  of  the  Arteries, 
Muscles,  Nerves,  Ganglia,  and  Plexuses;  Mineral  Springs  of  the  U.  S.,  Vital  Statis- 
tics, etc.      Small  octavo,  520  pages. 

Half  Dark  Leather,  $3.25  ;  Half  Morocco,  Thumb  Index,  $4.25 

"One  pleasing  feature  of  the  book  is  that  the  reader  can  almost  invariably  find  the  definition  under  the 
word  he  looks  for,  without  being  referred  from  one  place  to  another,  as  is  too  commonly  the  case  in  medical 
dictionaries.     The  tables  of  the  bacilli,  micrococci,  leucomaines,    and   ptomaines  are  excellent,  and  contain  a 

large  amount  of  information  in  a  limited  space.     The  anatomical  tables  are  also  concise  and  clear 

We  should  unhesitatingly  recommend  this  dictionary  to  our  readers,  feeling  sure  that  it  will  prove  of  much 
value  to  them." — The  American  Journal  of  Medical  Science. 

The    Pocket    Pronouncing    Medical    Lexicon.       Just 
.  About  12.000  Words. 


Ready. 


a  student's  pronouncing  medical  lexicon.  Containing  all  the  Words,  their  Defini- 
tion and  Pronunciation,  that  the  Student  generally  comes  in  contact  with  ;  also 
elaborate  Tables  of  the  Arteries,  Muscles,  Nerves,  Bacilli,  etc.,  etc.  ;  a  Dose  List  in 
both  English  and  Metric  System,  etc.,  arranged  in  a  most  convenient  form  for  refer- 
ence and  memorizing.     Thin  641T10.  Leather,  $1.00 

The  great  success  of  Dr.  Gould's  "  New  Medical  Dictionary"  suggested  the  publica- 
tion of  this  smaller  volume  for  the  pocket.  It  has  been  prepared  upon  the  same  practical, 
systematic  plan  as  the  larger  book,  and,  like  it,  has  been  based  upon  the  most  recent 
medical  literature.  It  contains  about  12,000  words — nearly  double  the  number  in 
any  other  pocket  medical  dictionary — and  as  many  of  these  words  are  not  to  be 
found  in  any  other  dictionary,  large  or  small,  it  may,  from  this  point  of  view,  be  consid- 
ered as  a  supplement  to  them. 

The  form  and  size  of  the  volume  have  been  selected  as  most  practical.  It  is  printed 
on  very  good,  thin,  opaque  paper,  from  a  clear,  new  type ;  it  is  no  wider  than  the  old- 
shaped  books ;  it  is  thinner ;  and  the  length  of  the  page  has  permitted  the  addition  of 
several  thousand  words.  It  will  be  found  to  slip  readily  into  any  pocket  that  will  take 
the  "  32mos,"  and,  unlike  them,  will  not  feel  or  look  bulky. 

The  tables  will  be  found  of  great  value,  as  much  of  the  material  thus  classified  is  not 
obtainable  by  English  readers  in  any  other  work,  either  in  this  or  any  other  shape. 

*:)c*Gould's  New  Dictionary  has  been  almost  unanimously  recommended  by  the 
medical  press  of  America  and  England.  It  has  been  recommended,  with  but  very  few 
exceptions,  in  all  American  medical  colleges,  and  is  recognized  as  "  Standard  "  by  all 
thinking  men.  The  Pocket  Book  will  be  found  deserving  of  the  same  high  praise. 
These  books  may  be  ordered  through  any  bookseller,  or  upon  receipt  of  price  the 
publishers  will  deliver  free  to  the  purchaser's  address.  Full  descriptive  circulars  and 
sample  pages  sent  free  upon  application. 


P.  BLAKISTON,  SON  &  CO.'S 
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AITKEN.  Animal  Alkaloids,  the  Ptomaines,  Leucomames  and  Extractives  in 
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ALLEN,   HARLAN,   HARTE,  VAN   HARLINGEN.     Local   Therapeutics. 

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ALLEN.    Commercial  Organic  Analysis.    A  Treatise  on  the  Modes  of  Assaying 
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Medicine,  etc.,  with  Concise  Methods  for  the  Detection  of  Impurities,  Adultera- 
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Vol.  I.  Alcohols,  Ethers,  Vegetable  Acids.  Starch,  etc.  Out  of  Print. 

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ANDERSON.  A  Treatise  on  Skin  Diseases.  With  special  reference  to  Diagnosis 
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5 


F.  BLAKISTON,  SON  5-  CO.'S 


ARMATAGE.  The  Veterinarian's  Pocket  Remembrancer :  being  Concise 
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Second  Edition,     32mo.  Boards,  $1.25 

BALLOU.  Veterinary  Anatomy  and  Physiology.  By  Wm.  R.  Ballou,  m.d., 
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BARRETT.  Dental  Surgery  for  General  Practitioners  and  Students  of  Medicine 
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BARTLEY.  Medical  Chemistry.  Second  Edition.  A  Text-book  for  Medical  and 
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Toxicology  at  the  Long  Island  College  Hospital ;  President  of  the  American 
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423  pages.     i2mo.  Cloth,  $2.50 

BEALE.  On  Slight  Ailments ;  their  Nature  and  Treatment.  By  Lionel  S.  Beale, 
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Protoplasm.  Physical  Life  and  Law;  or,  Nature  Viewed  from  Without. 
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The  Use  of  the  Microscope  in  Practical  Medicine.  .For  Students  and 
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How  to  Work  with  the  Microscope.  A  Complete  Manual  of  Microscopical 
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Containing  over  400  Illustrations,  marty  of  them  colored.     8vo.    Cloth,  $7.50 

One  Hundred  Urinary  Deposits,  on  eight  sheets,  for  the  Hospital,  Labora- 
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BEASLEY'S  Book  of  Prescriptions.  Containing  over  3100  Prescriptions,  collected 
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and  their  Remedies.     By  Henry  Beasley.     Seventh  Edition.  Cloth,  $2.25 

Druggists'  General  Receipt  Book.  Comprising  a  copious  Veterinary  Formu- 
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Compounds  Employed  in  Medical  Practice.    Eleventh  Edition.    Cloth,  $2.25 


MEDICAL  AND  SCIENTIFIC  PUBL1CA  TIONS.  7 

BIDDLE'S  Materia  Medica  and  Therapeutics.  Twelfth  Edition.  For  the  Use  of 
Students  and  Physicians.  By  Prof.  John  B.  Biddle,  m.d.,  Professor  of  Materia 
Medica  in  Jefferson  Medical  College,  Philadelphia.  The  Twelfth  Edition,  thor- 
oughly revised  by  Clement  Biddle,  m.d.,  Assistant  Surgeon,  U.  S.  Navy. 
With  64  Illustrations  and  a  Clinical  Index.  Cloth,  $4.25;  Sheep,  $5.00 

BIGELOW.  Plain  Talks  on  Medical  Electricity  and  Batteries,  with  a  Thera- 
peutic Index  and  a  Glossary.  Prepared  for  Practitioners  and  Students  of  Medi- 
cine. By  Horatio  R.  Bigelow,  m.d.,  Fellow  of  the  British  Gynaecological 
Society  ;  of  the  American  Electro-Therapeutic  Association  ;  Member  American 
Medical  Association,  etc.    43  Illus.,  and  a  Glossary.    2d  Ed.     i2mo.     Cloth,  $1.00 

BLACK.  Micro-Organisms.  The  Formation  of  Poisons.  A  Biological  study  of 
the  Germ  Theory  of  Disease.     By  G.  V.  Black,  m.d.,  d.d.s.  Cloth,  $1.50 

BLACKBURN.  Autopsies.  A  Manual  of  Autopsies,  Designed  for  the  use  of  Hos- 
pitals for  the  Insane  and  other  Public  Institutions.  By  I.  W.  Blackburn,  m.d., 
Pathologist  to  the  Government  Hospital  for  the  Insane,  Washington,  D.  C.  With 
ten  Full-page  Plates  and  four  other  Illustrations.     i2mo.  Cloth,  $1.25 

BLAIR.  Potable  Waters.  The  Organic  Analysis  of.  By  J.  A.  Blair,  m.  b., 
cm.,  d.  sc.  Edin.,  etc.     Second  Edition.     i2mo.  Cloth,  $1.00 

BLODGETT'S  Dental  Pathology.  By  Albert  N.  Blodgett,  m.d.,  Late  Prof,  of 
Pathology  and  Therapeutics,  Boston  Dental  Coll.    33  Illus.    i2mo.    Cloth,  $1.75 

BLOXAM.  Chemistry,  Inorganic  and  Organic.  With  Experiments.  By 
Charles  L.  Bloxam.  Edited  by  J.  M.  Thompson,  Professor  of  Chemistry  in 
King's  College,  London,  and  A.  G.  Bloxam,  Dem.  of  Chem.,  Royal  Agricultural 
College,  Cirencester.  Seventh  Edition.  Revised  and  Enlarged.  With  281 
Engravings.     8vo.  Cloth,  $4.50;  Leather,  $5.50 

BOWLBY.    Injuries  and  Diseases  of  the  Nerves,  and  their  surgical  treatment. 
By  Anthony  A.  Bowlby,  f.r.c.s.,  Dem.  of  Practical  Surgery  at  St.  Bartholo- 
mew's Hospital.    Illus.  by  4  Colored  and  20  Full-page  Plates.    8vo.    Cloth,  $4.50 
Surgical  Pathology  and  Morbid  Anatomy.     135  Illustrations.  Cloth,  $2.00 

BOWMAN.  Practical  Chemistry,  including  analysis,  with  about  100  Illustrations. 
By  Prof.  John  E.  Bowman.  Eighth  English  Edition.  Revised  by  Prof.  Bloxam, 
Professor  of  Chemistry,  King's  College,  London.  Cloth,  $2.00 

BBUBAKEB.     Physiology.     A  Compend  of  Physiology,  specially  adapted  for  the 
use   of  Students  and  Physicians.     By  A.  P.  Brubaker,  m.d.,  Demonstrator  of 
Physiology  at  Jefferson  Medical  College,  Prof,  of  Physiology,  Penn'a  College  of 
Dental  Surgery,  Philadelphia.     Sixth  Edition.       Revised,  Enlarged,  and  Illus- 
trated.   No.  4,? Quiz- Compend  Series?    i2mo.    Cloth,  $1.00;  Interleaved,  $1.25 
"The  fact  that  a  fourth  edition  of  this  book  has  been  called  for  within  three  years  of  the 
publication  of  the  first,  indicates  that  it  supplies  a  real  want  among  medical  students.     It  is  a 
true  compend,  and  contains  nearly  everything  the  student  or  practitioner  is  expected  to  know 
about  the  subject.     Physicians  will  find  this  book  an  excellent  means  of  acquainting  themselves 
in  a  short  time  with  the  great  advances  made  in  this  department  of  medical  science  within  the 
past  four  years." — Buffalo  Medical  and  Surgical  Journal. 

BTJLKLEY.  The  Skin  in  Health  and  Disease.  By  L.  Duncan  Bulkley,  m.d., 
Attending  Physician  at  the  New  York  Hospital.     Illustrated.  Cloth,  .50 

BUXTON.  On  Anaesthetics.  A  Manual.  By  Dudley  Wilmot  Buxton,  m.r.c.s., 
m.r.c.p.,  Ass't  to  Prof,  of  Med.,  and  Administrator  of  Anaesthetics,  University 
College  Hospital,  London.     Second  Edition,  Enlarged  and  Illustrated.     i2mo. 

Cloth,  $1.50 


F.BLAKISTON,  SON  <5-  CO.'S 


BURNET.  Foods  and  Dietaries.  A  Manual  of  Clinical  Dietetics.  By  R.  W. 
Burnet,  m.d.,  m.r.c.p.,  Physician  to  the  Great  Northern  Central  Hospital. 
General  Contents — Diet  in  Derangements  of  the  Digestive,  Nervous,  and  Res- 
piratory Organs ;  in  Gout,  Rheumatism,  Anaemia,  Fevers,  Obesity,  etc. ;  in  Dis- 
eases of  Children,  Alcoholism,  etc.  With  Appendix  on  Predigested  Foods  and 
Invalid  Cookery.  Full  directions  as  to  hours  of  taking  nourishment,  quantity, 
etc.,  are  given.     i2mo.  Cloth,  $1.75 

BURNETT.  Hearing,  and  How  to  Keep  It.  By  Chas.  H.  Burnett,  m.d.,  Prof, 
of  Diseases  of  the  Ear  at  the  Philadelphia  Polyclinic.     Illustrated.         Cloth,  .50 

BYFORD.  Diseases  of  Women.  The  Practice  of  Medicine  and  Surgery,  as 
applied  to  the  Diseases  and  Accidents  Incident  to  Women.  By  W.  H.  Byford, 
a.m.,  m.d.,  Professor  of  Gynaecology  in  Rush  Medical  College  and  of  Obstetrics 
in  the  Woman's  Medical  College;  Surgeon  to  the  Woman's  Hospital;  Ex-Presi- 
dent American  Gynaecological  Society,  etc.,  and  Henry  T.  Byford,  m.d.,  Sur- 
geon to  the  Woman's  Hospital  of  Chicago ;  Gynaecologist  to  St.  Luke's  Hos- 
pital ;  President  Chicago  Gynaecological  Society,  etc.  Fourth  Edition.  Revised, 
Rewritten,  and  Enlarged.  With  306  Illustrations,  over  100  of  which  are  original. 
Octavo.     832  pages.  Cloth,  $5.00;  Leather,  $6.00 

CAIRD  and  CATHCART.  Surgical  Handbook  for  the  use  of  Practitioners  and 
Students.  By  F.  Mitchell  Caird,  m.b.,  f.r.c.s.,  and  C.  Walker  Cathcart, 
m.b.,  f.r.c.s.,  Ass't  Surgeons  Royal  Infirmary.  With  over  200  Illustrations. 
32mo.     400  pages.     Pocket  size.  Leather  covers,  $2.50 

CALDWELL.  Chemical  Analysis.  Elements  of  Qualitative  and  Quantitative 
Chemical  Analysis.  By  G.  C.  Caldwell,  B.S.,  Ph.D.,  Professor  of  Agricultural 
and  Analytical  Chemistry  in  Cornell  University,  Ithaca,  New  York,  etc.  Second 
Edition.     Revised  and  Enlarged.     Octavo.  Cloth,  Net,  $1.50 

CAMERON.  Oils  and  Varnishes.  A  Practical  Handbook,  by  James  Cameron, 
f.i.c.     With  Illustrations,  Formulae,  Tables,  etc.     i2mo.  Cloth,'$2.5o 

Soap  and  Candles.     A  New  Handbook   for  Manufacturers,  Chemists,  Ana- 
lysts, etc.     54  Illustrations.     i2mo.  Cloth,  $2.25 

CANFIELD.  Hygiene  of  the  Sick-Room.  A  book  for  Nurses  and  others.  Being 
a  Brief  Consideration  of  Asepsis,  Antisepsis,  Disinfection,  Bacteriology,  Immun- 
ity, Heating  and  Ventilation,  and  kindred  subjects,  for  the  use  of  Nurses  and 
other  Intelligent  Women.  By  William  Buckingham  Canfield,  a.m.,  m.d., 
Lecturer  on  Clinical  Medicine  and  Chief  of  Chest  Clinic,  University  of  Mary- 
land, Physician  to  Bay  View  Hospital  and  Union  Protestant  Infirmary,  Balti- 
more.    i2mo.     Interleaved  for  Notes.  Cloth,  $1.50 

CARPENTER.  The  Microscope  and  Its  Revelations.  By  W.  B.  Carpenter, 
m.d.,  f.r.s.  Seventh  Edition.  By  Rev.  Dr.  Dallinger,  f.  r.  s.  Revised  and 
Enlarged,  with  800  Illustrations  and  many  Lithographs.     Octavo.     1100  Pages. 

Cloth,  $6.50 

CAZEAUX  and  TARNIER'S  Midwifery.  With  Appendix,  by  Munde.  The 
Theory  and  Practice  of  Obstetrics,  including  the  Diseases  of  Pregnancy  and 
Parturition,  Obstetrical  Operations,  etc.  By  P.  Cazeaux,  Member  of  the  Im- 
perial Academy  of  Medicine,  Adjunct  Professor  in  the  Faculty  of  Medicine  in 
Paris.  Remodeled  and  rearranged,  with  revisions  and  additions,  by  S.  Tarnier, 
m.d.  Eighth  American,  from  the  Eighth  French  and  First  Italian  Edition. 
Edited  by  Robert  J.  Hess,  m.d.,  Physician  to  the  Northern  Dispensary,  Phila., 
etc.,  with  an  Appendix  by  Paul  F.  Munde,  m.d.,  Professor  of  Gynaecology  at 
the  New  York  Polyclinic.  Illustrated  by  Chromo-Lithographs,  Lithographs,  and 
other  Full-page  Plates,  seven  of  which  are  beautifully  colored,  and  numerous 
Wood  Engravings.     One  Vol.,  8vo.  Cloth,  $5.00;  Full  Leather,  $6.00 

CHARTERIS.  Practice  of  Medicine.  The  Student's  Guide.  By  M.  Charteris, 
m.d.,  Professor  of  Therapeutics  and  Materia  Medica,  Glasgow  University,  etc. 
Sixth  Edition,  with  Therapeutical  Index  and  many  Illustrations.         Cloth,  $3.00 


MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  9 

CLEVELAND'S  Pocket  Dictionary.  A  Pronouncing  Medical  Lexicon,  containing 
correct  Pronunciation  and  Definition  of  terms  used  in  medicine  and  the  col- 
lateral sciences,  abbreviations  used  in  prescriptions,  list  of  poisons,  their  anti- 
dotes, etc.  By  C.  H.  Cleveland,  m.d.  Thirty-third  Edition.  Very  small 
pocket  size.  Cloth,  .75;  Tucks  with  Pocket,  $1.00 

COHEN.  The  Throat  and  Voice.   By  J.  Solis-Cohen,  m.d.  Illus.   i2mo.   Cloth,  .50 
COLLIE,    On  Fevers.  .A  Practical  Treatise  on  Fevers,  Their   History,  Etiology, 
Diagnosis,  Prognosis,  and  Treatment.     By  Alexander  Collie,  m.d.,  m.r.c.p., 
Lond.,  Medical  Officer  of  the  Homerton  and  of  the  London  Fever  Hospitals. 
With  Colored  Plates.     i2mo.  Cloth,  $2.50 

COOPER  AND  EDWARDS.  Diseases  of  the  Rectum  and  Anus.  By  Alfred 
Cooper,  f.r.c.s.,  Senior  Surgeon  to  St.  Mark's  Hospital  for  Fistula,  and  F. 
Swinford  Edwards,  f.r.c.s.,  Surgeon  to  the  West  London  and  St.  Peter's 
Hospitals  and  Senior  Assistant  Surgeon  to  St.  Mark's  Hospital.  Second  Edition, 
Enlarged.     Illustrated  with  9  Plates  and  60  Woodcuts.  Cloth,  $4.00 

COPLIN  and  BEVAN.  Practical  Hygiene.  By  W.  M.  L.  Coplin,  m.d.,  Adjunct 
Professor  of  Hygiene,  Jefferson  Medical  College,  Philadelphia,  and  D.  Bevan, 
m.d.,  Ass't  Department  of  Hygiene,  Jefferson  Medical  College;  Bacteriologist, 
St.  Agnes'  Hospital,  Philadelphia,  with  an  Introduction  by  Prof.  H.  A.  Hare, 
and  articles  on  Plumbing,  Ventilation,  etc.,  by  Mr.  W.  P.  Lockington,  Editor  of 
the  Architectural  Era.     Illustrated.  In  Press. 

CROCKER.  Diseases  of  the  Skin.  Their  Description,  Pathology,  Diagnosis,  and 
Treatment,  with  special  reference  to  the  Skin  Eruptions  of  Children.  By  H. 
Radcliffe  Crocker,  m.d.,  Physician  to  the  Dept.  of  Skin  Diseases,  University 
College  Hospital,  London.  92  Illustrations.  Second  Edition.  Enlarged.  987 
pages.     Octavo.  Cloth,  $5.00 

CULLINGWORTH.    A  Manual  of  Nursing,  Medical  and  Surgical.    By  Charles 

J.  Cullingworth,    m.d.,    Physician  to  St.  Thomas'  Hospital,  London.     Third 

Revised  Edition.     With  18  Illustrations.     i2mo.  Cloth,  .75 

A  Manual  for  Monthly  Nurses.    Third  Edition.    32mo.  Cloth,  .50 

DALBY.  Diseases  and  Injuries  of  the  Ear.  By  Sir  William  B.  Dalby,  m.d., 
Aural  Surgeon  to  St.  George's  Hospital,  London.  Illustrated.  Fourth  Edition. 
With  28  Wood  Engravings  and  7  Colored  Plates.  Cloth,  $3.50 

DAVIS.  Biology.  An  Elementary  Treatise.  By  J.  R.  Ainsworth  Davis,  of 
University  College,  Aberystwyth,  Wales.   Thoroughly  Illustrated.    i2mo.      $4.00 

DAVIS.  A  Manual  of  Obstetrics.  Being  a  complete  manual  for  Physicians  and 
Students.  By  Edward  P.  Davis,  m.d.,  Professor  of  Obtetrics  and  Diseases  of 
Infancy  in  the  Philadelphia  Polyclinic,  Clinical  Lecturer  on  Obstetrics,  Jeffer- 
son Medical  College ;  Professor  of  Diseases  of  Children  in  Woman's  Medical 
College,  etc.  With  11  Colored  and  other  Lithograph  Plates  and  128  other 
Illustrations.     i2mo.  Cloth,  $2.00 

Clinical  Obstetrical  Chart.  Designed  by  Ed.  P.  Davis,  m.d.,  and  J.  P.  Crozer 
.  Griffith,  m.d.   Sample  copies  free.     Put  up  in  loose  packages  of  50,  .50 

Price  to  Hospitals,  500  copies,  $4*00;  1000  copies,  $7.50. 

DAVIS.  Essentials  of  Materia  Medica  and  Prescription  Writing.  By  J. 
Aubrey  Davis,  m.d.,  Ass't  Dem.  of  Obstetrics  and  Quiz  Master  in  Materia 
Medica,  University  of  Pennsylvania;  Ass't  Physician,  Home  for  Crippled  Chil- 
dren, Philadelphia.     i2mo.  Net,  $1.50 

DAY.  On  Headaches.  The  Nature,  Causes  and  Treatment  of  Headaches.  By 
Wm.  H.  Day,  m.d.     Fourth  Edition.    Illustrated.    8vo.    Paper,  .75  ;  Cloth,  $1.25 

DOMVILLE.  Manual  for  Nurses  and  others  engaged  in  attending  to  the  sick.  By 
Ed.  J.  Domville,  m.d.  7th  Edition.  Revised.  With  E.ecipes  for  Sick-room 
Cookery,  etc.     i2mo.  Cloth,  .75 


10  P.  BLAKISTON,  SON  &*  CO:S 

DUCKWORTH.  On  Gout.  Illustrated.  A  treatise  on  Gout.  By  Sir  Dyce 
Duckworth,  m.d.  (Edin.),  f.r.c.p.,  Physician  to,  and  Lecturer  on  Clinical 
Medicine  at,  St.  Bartholomew's  Hospital,  London.  With  Chromo-lithographs 
and  Engravings.     Octavo.  Cloth,  $7.00 

DULLES.  What  to  Do  First,  In  Accidents  and  Poisoning.  By  C.  W.  Dulles,  m.d. 
Fourth  Edition,  Enlarged,  with  new  Illustrations.     i2mo.  Cloth.  $1.00 

EDIS.  Sterility  in  Women.  By  A.  W.  Edis,  m.d.,  f.r.c.p.,  late  President  British 
Gynaecological  Society;  Senior  Physician,  Chelsea  Hospital  for  Women;  Physician 
to  British  Lying-in  Hospital,  etc.     Illustrated.     8vo.  Cloth,  $1.75 

FAGGE.  The  Principles  and  Practice  of  Medicine.  By  C.  Hilton  Fagge,  m.d., 
f.r.c.p.,  f.r.m.c.s.,  Physician  to,  and  Lecturer  on  Pathology  in,  Guy's  Hospital, 
etc.  Edited  by  Philip  H.  Pye-Smith,  m.d.,  Lect.  on  Medicine  in  Guy's  Hospital. 
Including  a  Chapter  on  Cardiac  Diseases,  by  Samuel  Wilkes,  m.d.,  f.r.s.,  and 
Complete  Indexes  by  Robert  Edmund  Carrington.    2  vols.     Royal  8vo. 

Cloth,  $8.00;    Leather,  $10.00  ;    Half  Russia,  $12.00 

FENWICK.  Student's  Guide  to  Physical  Diagnosis.  By  Saml.  Fenwick,  m.d., 
m.r.c. p.,  Physician  to  the  London  Hospital.  7th  Ed.    1 17  Illus.  i2mo.  Cloth,  $2.25 

FIELD.  Evacuant  Medication — Cathartics  and  Emetics.  By  Henry  M.  Field, 
m.d.,  Professor  of  Therapeutics,  Dartmouth  Medical  College,  Corporate  Mem- 
ber Gynaecological  Society  of  Boston,  etc.     i2mo.     288  pp.  Cloth,  $1.75 

FILLEBROWN.  A  Text-Book  of  Operative  Dentistry.  Written  by  invitation 
of  the  National  Association  of  Dental  Faculties.  By  Thomas  Fillebrown,  m.d., 
d.m.d.,  Professor  of  Operative  Dentistry  in  the  Dental  School  of  Harvard  Uni- 
versity ;  Member  of  the  American  Dental  Assoc,  etc.    Illus.    8vo.     Clo.,  $2.50 

FLAGG.  Plastics  and  Plastic  Fillings,  as  pertaining  to  the  filling  of  all  Cavities 
of  Decay  in  Teeth  below  medium  in  structure,  and  to  difficult  and  inaccessible 
cavities  in  teeth  of  all  grades  of  structure.  By  J.  Foster  Flagg,  d.d.s.,  Professor 
of  Dental  Pathology  in  Philadelphia  Dental  College.  Fourth  Revised  Edition. 
With  many  Illustrations.     8vo.  Cloth,  $4.00 

FLOWER'S  Diagrams  of  the  Nerves  of  the  Human  Body.  Exhibiting  their 
Origin,  Divisions  and  Connections,  with  their  Distribution  to  the  various  Regions 
of  the  Cutaneous  Surface  and  to  all  the  Muscles.  By  William  H.  Flower, 
f.r.c.s.,  f.r.s. ,  Hunterian  Professor  of  Comparative  Anatomy,  and  Conservator 
of  the  Museum  of  the  Royal  College  of  Surgeons.  Third  Edition,  thoroughly 
revised.     With  six  Large  Folio  Maps  or  Diagrams.     4to.  Cloth,  $3.50 

FLUCKIGER.  The  Cinchona  Barks  Pharmacognostically  Considered.  By 
Professor  Friedrich  FlQckiger,  of  Strasburg.  Translated  by  Frederick  B. 
Power,  ph.d.     With  8  Lithographic  Plates.     Royal  octavo.  Cloth,  $1.50 

FOWLER'S  Dictionary  of  Practical  Medicine.  By  Various  Writers.  An  Ency- 
clopedia of  Medicine.  Edited  by  James  Kingston  Fowler,  m.a.,  m.d.,  f.r.c.p., 
Senior  Asst.  Physician  to,  and  Lecturer  on  Pathological  Anatomy  at,  the  Mid- 
dlesex Hospital  and  the  Hospital  for  Consumption  and  Diseases  of  the  Chest, 
Brompton,  London.     8vo.  Cloth,  $5.00  ;  Half  Morocco,  $6.00 

FOX.  Water,  Air  and  Food.  Sanitary  Examinations  of  Water,  Air  and  Food. 
By  Cornelius  B.  Fox,  m.d.    no  Engravings.    2d  Ed.,  Revised.        Cloth,  $4.00 

FOX   AND   GOULD.     Compend  on  Diseases  of  the  Eye  and  Refraction, 

including  Treatment  and  Surgery.  By  L.  Webster  Fox,  m.d.,  Chief  Clinical 
Assistant,  Ophthalmological  Department,  Jefferson  Medical  College  Hospital ; 
Ophthalmic  Surgeon,  Germantown  Hospital,  Philadelphia  ;  late  Clinical  Assistant 
at  Moorfields,  London,  England,  etc.,  and  Geo.  M.  Gould,  m.d.  Second  Edition. 
Enlarged.  71  Illustrations  and  39  Formulas.  Being  No.  8,  f  Quiz-  Compend  ? 
Series.  Cloth,  #1.00.      Interleaved  for  the  addition  of  notes,  $1.25 


MEDICAL  AND  SCIENTIFIC  PUBLICATIONS. 11 

FRANKLAND'S  Water  Analysis.  For  Sanitary  Purposes,  with  Hints  for  the  In- 
terpretation of  Results.  By  E.  Frankland,  m.d.  Illus.  i2mo.  Cloth,  $1.00 
FULLERTON.  Obstetrical  Nursing.  A  Handbook  for  Nurses,  Students  and 
Mothers.  By  Anna  M.  Fullerton,  m.d.,  Demonstrator  of  Obstetrics  in  the 
Woman's  Medical  College;  Physician  in  charge  of,  and  Obstetrician  and 
Gynaecologist  to,  the  Woman's  Hospital,  Philadelphia,  etc.  38  Illustrations. 
Third  Edition.     Revised  and  Enlarged,     nrao.  Cloth,  $1.25 

Nursing  in  Abdominal  Surgery  and  Diseases  of  Women.  Comprising  the 
Regular  Course  of  Instruction  at  the  Training  School  of  the  Woman's 
Hospital,  Philadelphia.     70  Illustrations.     i2mo.  Cloth,  $1.50 

GALABIN'S  Midwifery.  A  Manual  for  Students  and  Practitioners.  By  A.  Lewis 
Galabin,  m.d.,  f.r.c.p.,  Professor  of  Midwifery  at,  and  Obstetric  Physician  to, 
Guy's  Hospital,  London.     227  Illustrations.  Cloth,  $3.00;  Leather,  $3.50 

GARDNER.  The  Brewer,  Distiller  and  Wine  Manufacturer.  A  Handbook  for 
all  Interested  in  the  Manufacture  and  Trade  of  Alcohol  and  Its  Compounds. 
Edited  by  John  Gardner,  f.c.s.     Illustrated.  Cloth,  $1.75 

Bleaching,  Dyeing,  and  Calico  Printing.  With  Formulae.    Illustrated.     $1.75 
Acetic  Acid,  Vinegar,  Ammonia  and  Alum.     Illustrated.  Cloth,  gi.75 

GARROD.  On  Rheumatism.  A  Treatise  on  Rheumatism  and  Rheumatic  Arthritis. 
By  Archibald  Edward  Garrod,  m.a.  Oxon.,  m.d.,  m.r.c.s.  Eng.,  Asst.  Phy- 
sician, West  London  Hospital.  Illustrated.  Octavo.  Cloth,  $6.00 
GILLIAM'S  Pathology.  The  Essentials  of  Pathology ;  a  Handbook  for  Students. 
By  D.  Tod  Gilliam,  m.d.,  Professor  of  Physiology,  Starling  Medical  College, 
Columbus,  O.  With  47  Illustrations.  i2mo.  Cloth,  $2.00 
GOODHART  and  STARR'S  Diseases  of  Children.  The  Student's  Guide  to  the 
Diseases  of  Children.  By  J.  F.  Goodhart,  m.d.,  f.r.c.p.,  Physician  to  Evelina 
Hospital  for  Children  and  to  Guy's  Hospital.  Second  American  from  the  Third 
English  Edition.  Rearranged  and  Edited,  with  notes  and  additions,  by  Louis 
Starr,  m.d.,  Clinical  Professor  of  Diseases  of  Children  in  the  University  of 
Pennsylvania  ;  Physician  to  the  Children's  Hospital.  With  many  new  prescrip- 
tions. Cloth,  $3.00;  Leather,  $3. 50 
GOODHART.  Common  Neuroses,  or  the  Neurotic  Element  in  Disease  and  Its 
Rational  Treatment.  By  J.  F.  Goodhart,  m.d.,  f.r.c.p.,  Physician  to  Guy's 
Hospital,  etc.  i2mo.  Parchment  Covers,  $0.60 
GORGAS'S  Dental  Medicine.  A  Manual  of  Materia  Medica  and  Therapeutics. 
By  Ferdinand  J.  S.  Gorgas,  m.d.,  d.d.s.,  Professor  of  the  Principles  of  Dental 
Science,  Dental  Surgery  and  Dental  Mechanism  in  the  Dental  Dep.  of  the  Univ. 
of  Maryland.  4th  Edition.  Revised  and  Enlarged.  8vo.  Cloth,  $3.50 
GODLD.  The  New  Medical  Dictionary.  Including  all  the  Words  and  Phrases  used 
in  Medicine,  with  their  proper  Pronunciation  and  Definitions,  based  on  Recent 
Medical  Literature.  By  George  M.  Gould,  b.a.,  m.d.,  Ophthalmic  Surgeon  to 
the  Philadelphia  Hospital,  etc.,  With  Tables  of  the  Bacilli,  Micrococci,  Leuco- 
maines,  Ptomaines,  etc.,  of  the  Arteries,  Muscles,  Nerves,  Ganglia  and  Plexuses; 
Mineral  Springs  of  U.  S.,  Vital  Statistics,  etc.     Small  octavo,  520  pages. 

Half  Dark  Leather,  $3.25;  Half  Morocco,  Thumb  Index,  $4.25 
The  Pocket  Pronouncing  Medical  Lexicon.  A  Students'  Pronouncing 
Medical  Lexicon.  Containing  all  the  Words,  their  Definition  and  Pro- 
nunciation, that  the  Student  generally  comes  in  contact  with ;  also  elaborate 
Tables  of  the  Arteries,  Muscles,  Nerves,  Bacilli,  etc.,  etc.;  a  Dose  List  in 
both  English  and  Metric  System,  etc.,  arranged  in  a  most  convenient  form 
for  reference  and  memorizing.  Just  Ready.  About  12,000  Words.  Thin 
64010.     (6  x  33^  inches.)  Full  Limp  Leather,  Gilt  Edges,  $1.00 

***  Sample  pages  and  descriptive  circular  of  Gould's  Dictionaries  sent  free  upon 
application.     See  page  4. 


12  P.  BLAKISTON,  SON  &*  CO.'S 

GOWERS,  Manual  of  Diseases  of  the  Nervous  System.  A  Complete  Text-book. 
By  William  R.  Gowers,  m.d.,  f.r.s.,  Prof.  Clinical  Medicine,  University  College, 
London.  Physician  to  National  Hospital  for  the  Paralyzed  and  Epileptic.  Second 
Edition.  Revised,  Enlarged  and  in  many  parts  rewritten.  With  many  new 
Illustrations.     Two  Volumes.     Octavo. 

Vol.  I.    Diseases  of  the  Nerves  and  Spinal  Cord.    616  pages.       Cloth,  $3.50 
Vol.  II.     Diseases  of   the    Brain    and    Cranial    Nerves;    General  and 
Functional  Diseases.  Nearly  Ready. 

Syphilis  and  the  Nervous  System.  Being  a  revised  reprint  of  the  Lettso- 
mian  Lectures  for  1890,  delivered  before  the  Medical  Society  of  London. 
nmo.  Cloth,  $1.00 

Diagnosis  of  Diseases  of  the  Brain.  8vo.  Second  Ed.  Illus.  Cloth,  $2.00 
Medical  Ophthalmoscopy.  A  Manual  and  Atlas,  with  Colored  Autotype  and 
Lithographic  Plates  and  Wood-cuts,  comprising  Original  Illustrations  of  the 
changes  of  the  Eye  in  Diseases  of  the  Brain,  Kidney,  etc.  Third  Edition. 
Revised,  with  the  assistance  of  R.  Marcus  Gunn,  f.r.c.s.,  Surgeon,  Royal 
London  Ophthalmic  Hospital,  Moorfields.     Octavo.  Cloth,  $5.50 

GROSS  (S.  D.,  m.d.).    John  Hunter  and  His  Pupils.    Portrait.    8vo.       Paper,  .75 
GREENHOW  (E.  H.,  M.D).    Chronic  Bronchitis,     nmo.  Paper,  .75 

GRIFFITH'S  Graphic  Clinical  Chart.  Designed  by  J.  P.  Crozer  Griffith, 
m.d.,  Instructor  in  Clinical  Medicine  in  the  University  of  Pennsylvania.  Printed 
in  three  colors.     Sample  copies  free.  Put  up  in  loose  packages  of  50,    .50 

Price  to  Hospitals,  500  copies,  $4.00;  1000  copies,  $7.50.  With  name  of  Hos- 
pital printed  on,  50  cents  extra. 
GROVES  AND  THORP.  Chemical  Technology.  A  new  and  Complete  Work. 
The  Application  of  Chemistry  to  the  Arts  and  Manufactures.  Edited  by 
Charles  E.  Groves,  f.r.s.,  and  Wm.  Thorp,  b.sc,  f.i.c.  In  about  eight  vol- 
umes, with  numerous  illustrations.     Each  volume  sold  separately. 

Vol.  I.     Fuel.     By  Dr.  E.  J.  Mills,  f.r.s.,  Professor  of  Chemistry,  Anderson 

College,  Glasgow;  and  Mr.  F.  J.  Rowan,  assisted  by  an  American  expert.      607 

Illustrations  and  4  plates.     Octavo.  Cloth,  7.50;  Half  Morocco,  $9.00 

HACKER.    Antiseptic  Treatment  of  Wounds,  Introduction  to  the,  according  to 

the  Method  in  Use  at  Professor  Billroth's  Clinic,  Vienna.     By  Dr.  Victor  R.  v. 

Hacker,  Assistant  in  the  Clinic  Billroth,  Professor  of  Surgery,  etc.     Authorized 

Translation,  by  Surgeon-Captain   C.  R.  Kilkelly,  M.B.,  British  Army  Medical 

Staff,  with  a  Photo-Engraving  of  Billroth  in  his  Clinic.     i2mo.  Cloth,  .75 

HADDON'S   Embryology.      An   Introduction  to  the  Study  of  Embryology.     For 

the  Use  of  Students.     By  A.  C.  Haddon,  m.a.,  Prof,  of  Zoology,  Royal  College 

of  Science,  Dublin.     190  Illustrations.  Cloth,  $6.00 

HAIG.    Causation  of  Disease  by  Uric  Acid.    A  Contribution  to  the  Pathology  of 

High   Arterial    Tension,    Headache,    Epilepsy,    Gout,   Rheumatism,    Diabetes, 

Bright's  Disease,  etc.     By  Alex.  Haig,  m.a.,  m.d.  Oxon.,  f.r.c.p.,  Physician  to 

Metropolitan  Hospital,  London.     Illustrated.     Octavo.  Cloth,  $3.00 

HALE  On  the  Management  of  Children  in  Health  and  Disease.  A  Book  for 
Mothers.     By  Amie  M.  Hale,  m.d.    New  Enlarged  Edition.     i2mo.     Cloth,  .75 

HANSEIL  and  BELL.  Clinical  Ophthalmology,  Illustrated.  A  Manual  for 
Students  and  Physicians.  By  Howard  F.  Hansell,  a.m.,  m.d.,  Lecturer  on 
Ophthalmology  in  the  Jefferson  College  Hospital,  Philadelphia,  etc.,  and  James 
H.  Bell,  m.d. ,  late  Demonstrator  of  Anatomy  in  Jefferson  Medical  College; 
Member  Ophthalmic  Staff,  Jefferson  College  Hospital;  Ophthalmic  Surgeon, 
Southwestern  Hospital,  Phila.  With  Colored  Plate  of  Normal  Fundus  and  120 
Illustrations,     nmo.  Cloth,  $1.75 


MEDICAL  AND  SCIENTIFIC  PUBLICATIONS.  13 

HARE.  Mediastinal  Disease.  The  Pathology,  Clinical  History  and  Diagnosis  of 
Affections  of  the  Mediastinum  other  than  those  of  the  Heart  and  Aorta.  By  H.  A. 
Hare,  m.d.  (Univ.  of  Pa.),  Professor  of  Materia  Medica  and  Therapeutics  in 
Jefferson  Medical  College,  Phila.     8vo.     Illustrated  by  Six  Plates.       Cloth,  $2.00 

HARLAN.  Eyesight,  and  How  to  Care  for  It.  By  George  C.  Harlan,  m.d., 
Prof,  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic.     Illustrated.         Cloth,  .50 

HARRIS'S  Principles  and  Practice  of  Dentistry.  Including  Anatomy,  Physi- 
ology, Pathology,  Therapeutics,  Dental  Surgery  and  Mechanism.  By  Chapin  A. 
Harris,  m.d.,  d.d.s.,  late  President  of  the  Baltimore  Dental  College,  author  of 
"Dictionary  of  Medical  Terminology  and  Dental  Surgery."  Twelfth  Edition. 
Revised  and  Edited  by  Ferdinand  J.  S.  Gorgas,  a.m.,  m.d.,  d.d.s.,  author  of 
"Dental  Medicine;"  Professor  of  the  Principles  of  Dental  Science,  Dental 
Surgery  and  Dental  Mechanism  in  the  University  of  Maryland.  Two  Full-page 
Plates  and  1086  Illustrations.     1225  pages.    8vo.        Cloth,  $7.00;  Leather,  $8.00 

Dictionary  Of  Dentistry.  Fifth  Edition,  Revised.  Including  Definitions  of 
such  Words  and  Phrases  of  the  Collateral  Sciences  as  Pertain  to  the  Art  and 
Practice  of  Dentistry.  Fifth  Edition.  Rewritten,  Revised  and  Enlarged. 
By  Ferdinand  J.  S.  Gorgas,  m.d.,  d.d.s.,  Author  of  "Dental  Medicine;" 
Editor  of  Harris's  "  Principles  and  Practice  of  Dentistry ; "  Professor  of 
Principles  of  Dental  Science,  Dental  Surgery,  and  Prosthetic  Dentistry  in  the 
University  of  Maryland.     Octavo.  Cloth,  $5.00  ;  Leather,  $6.00 

HARTRIDGE.  Refraction.  The  Refraction  of  the  Eye.  A  Manual  for  Students. 
By  Gustavus  Hartridge,  f.r.c.s.,  Consulting  Ophthalmic  Surgeon  to  St.  Bar- 
tholomew's Hospital ;  Ass't  Surgeon  to  the  Royal  Westminster  Ophthalmic  Hos- 
pital, etc.     96  Illustrations  and  Test  Types.     Fifth  Edition.  Cloth,  $1.75 

On  The  Ophthalmoscope.  A  Manual  for  Physicians  and  Students.  With 
Colored  Plates  and  many  Woodcuts.     i2mo.  Cloth,  $1.50 

HARTSHORNE.  Our  Homes.  Their  Situation,  Construction,  Drainage,  etc.  By 
Henry  Hartshorne,  m.d.     Illustrated.  Cloth,  .50 

HATFIELD.  Diseases  of  Children.  By  Marcus  P.  Hatfield,  Professor  of 
Diseases  of  Children,  Chicago  Medical  College.  With  a  Colored  Plate.  Being 
N0.14,?  Quiz- Comfiend?  Series.     i2mo.  Cloth,  $1.00 

Interleaved  for  the  addition  of  notes,  $1.25 

HEADLAND'S  Action  of  Medicines.  On  the  Action  of  Medicines  in  the  System. 
By  F.  W.  Headland,  m.d.     Ninth  American  Edition.     8vo.  Cloth,  $3.00 

HEATH'S  Minor  Surgery  and  Bandaging.    By  Christopher  Heath,  f.r.c.s., 

Holme   Professor  of  Clinical   Surgery  in   University  College,  London.     Ninth 

Edition.     Revised  and  Enlarged.     With  142  Illustrations.     i2mo.      Cloth,  $2.00 

Practical  Anatomy.     A  Manual  of  Dissections.     Seventh  London  Edition. 

24  Colored  Plates,  and  nearly  300  other  Illustrations.  Cloth,  $5.00 

HEATH.    Injuries  and  Diseases  of  the  Jaws.    Third  Edition.    Revised,  with  over 
150  Illustrations.     8vo.  Cloth,  $4.50 

Lectures  on  Certain  Diseases  of  the  Jaws,  delivered  at  the  Royal  College  of 
Surgeons  of  England,  1887.     64  Illustrations.     8vo.  Boards,  $1.00 

HENRY.  Anaemia.  A  Practical  Treatise.  By  Fred'k  P.  Henry,  m.d.,  Prof. 
Clinical  Med.  Phila.  Polyclinic,  Physician  to  Episcopal  and  Phila.  Hospitals,  to 
Home  for  Consumptives,  etc.     i2mo.  Half  Cloth,  .75 

HIGGENS'  Ophthalmic  Practice.  A  Manual  for  Students  and  Practitioners.  By 
Charles  Higgens,  f.r.c.s.,  Ophthalmic  Surgeon  at  Guy's  Hospital.  Illus- 
trated.    i2mo.  Cloth,  $1.75 


14  P.  BLAKISTON,  SON  <5-  CO.'S 

HILL  AND  COOPER.  Venereal  Diseases.  The  Student's  Manual  of  Venereal 
Diseases,  being  a  concise  description  of  those  Affections  and  their  Treatment. 
By  Berkeley  Hill,  m.d.,  Professor  of  Clinical  Surgery,  University  College,  and 
Arthur  Cooper,  m.d.,  Late  House  Surgeon  to  the  Lock  Hospital,  London. 
4th  Edition.     i2mo.  Cloth,  $1.00 

HOLDER'S  Landmarks.  Medical  and  Surgical.  4th  Edition.  8vo.  Cloth,  $1.25 
HOLDEN'S  Anatomy.  A  Manual  of  the  Dissections  of  the  Human  Body.  By 
Luther  Holden,  f.r.c.s.  Fifth  Edition.  Carefully  Revised  and  Enlarged. 
Specially  concerning  the  Anatomy  of  the  Nervous  System,  Organs  of  Special 
Sense,  etc.  By  John  Langton,  f.r.c.s.,  Surgeon  to,  and  Lecturer  on  Anatomy 
at,  St.  Bartholomew's  Hospital.     208  Illustrations.     8vo. 

Oilcloth  Covers,  for  the  Dissecting  Room,  $4.50 
Human  Osteology.  Comprising  a  Description  of  the  Bones,  with  Colored 
Delineations  of  the  Attachments  of  the  Muscles.  The  General  and  Micro- 
scopical Structure  of  Bone  and  its  Development.  Carefully  Revised,  by 
the  Author  and  Prof.  Stewart,  of  the  Royal  College  of  Surgeons'  Museum. 
With  Lithographic  Plates  and  Numerous  Illustrations.   7th  Ed.    Cloth,  $6.00 

HOLLAND.  The  Urine,  the  Common  Poisons  and  the  Milk.  Memoranda,  Chem- 
ical and  Microscopical,  for  Laboratory  Use.  By  J.  W.  Holland,  m.d.,  Professor 
of  Medical  Chemistry  and  Toxicology  in  Jefferson  Medical  College,  of  Philadel- 
phia. Fourth  Edition.  Enlarged.  Illustrated  and  Interleaved.  i2mo.  Cloth,  $1.00 
HORSLEY.  The  Brain  and  Spinal  Cord.  The  Structure  and  Functions  of.  Being 
the  Fullerian  Lectures  on  Physiology  for  1891.  By  Victor  A.  Horsley,  m.b., 
f.r.s.,  etc.,  Assistant  Surgeon,  University  College  Hospital,  Professor  of  Pathology, 
University  College,  London,  etc.     With  numerous  Illustrations.  Cloth,  $3.00 

HORWITZ'S  Compend  of  Surgery,  including  Minor  Surgery,  Amputations,  Frac- 
tures, Dislocations,  Surgical  Diseases,  and  the  Latest  Antiseptic  Rules,  etc.,  with 
Differential  Diagnosis  and  Treatment.  By  Orville  Horwitz,  b.s.,  m.d.,  Pro- 
fessor of  Genito-Urinary  Diseases,  late  Demonstrator  of  Surgery,  Jefferson  Medi- 
cal College.  Fifth  Edition.  Very  much  Enlarged  and  Rearranged.  Over  300 
pages.     167  Illustrations  and  98  Formulae.    i2mo.  No.g  ? Quiz- Compend  f  Series. 

Cloth,  $1.00.     Interleaved  for  notes,  $1.25 

HUGHES.  Compend  of  the  Practice  of  Medicine.  Fourth  Edition.    Revised  and 

Enlarged.    By  Daniel  E.  Hughes,  m.d.,  Demonstrator  of  Clinical  Medicine  at 

Jefferson  Medical  College,  Philadelphia.     In  two  parts.     Being  Nos.  2  and  3, 

?  Quiz-  Compend  ?  Series. 

Part  I. — Continued,  Eruptive  and  Periodical  Fevers,  Diseases  of  the  Stomach, 
Intestines,  Peritoneum,  Biliary  Passages,  Liver,  Kidneys,  etc.,  and  General 
Diseases,  etc. 

Part  II. — Diseases  of  the  Respiratory  System,  Circulatory  System  and  Ner- 
vous System  ;  Diseases  of  the  Blood,  etc. 

Price  of  each  Part,  in  Cloth,  $1.00 ;  interleaved  for  the  addition  of  Notes,  $1.25 
Physicians'  Edition. — In  one  volume,  including  the  above  two  parts,  a  sec- 
tion on  Skin  Diseases,  and  an  index.     Fourth  revised,  enlarged  Edition. 
462  pages.  Full  Morocco,  Gilt  Edge,  $2.50 

"  Carefully  and  systematically  compiled." — The  London  Lancet. 

"The  best  condensation  of  the  essentials  of  Practice  I  have  yet  seen.  ...  It  will  be 
an  admirable  review  book  for  students  after  a  solid  course  of  study,  and  it  will  be  scarcely  less 
useful  to  the  busy  practitioner  as  a  ready  means  of  refreshing  his  memory." — C.  A.  Lindsley, 
M.D.,  Professor  of  Theory  and  Practice  of  Medicine,   Yale  College,  New  Haven. 

HUMPHREY.  A  Manual  for  Nurses.  Including  general  Anatomy  and  Physiology, 
management  of  the  sick-room,  etc.  By  Laurence  Humphrey,  m.a.,  m.b., 
m.r.c.s.,  Assistant  Physician  to,  and  Lecturer  at,  Addenbrook's  Hospital,  Cam- 
bridge, England.     6th  Edition.     i2mo.     Illustrated.  Cloth,  $1.25 


MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  15 

HUTCHINSON.     The  Nose  and  Throat.     A  Manual  of  the  Diseases  of  the  Nose 

and  Throat,   including  the  Nose,   Naso-Pharynx,   Pharynx  and    Larynx.      By 

Procter  S.  Hutchinson,  m.r.c.s.,  Ass't  Surgeon  to  the  London  Hospital  for 

Diseases  of  the  Throat.     Illustrated  by  several  Lithograph  Plates  and  40  other 

Illus.,many  of  which  have  been  made  from  original  drawings.   i2mo.  Cloth,  $1.25 

JACOBSON.     Operations  of  Surgery.     By  W.  H.  A.  Jacobson,  b.a.  oxon., 

f.r cs.,  Eng. ;  Ass't  Surgeon,  Guy's  Hospital ;    Surgeon  at  Royal  Hospital  for 

Children  and  Women,  etc.     With  over  200  Must.      Cloth,  $5.00  ;  Leather,  $6.00 

"  This  handsome  book  is  one  of  the  most  admirable  works  on  operative  surgery  which  we 

have  seen  for  a  long  time.     The  author  has  brought  to  its  preparation  a  large  observation  and 

experience  and  a  very  thorough  acquaintance  with  the  methods  of  other  surgeons.     His  book  is 

comprehensive  and  its  directions  are  clear  and  reliable.     It  is  gratifying  to  an  American  reader 

to  find  that  full  justice  is  done  to  the  work  of  American  surgeons  by  Mr.  Jacobson,  and  that  his 

book  bears  no  marks  of  th'e  distance  which  stretches  between  his  land  and  ours." — The  Medical 

and  Surgical  Reporter,  Philadelphia. 

KENWOOD.    Public  Health  Laboratory  Work.     By  H.  R.  Kenwood,  m.b., 

d.p.h.,  f.c.s.,  Instructor  in  Hygienic  Laboratory,  University  College,  late  Assistant 

Examiner  in  Hygiene,  Science  and  Art  Department,  South  Kensington,  London, 

etc.     With  116  Illustrations  and  3  Plates.  Cloth,  $3.00 

\*  A  manual  dealing,  in  a  concise  and  practical  manner,  with  those  analyses 

ot  Water,  Air,  Food,  etc.,  which  are  especially  related  to  Hygiene,  and  a  knowledge 

of  which  is  valuable  to  the  Public  Health  Student  and  the  Medical  Officer  of  Health. 

The  book  includes  a  brief  account  of  the  more  common  Bacteriological  methods 

employed   in   the    Examination  of  Water,  Air,  Food,  etc.,  by  Rubert  Boyce,  m.b., 

m.r.c.s..,  Assistant  Professor  of  Pathology  in  University  College,  London. 

KIFvXES'  Physiology.    {13th  Authorized  Edition.    Just  Ready.    i2mo.    Dark  Red 

Cloth.)     A  Handbook  of  Physiology.     Thirteenth  London  Edition,  Revised  and 

Enlarged.    By  W.  Morrant  Baker,  m.d.,  and  Vincent  Dormer  Harris,  m.d. 

516  Illustrations,  some  of  which  are  printed  in  Colors.     i2mo. 

Cloth,  $4.00;  Leather,  $5.00 

KLEEN  AND  HARTWELL.  Handbook  of  Massage.  By  Emil  Kleen,  m.d., 
PH.D.,  Stockholm  and  Carlsbad.  Authorized  Translation  from  the  Swedish,  by 
Edward  Mussey  Hartwell,  m.d.,  ph.d.,  Director  of  Physical  Training  in  the 
Public  Schools  of  Boston.  With  an  Introduction  by  Dr.  S.  Weir  Mitchell, 
of  Philadelphia.  Illustrated  with  a  series  of  Photographs  made  specially  by 
Dr.  Kleen  for  the  American  Edition.     8vo.  Cloth,  $2.75 

LANDIS'  Compend  of  Obstetrics  ;  especially  adapted  to  the  Use  of  Students  and 
Physicians.  By  Henry  G.  Landis,  m.d.,  Professor  of  Obstetrics  and  Diseases 
of  Women  in  Starling  Medical  College,  Columbus,  Ohio.  Fourth  Edition. 
Enlarged.     With  Many  Illustrations.     No.  5  ? Quiz- Compend?  Series. 

Cloth,  $1.00;  interleaved  for  the  addition  of  Notes,  $1.25 

LANDOIS.  A  Text-Book  of  Human  Physiology  ;  including  Histology  and  Micro- 
scopical Anatomy,  with  special  reference  to  the  requirements  of  Practical  Medi- 
cine. By  Dr.  L.  Landois,  Professor  of  Physiology  and  Director  of  the  Physio- 
logical Institute  in  the  University  of  Greifswald.  Fourth  American,  translated 
from  the  Seventh  German  Edition,  with  additions,  by  Wm.  Stirling,  m.d.,  d.Sc, 
Brackenbury  Professor  of  Physiology  and  Histology  in  Owen's  College,  and  Pro- 
fessor in  Victoria  University,  Manchester  ;  Examiner  in  Physiology  in  University 
of  Oxford,  England.  With  845  Illustrations,  many  of  which  are  printed  in 
Colors.     8vo.  Cloth,  $7.00 ;  Leather,  $8.00 

"The  MOST  complete  resumi  of  all  the  facts  in  physiology  in  the  language." — The  Lancet. 
"Excellently  clear,  attractive,  and  succinct." — British  Medical  Journal. 

LEBER  AND  ROTTENSTEIN.  Dental  Caries  and  Its  Causes.  .  An  Investigation 
into  the  Influence  of  Fungi  in  the  Destruction  of  the  Teeth.  By  Drs.  Leber 
and  Rottenstein.     Illustrated.  Paper,  .75 


16  P.  BLAKISTON,  SON  &*  CO.'S 

LEE.  The  Microtomist's  Vade  Mecum.  Third  Edition.  A  Handbook  of 
Methods  of  Microscopical  Anatomy.  By  Arthur  Bolles  Lee,  Ass't  in  the  Rus- 
sian Laboratory  of  Zoology,  at  Villefranche-sur-Mer  (Nice).  660  Formulae,  etc. 
Enlarged  and  Revised.  In  Press. 

LEFFMANN'S  Compend  of  Chemistry,  Inorganic  and  Organic.  Including  Urine 
Analysis.  By  Henry  Leffmann,  m.d.,  Prof,  of  Chemistry  and  Metallurgy  in 
the  Penna.  College  of  Dental  Surgery  and  in  the  Wagner  Free  Institute  of 
Science,  Philadelphia.  No.  10  ? Quiz- Com.fi end?  Series.  Third  Edition.  Re- 
written. Cloth,  $1.00.  Interleaved  for  the  addition  of  Notes,  $1.25 
The  Coal-Tar  Colors,  with  Special  Reference  to  their  Injurious  Qualities  and 
the  Restrictions  of  their  Use.  A  Translation  of  Theodore  Weyl's  Mono- 
graph.    i2mo.  Cloth,  $1.25 

LEFFMANN  AND  BEAM.  Examination  of  Water  for  Sanitary  and  Technical 
Purposes.  By  Henry  Leffmann,  m.d.,  Professor  of  Chemistry  and  Metallurgy, 
Penna.  College  of  Dental  Surgery,  Hygienist  and  Food  Inspector  Penna.  State 
Board  of  Agriculture,  etc.;  and  William  Beam,  a.m.,  formerly  Chief  Chemist 
B.  &  O.  R.  R.  Second  Edition.  Enlarged.  Illustrated.  i2mo.  Cloth,  $1.25 
Progressive  Exercises  in  Practical  Chemistry.  A  Laboratory  Handbook. 
Illustrated.     i2mo.  Cloth,  $1.00 

LEGGr  on  the  Urine.  Practical  Guide  to  the  Examination  of  Urine.  By  J. 
Wickham  Legg,  m.d.   Seventh  Edition,  Enlarged.    Illustrated.    i2mo.    Cloth,  .75 

LEWEES.  On  the  Diseases  of  Women.  A  Practical  Treatise.  By  Dr.  A.  H. 
N.  Lewers,  Assistant  Obstetric  Physician  to  the  London  Hospital  ;  and  Phy- 
sician to  Out-patients,  Queen  Charlotte's  Lying-in  Hospital;  Examiner  in  Mid- 
wifery and  Diseases  of  Women  to  the  Society  of  Apothecaries  of  London.  With 
146  Engravings.     Third  Edition,  Revised.  Cloth,  $2.50 

LEWIS  (BEVAN).  Mental  Diseases.  A  text-book  having  special  reference  to  the 
Pathological  aspects  of  Insanity.  By  Bevan  Lewis,  l.r.c.p.,  m.r.c.s.,  Medi- 
cal Director,  West  Riding  Asylum,  Wakefield,  England.  18  Lithographic  Plates 
and  other  Illustrations.     8vo.  Cloth,  $6.00 

LINCOLN.    School  and  Industrial  Hygiene.    By  D.  F.  Lincoln,  m.d.    Cloth,  .50 

LIZARS  (JOHN).     On  Tobacco.     The  Use  and  Abuse  of  Tobacco.  Cloth,  .50 

LONGLEY'S  Pocket  Medical  Dictionary  for  Students  and  Physicians.  Giving 
the  Correct  Definition  and  Pronunciation  of  all  Words  and  Terms  in  General 
Use  in  Medicine  and  the  Collateral  Sciences,  with  an  Appendix,  containing 
Poisons  and  their  Antidotes,  Abbreviations  Used  in  Prescriptions,  and  a  Metric 
Scale  of  Doses.     By  Elias  Longley.         Cloth,  $1.00;  Tucks  and  Pocket,  $1.25 

MACNAMABA.  On  the  Eye.  A  Manual  of  the  Diseases  of  the  Eye.  By  C. 
Macnamara,  m.d.  Fifth  Edition,  Carefully  Revised ;  with  Additions  and 
Numerous  Colored  Plates,  Diagrams  of  Eye,  Wood-cuts,  and  Test  Types. 
Demi  8vo.  Cloth,  $4.00 

MACALISTER'S  Human  Anatomy.  800  Illustrations.  A  New  Text-book  for 
Students  and  Practitioners.  Systematic  and  Topographical,  including  the 
Embryology,  Histology  and  Morphology  of  Man.  With  special  reference  to  the 
requirements  of  Practical  Surgery  and  Medicine.  By  Alex.  Macalister,  m.d., 
f.r.s.,  Professor  of  Anatomy  in  the  University  of  Cambridge,  England ;  Examiner 
in  Zoology  and  Comparative  Anatomy,  University  of  London  ;  formerly  Professor 
of  Anatomy  and  Surgery,  University  of  Dublin.  With  816  Illustrations,  400  of 
which  are  original.     Octavo.  Cloth,  $7.50;  Leather,  $8.50 

MACDONALD'S  Microscopical  Examinations, of  Water  and  Air.  A  Guide  to  the 
Microscopical  Examination  of  Drinking  Water,  with  an  Appendix  on  the  Micro- 
scopical Examination  of  Air.  By  J.  D.  Macdonald,  m.d.  With  25  Litho- 
graphic Plates,  Reference  Tables,  etc.   Second  Ed.,  Revised.     8vo.    Cloth,  $2.75 


MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  11 

MACKENZIE.  The  Pharmacopoeia  of  the  Hospital  for  Diseases  gf  the  Throat 
and  Nose.  By  Sir  Morell  Mackenzie,  m.d.,  Senior  Physician  to  the  Hospital 
for  Diseases  of  the  Chest  and  Throat,  London.  Fourth  Edition,  Enlarged,  Con- 
taining 250  Formulae,  with  Directions  for  their  Preparation  and  Use.     i6mo. 

Cloth,  $1.25 

MANN'S  Manual  of  Psychological  Medicine  and  Allied  Nervous  Diseases.  Their 
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Aspects  ;  with  chapter  on  Expert  Testimony,  and  an  abstract  of  the  laws  relating 
to  the  Insane  in  all  the  States  of  the  Union.  By  Edward  C.  Mann,  m.d., 
member  of  the  New  York  County  Medical  Society.  With  Illustrations  of  Typical 
Faces  of  the  Insane,  Handwriting  of  the  Insane,  and  Micro-photographic  Sec- 
tions of  the  Brain  and  Spinal  Cord.  Octavo.  Cloth,  $5.00 
MARSHALL'S  Physiological  Diagrams,  Life  Size,  Colored.  Eleven  Life-size 
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the  Class.  By  John  Marshall,  f.r.s.,  f.r.c.s.,  Professor  of  Anatomy  to  the 
Royal  Academy ;  Professor  of  Surgery,  University  College,  London,  etc. 

In  Sheets  Unmounted,  Net,  $40.00 
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MARSHALL  &  SMITH.  On  the  Urine.  The  Chemical  Analysis  of  the  Urine. 
By  John  Marshall,  m.d.,  and  Prof.  Edgar  F.  Smith,  of  the  Chemical  Labora- 
tories, University  of  Pennsylvania.  Phototype  Plates.  i2mo.  Cloth,  $1.00 
MASON'S  Compend  of  Electricity,  and  its  Medical  and  Surgical  Uses.  By 
Charles  F.  Mason,  m.d.,  Assistant  Surgeon  U.  S.  Army.  With  an  Intro- 
duction by  Charles  H.  May,  m.d.,  Instructor  in  the  New  York  Polyclinic. 
Numerous  Illustrations.     i2mo.                                                                      Cloth,  $1.00 

McBRIDE.  Diseases  of  the  Throat,  Nose  and  Ear.  A  Clinical  Manual  for  Stu- 
dents and  Practitioners.  By  P.  McBride,  m.  d.,  f.  r.  c.  p.  Edin.,  Surgeon  to  the 
Ear  and  Throat  Department  of  the  Royal  Infirmary ;  Lecturer  on  Diseases  of 
Throat  and  Ear,  Edinburgh  School  of  Medicine,  etc.  With  Colored  Illustrations 
from  Original  Drawings.     Octavo.  Handsome  Cloth,  Gilt  top,  $7.00 

MAXWELL.  Terminologia  Medica  Polyglotta.  By  Dr.  Theodore  Maxwell, 
assisted  by  others  in  various  countries.     8vo.  Cloth,  $4.00 

The  object  of  this  work  is  to  assist  the  medical  men  of  any  nationality  in  reading  medical  literature  written 
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MAYS'  Therapeutic  Forces  ;  or,  The  Action  of  Medicine  in  the  Light  of  the  Doc- 
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Theine  in  the  Treatment  of  Neuralgia.     i6mo.                       y2  bound,  .50 

MEDICAL  Directory  of  Philadelphia  and  Camden,  1889.  Containing  lists  of 
Physicians  of  all  Schools  of  Practice,  Dentists,  Veter  narians,  Druggists  and 
Chemists,  with  information  concerning  Medical  Societies,  Colleges  and  Associa- 
tions, Hospitals,  Asylums,  Charities,  etc.  Morocco,  Gilt  edges,  $2.50 

MEIGS.  Milk  Analysis  and  Infant  Feeding.  A  Treatise  on  the  Examination  of 
Human  and  Cows'  Milk,  Cream,  Condensed  Milk,  etc.,  and  Directions  as  to  the 
Diet  of  Young  Infants.     By  Arthur  V.  Meigs,  m.d.     i2mo.  Cloth,  $1.00 


18  P.  BLAKISTON,  SON  &*  CO.'S 

MEMMINGER.  Diagnosis  by  the  Urine.  The  Practical  Examination  of  Urine, 
with  Special  Reference  to  Diagnosis.  By  Allard  Memminger,  M.D.,  Professor 
of  Chemistry  and  of  Hygiene  in  the  Medical  College  of  the  State  of  S.  C. ;  Visiting 
Physician  in  the  City  Hospital  of  Charleston,  etc.    23  Illus.     i2mo.     Cloth,  $1.00 

MERRELL'S  Digest  of  Materia  Medica.  Forming  a  Complete  Pharmacopoeia  for 
the  use  of  Physicians,  Pharmacists  and  Students.  By  Albert  Merrell,  m.d. 
Octavo.  Half  dark  Calf,  $4.00 

MEYER.  Ophthalmology.  A  Manual  of  Diseases  of  the  Eye.  By  Dr.  Edouard 
Meyer,  Prof,  a  L'Ecole  de  la  Faculte  de  Medecine  de  Paris,  Chev.  of  the  Legion 
of  Honor,  etc.  Translated  from  the  Third  French  Edition,  with  the  assistance 
of  the  author,  by  A.  Freedland  Fergus,  m.b.,  Assistant  Surgeon  Glasgow 
Eye  Infirmary.  With  270  Illustrations,  and  two  Colored  Plates  prepared 
under  the  direction  of  Dr.  Richard  Liebreich,  m.r.cs.,  Author  of  the  "Atlas 
of  Ophthalmoscopy."     8vo.  Cloth,  $4.50;  Leather,  $5.50 

MILLS.  Fuel  and  Its  Applications.  By  E.  J.  Mills,  d.sc,  f.r.s.,  and  E.  J. 
Rowan,  c.e.  (See  Groves  and  Thorp  Technology.)  8vo.  Clo.,  $7.50 ;  Half  Mor.  $9.00 

MONEY.  On  Children.  Treatment  of  Disease  in  Children,  including  the  Outlines 
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Adults.  By  Angel  Money,  m.d.,  m.r.c.p.,  Ass't  Physician  to  the  Hospital  for 
Sick  Children,  Great  Ormond  St.,  and  to  the  Victoria  Park  Chest  Hospital,  Lon- 
don.    2d  Edition.     i2mo.    560  pages.  Cloth,  $3.00 

MORRIS.  Compend  of  Gynaecology.  By  Henry  Morris,  m.d.,  late  Demonstrator 
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MORRIS.  Text-Book  of  Anatomy.  791  Illustrations,  many  in  Colors.  A  com- 
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Anatomy  at,  Middlesex  Hospital,  assisted  by  J.  Bland  Sutton,  f.r  c.s.,  J.  h. 
Davies-Colley,  f.r.c.s.,  Wm.  J.  Walsham,  f.r. c.s.,  H.  St.  John  Brooks,  m.d., 
R.  Marcus  Gunn,  f.r.c.s.,  Arthur  Hensman,  f.r.c.s.,  Frederick  Treves, 
f.r.c.s.,  William  Anderson,  f.r.c.s.,  and  Prof.  W.  H.  A.  Jacobson.  One 
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colors.  Cloth,  $7.50;  Leather,  $8.50;  Half  Russia,  $9.50 

MOULLIN.  Surgery.  Second  Edition,  by  Hamilton.  A  Complete  Text-book. 
By  C.  W.  Mansell  Moullin,  m.a.,  m.d.  oxon.,  f.r.c.s.,  Surgeon  and  Lec- 
turer on  Physiology  to  the  London  Hospital ;  formerly  Radcliffe  Traveling 
Fellow  and  Fellow  of  Pembroke  College,  Oxford.  Second  American  Edition. 
Revised  and  edited  by  John  B.  Hamilton,  m.d.,  ll.d.,  Professor  of  the  Principles 
of  Surgery  and  Clinical  Surgery,  Rush  Medical  College,  Chicago  ;  Professor  of 
Surgery,  Chicago  Polyclinic  ;  Surgeon,  formerly  Supervising  Surgeon-General, 
U.  S.  Marine  Hospital  Service ;  Surgeon  to  Presbyterian  Hospital ;  Consulting 
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"  The  aim  to  make  this  valuable  treatise  practical  by  giving  special  attention  to  questions  of 

treatment  has  been  admirably  carried  out.     Many  a  reader  will  consult  the  work  with  a  feeling 

of  satisfaction  that  his  wants  have  been  understood,  and  that  they  have  been  intelligently  met. 

He  will  not  look  in  vain  for  details,  without  proper  attention  to  which  he  well  knows  that  the 

highest  success  is  impossible." — The  American  Journal  of  Medical  Sciences. 

MTJRRELL.     Massotherapeutics.     Massage  as  a  Mode  of  Treatment.     By  Wm. 
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minster Hospital.     5th  Edition.    Revised.    i2mo.  Cloth,  $1.50 
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MEDICAL  AND  SCIENTIFIC  PUBLICATIONS.  ^jL9 

MUSKETT.  Prescribing  and  Treatment  in  the  Diseases  of  Infants  and  Child- 
ren. By  Philip  E.  Mcjskett,  Late  Surgeon  to  the  Sydney  Hospital,  Formerly 
Senior  Resident  Medical  Officer,  Sydney  Hospital.     321110.  Cloth,  $1.75 

MORTON  on  Refraction  of  the  Eye.  Its  Diagnosis  and  the  Correction  of  its  Errors. 
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MUTER.  Practical  and  Analytical  Chemistry.  By  John  Muter,  f.r.s.,  f.c.s., 
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Colleges,  by  Claude  C.  Hamilton,  m.d.,  Professor  of  Analytical  Chemistry 
in  University  Med.  Col.  and  Kansas  City  Col.  of  Pharmacy.     51  Illus.    Cloth,  $2.00 

"  Muter's  Manual  of  Analytical  Chemistry,  several  previous  editions  of  which  we  have 
noticed,  now  appears,  revised  in  an  American  edition  by  Dr.  Claude  C.  Hamilton.  This 
revision  is  based  upon  the  fourth  English  edition.  The  editor  has  made  only  such  changes  as 
were  required  to  adapt  the  book  to  the  U.  S.  Pharmacopoeia,  except  in  the  chapter  on  urine 
analysis,  which  has  been  enlarged  and  to  which  cuts  of  microscopic  sediments  and  other  illus- 
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Popular  Science  Monthly. 

NAPHEYS'  Modern  Therapeutics.  New  Revised  Edition,  Enlarged  and  Im- 
proved. In  Two  Handsome  Volumes.  Edited  by  Allen  J.  Smith,  m.d.,  Pro- 
fessor of  Pathology,  University  of  Texas,  Galveston,  late  Ass't  Demonstrator  of 
Morbid  Anatomy  and  Pathological  Histology,  Lecturer  on  Urinology,  University 
of  Pennsylvania ;  and  J.  Aubrey  Davis,  m.d.,  Ass't  Demonstrator  of  Obstetrics, 
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Vol.  I. — General  Medicine  and  Diseases  of  Children. 

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OBERSTEINER.  The  Anatomy  of  the  Central  Nervous  Organs.  A  Guide  to  the 
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of  the  University  of  Vienna.  Translated  and  Edited  by  Alex.  Hill,  m.a.,  m.d., 
Master  of  Downing  College,  Cambridge.     198  Illustrations.     8vo.       Cloth,  $6.00 

OPHTHALMIC  REVIEW.  A  Monthly  Record  of  Ophthalmic  Science.  Published 
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ORMEROD.  Diseases  of  Nervous  System,  Student's  Guide  to.  By  J.  A.  Ormerod, 
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Physician  to  National  Hospital  for  Paralyzed  and  Epileptic  and  to  City  of  London 
Hospital  for  Diseases  of  the  Chest,  Dem.  of  Morbid  Anatomy,  St.  Bartholo- 
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20  P.  BLAKISTON,  SON  &•>  CO.'S 

OSTROM.    Massage  and  the  Original  Swedish  Movements.    Their  Application 
to  Various  Diseases  of  the  Body.    A  Manual  for  Students,  Nurses  and  Physicians. 
By  Kurre  W.  Ostrom,  from  the  Royal  University  of  Upsala,  Sweden ;  Instructor 
in    Massage   and   Swedish   Movements   in   the    Hospital   of  the   University    ot 
Pennsylvania,  and  in  the  Philadelphia  Polyclinic  and  College  for  Graduates  in 
Medicine,  etc.     Second  Edition.     Enlarged.     Illustrated  by  87  Wood  Engrav- 
ings, many  of  which  were  drawn  especially  for  this  purpose.    i2mo.     Cloth,  $1  00 
"  This  book,  which  is  well  written  and  carefully  illustrated,  will  be  of  service  both  to  phy- 
sicians and  nurses  as  well  as  to  manipulators.      Mr.  Ostrom,  who  came   to  this   country  from 
Sweden,  has  proven  himself  a  capable  teacher  as  well  as  a  good  masseur,  his  instructions  being 
careful,  accurate,  and  complete.'' — University  Medical  Magazine,  Philadelphia. 

OVERMAN'S  Practical  Mineralogy,  Assaying  and  Mining,  with  a  Description  of 
the  Useful  Minerals,  etc.  By  Frederick  Overman,  Mining  Engineer.  Elev- 
enth Edition.     i2mo.  Cloth,  Si. 00 

PACKARD'S  Sea  Air  and  Sea  Bathing.    By  John  H.  Packard,  m.d.      Cloth,  .50 

PAGE.     Railroad  Injuries.     With  Special  Reference  to  those  of  the   Back  and 

Nervous  System.     By  Herbert  Page,  f.r.c.s.,  Surgeon  to  St.  Mary's  Hospital, 

and  Lecturer  on  Surgery  at  its  Medical  School.     Octavo.  Cloth,  $2.25 

Injuries  of  the  Spine  and  Spinal  Cord.     In  their  Surgical  and  Medico-Legal 

Aspects.     Third  Edition.     Revised.     Octavo.  Preparing. 

PARKES'  Practical  Hygiene.  By  Edward  A.  Parkes,  m.d.  The  Eighth  Re- 
vised and  Enlarged  Edition.  Edited  by  J.  Lane  Notter,  m.a.,  m.d.,  f.c.s., 
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graphic Plates  and  over  100  other  Illustrations.     8vo.  Cloth,  S5.C0 

PARKES.  Hygiene  and  Public  Health.  A  Practical  Manual.  By  Louis  C. 
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PHILLIPS.  Spectacles  and  Eyeglasses,  Their  Prescription  and  Adjustment.  By 
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Nurses  of  the  Philadelphia  Hospital.     By  Theophilus  Parvin,  m.d.,  Professor 

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PHYSICIAN'S  VISITING-  LIST.  Published  Annually.  Forty-First  Year  of  its 
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5°        "  "-ol,     {j££g£}  •        •  -5° 

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MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS,  21 

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m        <<  <<  i       f  Tan.  to  Tune }      ((        <«         ,,         ,,  „  „ 

So  "2  vols.    {julyt0JDec.j  •        •  3-oo 

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cluding over  600  Prescriptions  and  Formulae.     By  Samuel  O.  L.  Potter,  m.a., 
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lege, San  Francisco ;  late  A.  A.  Surgeon  U.  S.  Army.  Fourth  Edition,  Revised  and 
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Compend  of  Anatomy,  including  Visceral  Anatomy.    Based  tipon  Gray. 
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Cloth,  $1.00;  Interleaved  for  taking  Notes,  $1.25 
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Speech    and    Its   Defects.     Considered  Physiologically,  Pathologically  and 
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Revised  and  Corrected.     i2mo.  Cloth,  $1.00 

PRITCHARD  on  the  Ear.  Handbook  of  Diseases  of  the  Ear.  By  Urban 
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Aural  Surgeon  to  King's  College  Hospital,  Senior  Surgeon  to  the  Royal  Ear  Hos- 
pital, etc.  Second  Edition.  Many  Illustrations  and  Formulas.  i2mo.  Cloth,  $1.50 
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with  advantage  by  anyone  interested  in  the  subject,  whether  surgeon,  practitioner,  or  student." 
—  The  London  Practitioner. 

PROCTOR'S  Practical  Pharmacy.  Lectures  on  Practical  Pharmacy.  With  Wood 
Engravings  and  32  Lithographic  Fac -simile  Prescriptions.  By  Barnard  S. 
Proctor.  Third  Edition.  Revised  and  with  elaborate  Tables  of  Chemical 
Solubilities,  etc.  Cloth,  $4.50 


22  P.  BLAKISTON,  SON  <5-  CO.'S 

RALFE.     Diseases  of  the  Kidney  and  Urinary  Derangements.     By  C.  H.  Ralfe, 

m.d.,  f.r.c. p.,  Ass't  Physician  to  the  London  Hospital.    Illus.    i2mo.    Cloth,  #2.75 

RAMSAY.  A  System  of  Inorganic  Chemistry.  By  William  Ramsay,  ph.d., 
f.r.s.,  Prof,  of  Chem.  in  University  College,  London.    Illus.     8vo.     Cloth,  $4.50 

REESE'S  Medical  Jurisprudence  and  Toxicology.  A  Text-book  for  Medical  and 
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Jurisprudence,  Professor  of  the  Principles  and  Practice  of  Medical  Jurisprudence, 
including  Toxicology,  in  the  University  of  Pennsylvania  Medical  Department. 
Third  Edition.  Enlarged.  Crown  Octavo.  666  pages.    Cloth,  $3.00;  Leather,  $3.50 

"  The  third  edition  of  this  well-known  book  needs  scarcely  any  comment  at  our  hands.  It 
has  been  so  fully  and  favorably  dwelt  upon  in  the  Journal  at  its  former  appearances  that  but  little 
more  can  be  added  now.  That  it  is  a  standard  work  of  American  medical  literature  is  not  say- 
ing too  much  for  it,  also  that  it  is  a  thoroughly  reliable  guide  for  the  practitioner  if  called  upon 
to  define  his  position  in  the  judicial  forum.  To  the  student  of  medical  jurisprudence  and  toxi- 
cology it  is  invaluable,  as  it  is  concise,  clear,  and  thorough  in  every  respect.  The  absence  of 
cumbersome  quotations  enhances  its  value.  The  additions  especially  valuable  in  the  present 
revision  are  the  chapter  on  the  Ptomaines  and  Formad's  investigation  and  technique  for  the 
restoration  and  measurement  of  blood  corpuscles." — The  American  Journal  of  the  Medical 
Sciences. 

REEVES.  Bodily  Deformities  and  their  Treatment.  A  Handbook  of  Practical 
Orthopaedics.  By  H.  A.  Reeves,  m.d.,  Senior  Ass't  Surgeon  to  the  London  Hos- 
pital, Surgeon  to  the  Royal  Orthopaedic  Hospital.     228  Illustrations.     Cloth,  $2.25 

RICHARDSON.  Long  Life,  and  How  to  Reach  It.  By  J.  G.  Richardson,  Prof, 
of  Hygiene,  University  of  Penna.  Cloth,  .50 

RICHARDSON'S  Mechanical  Dentistry.  A  Practical  Treatise  on  Mechanical 
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With  569  Illustrations.     8vo.  Cloth,  $4.50;  Leather,  $5.50 

RIGBY'S  Obstetric  Memoranda.    4th  Ed.    By  Meadows.    32mo.         Cloth,  .50 

RICHTER'S  Inorganic  Chemistry.  A  Text-book  for  Students.  By  Prof.  Victor 
von  Richter,  University  of  Breslau.  Fourth  American,  from  Sixth  German 
Edition.  Authorized  Translation  by  Edgar  F.  Smith,  m.a.,  ph.d.,  Prof,  of 
Chemistry,  University  of  Pennsylvania,  Member  of  the  Chemical  Societies  of 
Berlin  and  Paris.    89  Illustrations  and  a  Colored  Plate.     i2mo.  Cloth,  $2.00 

Organic  Chemistry.  The  Chemistry  of  the  Carbon  Compounds.  Second 
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m.  A.,  ph.  D.,  Professor  of  Chemistry,  University  of  Pennsylvania.  Illustrated. 
1040  pages.     i2mo.  Cloth,  $4.50 

ROBERTS.  Practice  of  Medicine.  The  Theory  and  Practice  of  Medicine.  By 
Frederick  Roberts,  m.d.,  Professor  of  Therapeutics  at  University  College, 
London.    Eighth  Edition,  with  Illustrations.    8vo.      Cloth,  $5.50;  Leather,  $6.50 

ROBINSON.  Latin  Grammar  of  Pharmacy  and  Medicine  By  D.  H.  Robinson, 
ph.d.,  Professor  of  Latin  Language  and  Literature,  University  of  Kansas,  Law- 
rence. With  an  Introduction  by  L.  E.  Sayre,  ph.g.,  Professor  of  Pharmacy  in, 
and  Dean  of  the  Dept.  of  Pharmacy,  University  of  Kansas.    1 2mo.        Cloth,  $2.00 

SANDERSON'S  Physiological  Laboratory.  A  Handbook  of  the  Physiological 
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and  T.  Lauder  Brunton,  m.d.  With  over  350  Illustrations  and  Appropriate 
Letter-press  Explanations  and  References.     One  Volume.  Cloth,  $5.00 


MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  23 

SANSOM.  Diseases  of  The  Heart.  The  Diagnosis  of  Diseases  of  the  Heart  and 
Thoracic  Aorta,  and  the  Pathology  which  serves  for  the  recognition  of  Morbid 
States  of  the  Organs  of  Circulation.  By  A.  Ernest  Sansom,  m.d.,  f.r.c.p., 
Physician  to  the  London  Hospital,  Examiner  in  Medicine  Royal  College  of 
Physicians,  etc.     With  Plates  and  other  Illustrations.     8vo.  Cloth,  $7.50 

SCHULTZE.  Obstetrical  Diagrams.  Being  a  Series  of  20  Colored  Lithograph 
Charts,  imperial  map  size,  of  Pregnancy  and  Midwifery,  with  accompanying 
explanatory  (German)  text,  illustrated  by  wood-cuts.  By  Dr.  B.  S.  Schultze, 
Professor  of  Obstetrics,  University  of  Jena.     Second  Revised  Edition. 

Price,  in  Sheets,  net,  $26.00 ;  Mounted  on  Rollers,  Muslin  Backs,  net,  $36.00 

SELF-EXAMINATION,  being-  3000  Questions  on  Medical  Subjects,  Anatomy, 
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SEWELL.  Dental  Surgery,  including  Special  Anatomy  and  Surgery.  By  Henry 
Sewell,  m.r.c.s.,  l.d.s.,  President  Odontological  Society  of  Great  Britain.  3d 
Edition,  greatly  enlarged,  with  about  200  Illustrations.  Cloth,  $3.00 

SHAWE.  Notes  for  Visiting  Nurses,  and  all  those  interested  in  the  working  and 
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Gillette  Shawe,  District  Nurse  for  the  Brooklyn  Red  Cross  Society.  With  an 
Appendix  explaining  the  organization  and  working  of  various  Visiting  and  Dis- 
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SMITH'S  Wasting  Diseases  of  Infants  and  Children.  By  Eustace  Smith,  m.d., 
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Edition,  Enlarged.     8vo.  Cloth,  $3.00 

SMITH.  Abdominal  Surgery.  Being  a  Systematic  Description  of  all  the  Princi- 
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firmary ;  Lecturer  on  Surgery,  Bristol  Medical  School ;  Late  Examiner  in  Surgery, 
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SMITH.  Electro-Cbemical  Analysis.  By  Edgar  F.  Smith,  Professor  of  Chem- 
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SMITH  AND  KELLER.  Experiments.  Arranged  for  Students  in  General  Chem- 
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Dr.  H.  F.  Keller,  Professor  of  Chemistry,  Michigan  School  of  Mines,  Houghton, 
Michigan.     Second  Edition.     i2mo.     Illustrated.  Cloth,  Net,  .60 

STAMMER.  Chemical  Problems,  with  Explanations  and  Answers.  By  Karl 
Stammer.  Translated  from  the  2d  German  Edition,  by  Prof.  W.  S.  Hoskinson, 
a.m.,  Wittenberg  College,  Springfield,  Ohio.     i2mo.  Cloth.  .75 

STARR.  The  Digestive  Organs  in  Childhood.  Second  Edition.  The  Diseases 
of  the  Digestive  Organs  in  Infancy  and  Childhood.  With  Chapters  on  the 
Investigation  of  Disease  and  the  Management  of  Children.  By  Louis  Starr, 
m.d.,  late  Clinical  Prof,  of  Diseases  of  Children  in  the  Hospital  of  the  University 
of  Penn'a;  Physician  to  the  Children's  Hospital,  Phila.  Second  Edition. 
Revised  and  Enlarged.  Illustrated  by  two  Colored  Lithograph  Plates  and 
numerous  wood-engravings.     Crown  Octavo.  Cloth,  $2.25 

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ing of  Infants  and  Children,  and  the  Domestic  Management  of  the  Ordinary 
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See  also  Goodhart  and  Starr.    Page  10. 


24  P.  BLAK1ST0N,  SON  6-  CO.'S 

STARLING.  Elements  of  Human  Physiology.  By  Ernest  H.  Starling,  m.d., 
Lond.,  M.  R.  c.  P.,  Joint  Lecturer  on  Physiology  at  Guy's  Hospital,  London; 
Member  of  Physiological  Society,  etc.  With  ioo  Illustrations.  i2mo.  437 
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STEARNS.  Mental  Diseases.  Lectures  on  Mental  Diseases,  designed  especially  for 
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Physician  Superintendent  at  the  Hartford  Retreat,  Lecturer  on  Mental  Diseases 
in  Yale  University,  Member  of  the  American  Medico-Psychological  Ass'n,  Hon- 
orary Member  of  the  Boston  Medico-Pyschological  Society  Illustrated.  New 
Series  of  Manuals.  Cloth,  $3. 00;  Sheep,  $3.50 

STEAVENSON  AND  JONES.  Medical  Electricity.  A  Practical  Handbook  for 
Students  and  Practitioners  of  Medicine.  By  W.  E.  Steavenson,  m.d.,  late  in 
charge  Electrical  Department,  St.  Bartholomew's  Hospital,  and  H.  Lewis  Jones, 
m.a.,  m.d.,  m.r.c.p.,  Medical  Officer  in  Charge  Electrical  Department,  St.  Bar- 
tholomew's Hospital.     103  Illustrations.     i2mo.  Cloth,  $2.50 

STEVENSON  AND  MURPHY.  A  Treatise  on  Hygiene.  By  Various  Authors. 
Edited  by  Thomas  Stevenson,  m.d.,  f.r.c.p.,  Lecturer  on  Chemistry  and  Medi- 
cal Jurisprudence  at  Guy's  Hospital,  London,  etc.,  and  Shirley  F.  Murphy, 
Medical  Officer  of  Health  to  the  County  of  London.  In  Two  Octavo  Volumes. 
Vol.  I.     1013  pages.     Octavo.  Cloth,  $7.50 

Vol.  II.     Octavo.  Nearly  Ready. 

^x  Special  Circular  tipon  application. 

STEWART'S  Compend  of  Pharmacy.  Based  upon  "  Remington's  Text-Book  of 
Pharmacy."  By  F.  E.  Stewart,  m.d.,  ph.g.,  Quiz  Master  in  Chem.  and  Theoreti- 
cal Pharmacy,  Phila.  College  of  Pharmacy;  Lect.  in  Pharmacology,  Jefferson 
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tems of  Weights  and  Measures.     ? Quiz- Competid?  Series.  Cloth,  $1.00 

Interleaved  for  the  addition  of  notes,  $1.25 

STIRLING.  Outlines  of  Practical  Physiology.  Including  Chemical  and  Experi- 
mental Physiology,  with  Special  Reference  to  Practical  Medicine.  By  W.  Stir- 
ling, m.d.,  Sc.d.,  Prof,  of  Phys.,  Owens  College,  Victoria  University,  Manchester. 
Examiner  in  Honors  School  of  Science,  Oxford,  England.  Second  Edition. 
234  Illustrations.  Cloth,  $3.00 

Outlines  of  Practical  Histology.     344  Illustrations.     Second  Edition.     Re- 
vised and  Enlarged  with  new  Illustrations.     i2mo.  In  Press. 
STOCKEN'S  Dental  Materia  Medica.    Dental  Materia  Medica  and  Therapeutics, 
with  Pharmacopoeia.     By  James  Stocken,  d.d.s.     Third  Edition.     Cloth,  $2.50 

STRAHAN.  Extra-Uterine  Pregnancy.  The  Diagnosis  and  Treatment  of  Extra- 
Uterine  Pregnancy.  Being  the  Jenks  Prize  Essay  of  the  College  of  Physicians 
of  Philadelphia.  By  John  Strahan,  m.d.  (Univ.  of  Ireland),  late  Res.  Surgeon 
Belfast  Union  Infirmary  and  Fever  Hospital.     Octavo.  Cloth,  $1.50 

SUTTON.  Lectures  on  Pathology.  Delivered  at  the  London  Hospital  by  the  late 
Henry  Gawen  Sutton,  m.b.,  f.r.c.p.,  Physician  and  Lecturer  on  Pathology  at 
the  London  Hospital.  Edited  by  Maurice  E.  Paul,  m.d.,  and  Revised  by  Samuel 
Wilks,  m.d.,  ll.d.,  f.r.s.     Octavo.     503  pages.  Cloth,  $4.50 

SUTTON'S  Volumetric  Analysis.  A  Systematic  Handbook  for  the  Quantitative 
Estimation  of  Chemical  Substances  by  Measure,  Applied  to  Liquids,  Solids  and 
Gases.  By  Francis  Sutton,  f.c.s.  Sixth  Edition,  Revised  and  Enlarged, 
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SWANZY.  Diseases  of  the  Eye  and  their  Treatment.  A  Handbook  for  Physi- 
cians and  Students.  By  Henry  R.  Swanzy,  a.m.,  m.b.,  f.r.c.s.l,  Surgeon  to 
the  National  Eye  and  Ear  Infirmary  ;  Ophthalmic  Surgeon  to  the  Adelaide  Hos- 
pital, Dublin.  Fourth  Edition,  Thoroughly  Revised.  Enlarged.  164  Illustra- 
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MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  25 

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Symonds,  a.m.,  m.d.,  Ass't  Physician  Roosevelt  Hospital,  Out-Patient  Department ; 
Attending  Physician  Northwestern  Dispensary,  New  York.  Second  Edition. 
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TAFT'S  Operative  Dentistry.  A  Practical  Treatise  on  Operative  Dentistry.  By 
Jonathan  Taft,  d.d.s.  Fourth  Revised  and  Enlarged  Edition.  Over  100  Il- 
lustrations.    8vo.  Cloth,  $4.25  ;  Leather,  $5.00 

Index  of  Dental  Periodical  Literature.    8vo.  Cloth,  $2.00 

TALBOT.  Irregularities  of  the  Teeth,  and  Their  Treatment.  By  Eugene  S. 
Talbot,  m.d.,  Professor  of  Dental  Surgery  Woman's  Medical  College,  and 
Lecturer  on  Dental  Pathology  in  Rush  Medical  College,  Chicago.  Second  Edi- 
tion, Revised  and  Enlarged  by  about  100  pages.  Octavo.  234  Illustrations 
(169  of  which  are  original).     261  pages.  Cloth,  $3.00 

TANNER'S  Memoranda  of  Poisons  and  their  Antidotes  and  Tests.  By  Thos. 
Hawkes  Tanner,  m.d.,  f.r.c.p.  7th  American,  from  the  Last  London  Edition. 
Revised  by  John  J.  Reese,  m.d.,  Professor  Medical  Jurisprudence  and  Toxi- 
cology in  the  University  of  Pennsylvania.     i2mo.  Cloth,  .75 

TAYLOR.  Practice  of  Medicine.  A  Manual.  By  Frederick  Taylor,  m.d., 
Physician  to,  and  Lecturer  on  Medicine  at,  Guy's  Hospital,  London  ;  Physician  to 
Evelina  Hospital  for  Sick  Children,  and  Examiner  in  Materia  Medica  and  Phar- 
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THOMPSON.  Urinary  Organs.  Diseases  of  the  Urinary  Organs.  Containing  32 
Lectures.  By  Sir  Henry  Thompson,  f.r.c.s.,  Emeritus  Professor  of  Clinical  Sur- 
gery in  University  College.  Eighth  London  Ed.  Octavo.  470  pages.    Cloth,  $3.50 

Calculous  Diseases.     The  Preventive  Treatment  of  Calculous  Disease,  and 
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THORBURN.  Surgery  of  the  Spinal  Cord.  A  Contribution  to  the  study  of.  By 
William  Thorburn,  b.Sc,  m.d.     Illustrated.     Octavo.  Cloth,  $4.50 

THORNTON.  The  Surgery  of  the  Kidney.  By  John  Knowsley  Thornton, 
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TILT'S  Change  of  Life  in  Women,  in  Health  and  Disease.  A  Practical  Treatise. 
By  Edward  John  Tilt,  m.d.     Fourth  London  Edition.     8vo.  Cloth,  $1.25 

TOMES'  Dental  Anatomy.    A  Manual  of  Dental  Anatomy,  Human  and  Compara- 
tive.    By  C.  S.  Tomes,  d.d.s.     212  Illustrations.     3d  Ed.     i2mo.       Cloth,  $4.00 
Dental  Surgery.    A  System  of  Dental  Surgery.    By  John  Tomes,  f.r.s. 
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26  P.  BLAKISTON,  SON  6-  CO.'S 


TREVES.  German-English  Medical  Dictionary.    By  Frederick  Treves,  f.r.c.s., 

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TRIMBLE.  Practical  and  Analytical  Chemistry.  Being  a  complete  course  in 
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istry in  the  Philadelphia  College  of  Pharmacy.  Fourth  Edition.  Enlarged. 
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ministration ;  Considering  their  Relative  Risks ;  Tests  of  Purity ;  Treatment  of 
Asphyxia ;  Spasms  of  the  Glottis ;  Syncope,  etc.  By  Laurence  Turnbull,  m.d., 
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vised and  Enlarged.     40  Illustrations.     i2mo.  Cloth,  $3.00 

TTJSON.  Veterinary  Pharmacopoeia.  Including  the  Outlines  of  Materia  Medica 
and  Therapeutics.  For  the  Use  of  Students  and  Practitioners  of  Veterinary 
Medicine.     By  Richard  V.  Tuson,  f.c.s.     Third  Edition.     i2mo.     Cloth,  $2.50 

TUKE.  Dictionary  of  Psychological  Medicine.  Giving  the  Definition,  Ety- 
mology, and  Synonyms  of  the  terms  used  in  Medical  Psychology,  with  the 
Symptoms,  Pathology,  and  Treatment  of  the  recognized  forms  of  Mental  Dis- 
orders, together  with  the  Law  of  Lunacy  in  Great  Britain  and  Ireland.  Edited  by 
D.  Hack  Tuke,  m.d.,ll.d.,  Examiner  in  Mental  Physiology  in  the  University 
of  London  ;  Co-Editor  of  "  The  Journal  of  Mental  Science."  Two  Volumes. 
Octavo.  Cloth,  $13.00 

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and  Therapeutics.  By  James  Tyson,  m.d.,  Professor  of  Clinical  Medicine  in 
the  University  of  Pennsylvania.  Including  a  Section  on  Retinitis  in  Bright's 
Disease.  By  Wm.  F.  Norris,  m.d.,  Clin.  Prof,  of  Ophthalmology  in  Univ.  of 
Penna.     With  Colored  Plates  and  many  Wood  Engravings.     8vo.     Cloth,  $3.50 

TYSON.    Guide  to  the  Examination  of  Urine.    Seventh  Edition.    For  the  Use 

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of  the  subject.     Illustrated.     Second  Edition.     8vo.  Cloth,  $2.00 

Handbook  of  Physical  Diagnosis.    Illustrated,    nmo.  Cloth,  $1.25 

VAN  HARLINGEN  on  Skin  Diseases.  A  Practical  Manual  of  Diagnosis  and 
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Skin  in  the  Philadelphia  Polyclinic ;  Clinical  Lecturer  on  Dermatology  at  Jef- 
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VAN  NUYS  on  The  Urine.     Chemical  Analysis  of  Healthy  and  Diseased  Urine, 

Qualitative  and   Quantitative.      By  T.  C.  Van   Nuys,  Professor  of  Chemistry 

.    Indiana  University.     39  Illustrations.     Octavo.  Cloth,  $2.00 

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Method  of  Performing  them  in  the  Dead  House  of  the  Berlin  Charite  Hospital, 
with  especial  reference  to  Medico-legal  Practice.  By  Prof.  Virchow.  Trans- 
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"WALSHAM.  Manual  of  Practical  Surgery.  For  Students  and  Physicians.  By 
Wm.  J.  Walsham,  m.d.,  f.r.c.s.,  Ass't  Surg,  to,  and  Dem.  of  Practical  Surg,  in, 
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MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  27 


WARING.  Practical  Therapeutics.  A  Manual  for  Physicians  and  Students.  By 
Edward  J.  Waring,  m.d.  Fourth  Edition.  Revised,  Rewritten  and  Rearranged 
by  Dudley  W.  Buxton,  m.d.,  Assistant  to  the  Professor  of  Medicine,  University 
College,  London.     Crown  Octavo.  Cloth,  $3.00;  Leather,  $3.50 

WARREN.  Compend  Dental  Pathology  and  Dental  Medicine.  Containing  all 
the  most  noteworthy  points  of  interest  to  the  Dental  Student.  By  Geo.  W. 
Warren,  d.d.s.,  Clinical  Chief,  Penn'a  College  of  Dental  Surgery,  Phila.  Illus. 
Being  No.  13  ?  Quiz-  Compend  f  Series.     i2mo.  Cloth,  $1.00 

Interleaved. for  the  addition  of  Notes,  $1.25 
WATSON   on  Amputations   of   the   Extremities   and  Their   Complications.      By 
B.  A.  Watson,  a.m.,  m.d.,  Surgeon  to  the  Jersey  City  Charity  Hospital  and  to 
Christ's  Hospital,  Jersey  City,  N.  J.     250  Illustrations.  Cloth,  $5.50 

Concussions.     An  Experimental  Study  of  Lesions  arising  from  Severe  Con- 
cussions.    8vo.  Paper  cover,  $1.00 
WATTS'  Inorganic  Chemistry.     A  Manual  of  Chemistry,  Physical  and  Inorganic. 
(Being  the  14th  Edition  of  Fowne's  Physical  and  Inorganic   Chemistry.) 
By  Henry  Watts,  b.a.,  f.r.s.     With  Colored  Plate  of  Spectra  and  other  Illus- 
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(Being  the  13th  Edition  of  Fowne's  Organic  Chemistry.)     Illustrated. 
i2mo.  Cloth,  $2.25 

WESTLAND.  The  Wife  and  Mother.  A  Handbook  for  Mothers.  By  A. 
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WETHERED.  Medical  Microscopy.  A  Practical  Manual  for  Students.  By  Frank 
J.  Wethered,  m.d  ,  m.r.c.p.,  Demonstrator  of  Practical  Medicine,  Middlesex 
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WEYL.  Sanitary  Relations  of  the  Coal-Tar  Colors.  By  Theodore  Weyl. 
Authorized  Translation  by  Henry  Leffmann,  m.d.,  ph.d.  This  work  contains 
the  most  recent  trustworthy  information  on  the  physiological  action  of  the  coal- 
tar  colors.  Tests  for  recognizing  the  different  colors  are  given.  A  summary  of 
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coal-tar  colors,  now  so  much  used  in  articles  of  food  and  drink.  i2mo.  154 
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WHITE  AND  WILCOX.  Materia  Medica,  Pharmacy,  Pharmacology,  and 
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etc.,  Physician  to  and  Lecturer  on  Materia  Medica,  Guy's  Hospital;  Examiner  in 
Materia  Medica,  Royal  College  of  Physicians,  London,  etc.  American  Edition. 
Revised  by  Reynold  W.  Wilcox,  m.a.,  m.d.,  Professor  of  Clinical  Medicine 
at  the  New  York  Post- Graduate  Medical  School  and  Hospital ;  Assistant  Visiting 
Physician  Bellevue  Hospital.  Cloth,  $3.00;  Leather,  $3.50 

WILSON.  Handbook  of  Hygiene  and  Sanitary  Science.  By  George  Wilson, 
m.a.,  m.d.,  f.r.s.e.,  Medical  Officer  of  Health  for  Mid-Warwickshire,  England. 
With  Illustrations.    Seventh  Edition,  Enlarged  by  200  pages.    i2mo.    Cloth,  $3. 2 5 

WILSON.  The  Summer  and  its  Diseases.  By  James  C.  Wilson,  m.d.,  Prof,  of  the 
Practice  of  Med.  and  Clinical  Medicine,  Jefferson  Med.  Coll.,  Phila.     Cloth,  .50 

WILSON.  System  of  Human  Anatomy.  1  ith  Revised  Edition.  Edited  by  Henry 
Edward  Clark,  m.d.,  m.r.c.s.  492  Illustrations,  26  Colored  Plates,  and  a 
Glossary  of  Terms.     Thick  i2mo.  Cloth,  $6.00 


28  P.  BLAKISTON,  SON  &»  CO.'S  PUBLICA  TIONS. 

WINCKEL.  Diseases  of  Women.  Second  Edition.  Including  the  Dis- 
eases of  the  Bladder  and  Urethra.  By  Dr.  F.  Winckel,  Professor  of 
Gynaecology,  and  Director  of  the  Royal  University  Clinic  for  Women,  in  Munich. 
Translated  by  special  authority  of  Author  and  Publisher,  under  the  supervision 
of,  and  with  an  Introduction  by,  Theophilus  Parvin,  m.d.,  Professor  of 
Obstetrics  and  Diseases  of  Women  and  Children  in  Jefferson  Medical  Col- 
lege, Philadelphia.  With  152  Engravings  on  Wood,  most  of  which  are  original. 
2d  Edition,  Revised  and  Enlarged.  Cloth,  $3.00;  Leather,  $3.50 

"  Dr.  Winckel's  work  well  deserved  translation  into  English.  A  very  large  number  of 
treatises  and  text-books  on  gynaecology  have  been  written  by  British  and  American  authors,  but 
hardly  one  of  the  type  of  Dr.  Winckel's." — The  British  Medical  Journal. 

"  Winckel's  hand-book  is  a  work  that  will  be  profitably  consulted  by  all  classes  of  gynecol- 
ogical practitioners.  It  contains  better  and  more  elaborate  pathological  descriptions  than  any 
work  of  its  kind  in  the  English  language  that  we  are  acquainted  with.  ...  As  a  text-book 
for  students,  as  well  as  a  work  of  reference  for  the  practitioner,  we  can  conscientiously  recom- 
mend Winckel's  '  Diseases  of  Women.'  " — The  Medical  Record. 

Text-Book  of  Obstetrics  ;  Including  the  Pathology  and  Therapeutics  of  the 
Puerperal  State.  Authorized  Translation  by  J.  Clifton  Edgar,  a.m.,  m.d., 
Adjunct  Professor  to  the  Chair  of  Obstetrics,  Medical  Department,  University 
City  of  New  York.  With  nearly  200  Handsome  Illus.,  the  majority  of  which 
are  original  with  this  work.     Octavo.  Cloth,  $6.00;  Leather,  $7.00 

WOAKES.  Post-Nasal  Catarrh  and  Diseases  of  the  Nose,  causing  Deafness.  By 
Edward  Woakes,  m.d.,  Senior  Aural  Surgeon  to  the  London  Hospital  for 
Diseases  of  the  Throat  and  Chest.     26  Illustrations.  Cloth,  $1.50 

WOLFF.  Manual  of  Applied  Medical  Chemistry  for  Students  and  Practitioners  of 
Medicine.  By  Lawrence  Wolff,  m.d.,  Demonstrator  of  Chemistry  in  Jeffer- 
son Medical  College,  Philadelphia.  Cloth,  $  1.00 

WOOD.  Brain  Work  and  Overwork.  By  Prof.  H.  C.  Wood,  Clinical  Professor 
of  Nervous  Diseases,  University  of  Pennsylvania.     i2mo.  Cloth,  .50 

WOODY.  Essentials  of  Chemistry  and  Urinalysis.  By  Sam  E.  Woody,  a.m., 
m.d.,  Professor  of  Chemistry  and  Public  Hygiene,  and  Clinical  Lecturer  on 
Diseases  of  Children,  in  the  Kentucky  School  of  Medicine.  Third  Edition. 
Illustrated.     i2mo.  Cloth,  $1.25 

WYNTER  and  WETHERED.  Clinical  and  Practical  Pathology.  A  Manual 
of  Clinical  and  Practical  Pathology.  By  W.  Essex  Wynter,  m.d.,  Medical  Reg- 
istrar and  late  Dem.  of  Anat.  and  Chem.  at  the  Middlesex  Hospital,  and 
Frank  J.  Wethered,  m.d.,  Ass't  Phys.  to  the  City  of  London  Hospital  for  Dis. 
of  the  Chest.     4  Colored  Plates  and  67  other  Illustrations.     8vo.         Cloth,  $4.00 

WYTHE.  Dose  and  Symptom  Book.  The  Physician's  Pocket  Dose  and  Symptom 
Book.  Containing  the  Doses  and  Uses  of  all  the  Principal  Articles  of  the 
Materia  Medica,  and  Officinal  Preparations.  By  Joseph  H.  Wythe,  a.m.,  m.d. 
17th  Edition,  Revised  and  Rewritten. 

Cloth,  $1.00;  Leather,  with  Tucks  and  Pocket,  $1.25 

YEO'S  Manual  of  Physiology.  Sixth  Edition.  A  Text-book  for  Students  of 
Medicine.  By  Gerald  F.  Yeo.,  m.d.,  f.r.c.s.,  Professor  of  Physiology  in  King's 
College,  London.  Sixth  Edition ;  revised  and  enlarged  by  the  author.  With 
321  Wood  Engravings  and  a  Glossary.  Crown  Octavo.  Being  No.  4,  New 
Series  of  Manuals.  Nearly  Ready. 


JUST  READY. 


MORRIS'S  HUMAN  ANATOMY. 

A   NEW  TEXT  =  BOOK. 

791    Illustrations,  214   of    which  are  Printed    in   Several  Colors,  and  most  of  which 
are  original.    OCTAVO.     1200  PAGES. 

Handsome  Cloth,  $<r.50 ;  Full  Sheep,  $8.50 ;  Half  Russia,  Marbled  Edges,  $9.50. 


J.  Bland  Sutton,  f.r.c.s.,  Lecturer  on  Compara- 
tive Anatomy,  and  Senior  Demonstrator  of  Anatomy 
Middlesex  Hospital,  London. 

By  the  Editor,  Henry  Morris,  f.r.c.s.,  Surgeon  to, 
and  Lecturer  on  Surgery  at,  Middlesex  Hospital ; 
Examiner  on  Anatomy  in  Royal  College  of  Physi- 
cians and  Royal  College  of  Surgeons,  etc. 
J.  H.  Davies-Colley,  f.r.c.s.,  Surgeon  to,  and 
Lecturer  on  Surgery  at  (late  Lecturer  on  Anatomy), 
Guy's  Hospital,  etc. 

Wm.  J.  Walsham,  f.r.c.s.,  Author  of  "  Manual  of 
Practical  Surgery,"  Assistant  Surgeon  to,  and  Lec- 
turer on  Anatomy  at,  St.  Bartholomew's  Hospital, 
London. 

H.  St.  John  Brooks,  m.d.,  of  Dublin,  Secretary 
for  Ireland  of  Anatomical  Society  of  Great  Britain, 
Chief  Demonstrator  of  Anatomy  University  of  Dub- 
lin. 

R.  Marcus  Gunn,  f.r.c.s.,  Surgeon  to  Royal  Lon- 
don and  to  the  Western  Ophthalmological  Hospitals, 
Surgeon  to  Great  Northern  Central  Hospital,  etc., 
London. 

Arthur  Hensman,  f.r.c.s.,  Aural  Surgeon  (late 
Senior  Demonstrator  of  Anatomy)  Middlesex  Hos- 
pital, Lecturer  on  Aural  Surgery  and  Anatomy  Mid- 
dlesex Hospital  Medical  School,  London. 
Frederick  Treves,  f.r.c.s.,  Surgeon  to,  and  Lec- 
turer on  Anatomy  at,  London  Hospital,  etc. 
William  Anderson,    f.r.c.s.,  Assistant  Surgeon, 
Lecturer  on  Anatomy,  and  Surgeon  to  Skin  Depart- 
ment St.  Thomas'  Hospital,  Professor  of  Surgery  and 
Pathology  Royal  College  Surgeons,  etc.,  London. 
W.  H.  A.  Jacobson,  f.r.c.s.,  Assistant  Surgeon  to 
Guy's  Hospital,  Surgeon  to  Royal  Hospital  for  Chil- 
dren and  Women,  Lecturer  on  Anatomy  (late  Teacher 
of  Operative  Surgery)  Guy's  Hospital  Medical  School, 
Author  of  "The  Operations  of  Surgery,"  etc. 

The  book  will  consist  of  1200  pages,  octavo,  and  will  be  printed  upon  a  handsome 
paper  made  specially  for  it.  The  illustrations  have  been<  drawn  from  the  subjects  by 
artists  of  experience,  and  engraved  on  wood  in  the  most  careful  manner. 

g®"  Send  for  special  circular  and  sample  pages. 


BONES. 
JOINTS. 

MUSCLES. 

BLOOD  VESSELS  AND 
LYMPHATICS. 

NERVOUS  SYSTEM. 
EYE. 


TONGUE,  NOSE,  EAR,  HEART, 
VOICE,  RESPIRATION. 

ORGANS  OF  DIGESTION. 

URINARY  AND  GENERATIVE 
ORGANS. 

SURGICAL  AND  TOPOGRAPH- 
ICAL ANATOMY. 


Potter.      A   Compend    of  Anatomy.       Fifth   Edition. 
1 6  Lithograph  Plates.      117  other  Illus. 

including  the  viscera.  {Based  on  Gray.)  By  Saml.  O.  L.  Potter,  m.a,,  m.d., 
late  A.  A.  Surg.  U.  S.  Army ;  Professor  of  the  Practice  of  Medicine,  Cooper  Medical 
College,  San  Francisco.  Revised  and  Enlarged,  nmo.  Being  No.  i  ?  Qiiiz- 
Compend  ?  Series.     See  page  29.  Strongly  bound  in  cloth,  $1.00 

Interleaved,  for  the  addition  of  notes,    1.25 

*£*  An  Appendix  has  been  added  to  this  edition,  containing  16  Lithographic  Plates  of  the  Arterial  and 
Nervous  Systems,  with  explanatory  tables  that  will  be  found  exceedingly  useful  and  practical.  We  would 
call  special  attention  to  these  tables,  as  being  entirely  original  in  design  and  arrangement,  giving  graphic 
views  of  the  most  difficult  part  of  Human  Anatomy,  and  including  anastomoses  (the  arteries)  and  distri- 
bution (the  arteries  and  nerves) ;  a  thing  never  before  shown  completely  in  tabular  form.  The  different  types 
are  so  arranged  as  to  grade  the  branches  according  to  relative  importance,  and  by  the  systematic  and  ingenious 
use  of  brackets  with  various  types,  the  tables  are  veritable  pictures  themselves  of  their  objects. 

Dr.  Potter's  power  of  condensation  and  arrangement,  have  never  been  displayed  to  such  advantage  as  in 
these  tables,  which  must  take  their  proper  place  as  the  best  of  all  attempts  of  the  kind,  even  in  the  restricted 
space  of  pages  the  size  of  which  was  previously  determined,  and  to  which  the  tables  had  to  conform. 

The  plates  are  equally  original,  having  been  made  from  new  drawings  by  Dr.  Potter's  own  hand ;  they 
are  graphic  delineations,  and  being  diagrammatic,  do  not  represent  the  exact  forms  or  proportions  of  the  parts 
thus  shown.  If  colored  by  hand,  by  the  student,  as  may  be  done  with  very  little  trouble,  their  value  will  be 
greatly  increased. 

"  In  the  particular  line  to  which  it  belongs,  and  as  one  of  the  pioneers,  this  work  of  the  indefatigable  Dr. 
Potter  stands  in  the  list  of  the  very  best.  This  is  particularly  conspicuous  in  view  of  the  many  failures  to 
render  the  subject  of  anatomy  attractive  when  presented  in  compends." — American  P?-actitioner  and  News, 
January,  1 89 1. 

"This  is  ? Quiz-Compend  No.  1,  based  on  Gray  principally,  and  is  a  book  that  to  a  student  is  almost  a 
necessity,  and  to  the  practicing  physician  a  great  aid  as  a  ready  reference  work,  enabling  him,  at  almost  a 
glance,  to  keep  in  mind  a  great  many  valuable  points  in  anatomy  that  otherwise  he  would  forget." — The  Cin- 
cinnati Medical  Journal,  February  15th,  i8qi. 

"  Of  all  the  studies  in  a  medical  course,  anatomy  is  the  most  important.  To  wade  through  a  '  Gray,'  for 
review,  is  very  irksome,  and  by  having  an  Anatomy  in  an  epitomized  form  and  thoroughly  reliable,  both  time 
and  labor  will  be  saved.  Dr.  Potter  has  thus  conferred  a  boon  on  both  the  student  and  practitioner  alike,  by 
publishing  his  Compend  of  Anatomy.  The  tables  and  plates  of  the  nerves  and  arteries  are  excellent ;  these 
constitute  the  Appendix,  and  by  their  aid  one  can  review  this  important  part  of  the  work  in  a  short  space  of 
time." — Canada  Lancet,  Toronto,  February,  i8qi. 


Robinson.      The    Latin    Grammar   of  Pharmacy    and 
Medicine. 

By  H.  D.  Robinson,  ph.d.,  Professor  of  Latin  Language  and  Literature,  University 
of  Kansas,  Lawrence.  With  an  Introduction  by  L.  E.  Sayre,  ph.g.,  Professor  of 
Pharmacy,  and  Dean  of  the  Dept.  of  Pharmacy,  in  the  University  of  Kansas.  12 mo. 
275  Pages.  Cloth,  $2.00 

"  It  is  a  work  that  meets  with  my  hearty  approval.  There  is  great  need  of  just  such  a  book  in  our 
American  schools  of  pharmacy  and  medicine." — E.  S.  Bastin,  Professor  of  Botany,  Dept.  of  Pharmacy, 
Northwestern  University,  Chicago. 

"  The  object  of  this  useful  book  is  a  very  laudable  one,  namely,  to  improve,  if  possible,  the  Latin  used  by 
both  physicians  and  druggists,  chiefly  in  the  prescribing  of  drugs.  While  it  is  true  that  many  of  the  profession 
find  it  unnecessary  to  remember  the  genitive  endings  of  words  used  in  medicine,  because  of  the  customary 
abbreviations  in  prescribing-writing,  there  are  others  who  frequently  desire  to  write  their  directions  to  the 
druggist  in  Latin,  in  order  that  the  patient  may  not  learn  of  facts  about  which  it  is  often  necessary  for  him  to 
remain  in  ignorance.  We  hope  that  the  book  will  prove  a  success,  and  by  its  general  employment  in  both 
pharmaceutical  and  medical  schools,  improve  the  knowledge  of  Latin  in  both  professions." — The  Medical 
News,  Philadelphia,  January  loth,  1891. 

"  The  plan  of  the  book  is  excellent,  the  field  new,  as  it  fills  a  long-felt  want.  All  medical  students 
should  have  it,  both  the  collegian,  as  it  will  give  a  practical  turn  to  his  knowledge  of  Latin,  and  the  non- 
graduate,  as  it  will  give  him  a  direct  and  useful  acquaintance  with  that  language.  The  country  doctor  who 
has  not  had  the  advantages  of  the  younger  men  will  find  it  a  great  help  in  overcoming  this  defect,  and  may 
speedily  acquire  a  familiarity  with  this  language  that  will  surprise  his  classical  cotifrere." — Southern  Cat. 
Practitioner,  December,  1890. 


A   HANDBOOK 


Local  Therapeutics 


JUST  PUBLISHED. 


A  Handbook  of  Local  Therapeutics,  being  a  practical  description  of  all  those 
agents  used  in  the  local  treatment  of  disease,  such  as  Ointments,  Plasters,  Powders, 
Lotions,  Inhalations,  Suppositories,  Bougies,  Tampons,  etc.,  and  the  proper  methods 
of  preparing  and  applying  them.  By  Harrison  Allen,  m.d.,  Emeritus  Professor  of 
Physiology  in  the  University  of  Pennsylvania;  Laryngologist  to  the  Rush  Hospital 
for  Consumption ;  late  Surgeon  to  the  Philadelphia  and  St.  Joseph's  Hospitals. 
George  C.  Harlan,  m.d.,  late  Professor  of  Diseases  of  the  Eye  in  the  Philadelphia 
Polyclinic  and  College  for  Graduates  in  Medicine ;  Surgeon  to  the  Wills  Eye  Hospital, 
and  Eye  and  Ear  Department  of  the  Pennsylvania  Hospital.  Richard  H.  Harte, 
m.d.,  Surgeon  to  the  Episcopal  and  St.  Mary's  Hospital ;  Ass't  Surgeon  University 
Hospital ;  Demonstrator  of  Osteology,  University  of  Pennsylvania;  and  Arthur  Van 
Harlingen,  M.D.,  Professor  of  Diseases  of  the  Skin  in  the  Philadelphia  Polyclinic  and 
College  for  Graduates  in  Medicine  ;  late  Clinical  Lecturer  on  Dermatology  in  Jefferson 
Medical  College  ;  Dermatologist  to  the  Howard  Hospital. 

In  One  Handsome  Compact  Volume.     Cloth,  $4.00 


ANNOUNCEMENT. 

The  importance  of  the  local  application  of  simple  remedies  in  slight  ailments  of 
special  .organs  is  not  always  realized  by  the  general  practitioner,  and  the  average 
text-book  omits  altogether  any  mention  of  many  agents  that  in  the  hands  of  the 
specialist  become  valuable  aids  to  cure.  The  diseases  which  chiefly  require  local 
treatment  are  those  of  the  Respiratory  Passages,  Ear,  Eye,  Skin,  together  with  certain 
general  Surgical  affections,  including  the  Diseases  of  Women.  In  order,  therefore, 
that  the  various  uses  of  each  remedy  should  be  thoroughly  set  forth,  it  was  necessary 
to  have  a  combination  of  authors  who  have  had  a  large  practical  experience  in  these 
various  branches  of  Medicine  and  Surgery. 

Each  remedy  is  taken  up  in  alphabetical  order,  and  after  a  succinct  description 
of  its  pharmaceutical  properties  is  considered  with  reference  to  the  local  treatment 
of  the  affections  above  outlined.  The  publishers  believe  that  the  information  con- 
tained in  this  work  will  not  be  found  elsewhere,  as  much  of  it  is  the  results  obtained 
in  private  and  hospital  practice,  by  eminent  professors  and  specialists.  The  activity 
in  the  various  lines  of  special  medicine  is  one  of  the  most  striking  phases  of  the  times, 
and  has  materially  changed  many  of  the  older  methods  of  treating  disease  by  local 
means.  The  greater  part  of  the  literature  which  has  appeared  is  not  accessible  to 
most  physicians.  This  Handbook,  it  is  believed,  will  be  of  value  to  general  prac- 
titioners as  well  as  to  those  who,  like  the  authors,  are  especially  interested  in  sub- 
divisions of  the  clinical  field. 

The  work  forms  a  compact  octavo  volume,  arranged  in  a  manner  to  facilitate 
reference,  and  contains,  besides  the  usual  index,  a  complete  index  of  diseases,  that 
will  greatly  enhance  its  usefulness. 


AN    EMINENTLY   PRACTICAL   BOOK. 

Moullin's  Surgery, 

Second  Edition,  Enlarged. 

A  Complete  Practical  Treatise  on  Surgery,  with  Special  Reference  to  Treatment. 

By  C.  W.  MANSELL  MOULLIN,  M.A.,  M.D.  Oxon.,  F.R.C.S., 

Surgeon  and  Lecturer  on  Physiology  to  the  London  Hospital,  etc. 


Second  American   Edition, 

Edited  by  JOHN  B.  HAMILTON,  M.D.,  LL.D., 

Professor  of  the  Principles  of  Surgery  and  Clinical  Surgery,  Rush  Medical  College,  Chicago  ;    Professor  of 

Surgery,  Chicago  Polyclinic  ;   Formerly  Supervising  Surgeon-General,  U.  S.  Marine  Hospital 

Service  ;  Surgeon  to  Presbyterian  Hospital,  St.  Joseph's  Hospital,  and  Central 

Free  Dispensary,  Chicago,  etc. 

About  Six  Hundred  Illustrations, 

Over  two  hundred  of  which  are  original  with  this  work,  and  many  of  which  are 
printed  in  several  colors. 

Royal  Octavo.    1200  Pages.    Handsome  Cloth,  $7.00  ;  Leather,  Raised  Bands, 
$8.00 ;   Half  Russia,  Crushed,  Marble  Edges,  $9.00. 

These  Prices  are  Absolutely  Net. 

This  new  edition  has  been  very  thoroughly  revised,  important  additions 
have  been  incorporated, — including  a  chapter  on  military  surgery, — many  of 
the  old  illustrations  have  been  recut,  and  about  one  hundred  new  figures  added. 

Our  claim  that  Moullin's  Surgery  is  the  best  text-book  for  the 
student  and  general  work  of  reference  for  the  practitioner  is  based  upon  the 
reviews  of  a  large  number  of  journals  that  have  pronounced  it  eminently 
practical,  and  upon  the  fact  that  so  many  teachers  have  seen  fit  to  recommend 
it.  But  beyond  this  we  may  say  that  broad  principles  are  stated  in  a  clear, 
authoritative  manner,  that  the  relative  value  of  the  different  subjects  has  been 
carefully  considered,  and  that  about  the  whole  there  is  an  air  of  responsibility 
that  renders  plain  the  fact  that  the  author  knows  whereof  he  speaks,  not 
only  from  his  own  experience,  but  from  a  large  acquaintance  with  American 
and  foreign  literature.  There  is  also  a  uniformity  of  style,  an  elegance  of 
diction,  that  attracts  and  interests  the  reader,  while  it  makes  plain  the  subject 
under  discussion. 

4©- A  complete  circular,  with  sample  pages,  press  notices,  etc.,  will  be  sent  free  upon  application. 


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